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If you total up the world-wide health cost of chemical addiction (including alcoholism and smoking), the death toll is beyond imagination. The WHO produces estimates that seem to be going down over time as public health warnings finally take hold, but in our lifetimes we're likely to see the rate of deaths from chemical addiction match the rate of deaths caused by WWII. This does not include morbidity (disabilities and long term-complications) nor the financial costs, which are also staggering.

I have to say that research funding related to addiction is modest and doesn't really reflect the social costs of addiction (declaring conflict of interest here: I would likely benefit if addiction funding increased). I think in part it is because people do not value addicts as much as other patients due to victim-blaming, but perhaps also there is pessimism about developing treatments and cures. The only thing I see on the horizon that might stand a chance is the use of vaccines (both passive and active) against addictive drugs, but that raises a hornet's nest of ethical and practical issues - that is, if this approach works at all.
Longterm stigma definitely is a huge barrier in where we stand right now, though things have slowly been improving. What's makes it worse is that addiction is a leading cause of death among young people. You're absolutely correct the investment into addiction treatment does not meet severity of the situations.

The reality is a lot of addiction treatment is not very successful and yet very expensive... so a lot of cost with questionable reward, especially long term.

Drugs like Suboxone and Vivitrol have been game changers for opioid addiction... but there is this crazy anti-scientific belief perpetuated by many people in 12-step programs (ie AA, NA) that using these drugs are anti-sobriety. Suboxone/buprenorphine as you know is primarily an opioid agonist (technically partial agonist) but for opioid tolerant patients they're not going to get high. Yes, like any medication there are inappropriate and appropriate use cases. Now we have Sublocade (monthly BUPE injection) which gets rid of any diversion or compliance issues. Vivitrol/naloxone is a monthly opioid antagonist injection, so there's absolutely no psychotropic effects there. The goal needs to be recognized is saving and rehabilitating productive lives... not how many "days" someone has clean from all substances. There's such a huge disconnect between 12-step programs, which up until recently were basically the primary treatment modality. The decision to use such medications should between a person and their medical providers... not the opinions of a bunch of random people in a room using anecdotes.

I can't tell you how many patients I've had who oppose or learn to oppose medication assisted treatment because of what they're told in AA and NA meetings. Generally they stop taking it without consulting us and then end up relapsing... and sadly I've lost count of how many times these relapses have been fatal.

COVID has wreaked havoc on our addiction patients... I can only see things getting worse before they start improving.
 
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I can personally attest to this, most of my family works in healthcare and normally are very caring about their patients. However, my Grandma (who was a nurse for over 50 years, a CNA before that) has expressed many times that she thinks we shouldn't use NARCAN and just let addicts die. This despite the fact that she herself has overcome 30 years of cigarette addiction, and her stepson (who she considers her son, and vice versa) nearly died due to a combination of substances. My sister, who doesn't have any addictions (though she does drink on weekends) feels the same way (she works in admitting).

One thing that always stuck with me was the way my uncle went in for a hug from my grandpa, and Grandpa pushed him away.

This may make them sound horrible, but they're genuinely loving, caring people. It's just that when addiction is brought up they lose all sympathy for some reason.

I have never understood the thought that Narcan will encourage more opioid use... that’s not how that works. It’s very rarely an opioid user is able or willing to voluntarily self- administer it.

Unfortunately because of just how potent fentanyl and it’s derivatives are versus heroin and most pharmaceutical opioids, it’s not nearly as effective as it was pre-street fentanyl. We really could use a more potent antagonist


Hi!

Things are going great - I am in a 12-step program and only had one relapse since June 28th. Although, what I've truly been struggling with recently is my addiction has been replaced by many smaller, less dangerous addictions... online shopping, video games, and web browsing. I'm thankful everyday to not be where I was, but it's still an uphill battle. The biggest change that has led to my success is when the withdrawals come back, I no longer try to fight the withdrawals or urges to use, but actively accept that it's happening and reach out to fellows in my 12 step group or friends and family until the feelings and mindspace passes.

I would say right now I do not have a purpose in life, you're right. Life is very murky as a young person. I picked up that book by Viktor Frankel years ago and it made me actually feel very depressed, but maybe it wasn't the right time to read it. I'll pick it up and give it another shot sometime.


Hope things are going well with you as well, and thanks for asking.
I’m so happy to hear that! That’s awesome! We’re certainly living in difficult times, glad you’re managing. Stick with it.

Sorry you found the book depressing, but maybe the existential philosophy garnered some inspiration if you made it that far. In my observation, it’s a lot harder for people who don’t create a semblance of “purpose” to stay sober. Otherwise what’s the point?

Things are good with me- super busy but had a much needed nice vacation recently... ready for this pandemic to be over. Thanks for asking.
 
There are only two types of drugs where the withdrawals can actually kill you.
Methadone withdrawal can also be directly fatal. Barbiturates as well, same idea as Benzos- though I don’t think many people have abused those since the 70’s... before my time
Sedative-hypnotics theoretically too.

There have been isolated fatal Opioid withdrawals indirectly due to dehydration from vomiting and diarrhea, though of course this is very rare.

For any substance not truly capable of fatal withdrawal directly, one could also argue to the effects of psychological withdrawal can lead to suicide... which is not exactly uncommon. This is especially true when you have concurrent psychological disorders (depression, bipolar, etc). This is why detoxes are usually built to psych ward standards and follow similar rules like restricting razor blades, shoe laces, drawstringed clothing etc. The detox in my hospital actually had to ban peanut butter because a guy in detox with a peanut allergy once tried to commit suicide by eating it.

The idea that stimulants "work differently" in people with ADHD is a complete myth.
In my observation it depends on the patient. Generally speaking, mild-moderate cases will have the traditional stimulant, euphoric, prosocial, effects. For those severely affected, that’s when you see the paradoxical effects. That said ADHD is way over diagnosed and narcotic stimulants are way over prescribed and dosed inappropriately.

For example, I work with a psychiatrist that drives me nuts. He’ll give patients multiple high doses of Adderall or Vyvanse (lisdexamphetamine) daily with a history of anorexia and then wonder why they’re not eating. It’s negligent and stupid.
 
If you are describing Ritalin, supposedly the dosage is low enough that the drug increases alertness without evoking euphoria. Seems like a somewhat suspect claim to me, but there are both subjective report data and functional imaging data to support it. The problem is absence of evidence is not evidence of absence.

If you have never taken a stimulant before, i.e. you have no tolerance, a low dose is still going to induce euphoria. If you take it daily in therapeutic dosages, you do develop a tolerance to the euphoria. However this happens to everyone who uses such drugs, whether they have ADHD or not. It is also pretty common for those prescribed stimulants to take breaks especially on weekends or for holidays. When they take their meds again after a break, they will probably feel a rush for the next few days because their tolerance reset.

Plenty of doctors seriously do subscribe to the idea that "if stimulants improve your concentration you must have ADHD." This is so wrong it's actually hilarious. Stimulants will boost anyone's concentration. For a doctor to believe otherwise, they must also believe anyone who drinks coffee in the morning has ADHD.

In fact that drug driving law actually treats amphetamine differently from every other drug because the possibility that amphetamine actually helps people concentrate on the road was considered. Not just for people prescribed it, as they're covered under the medical defence already. This was relating to illicit use.

For what it's worth I've been on Ritalin, Concerta, Vyvanse, Adderall, and Dexedrine. The latter is my current prescription and it is very good at getting me up and at it in the morning. But too much just makes me anxious and I crash badly. So I don't seem to be an upper guy. I just take it as the doctor orders. But even so, when the first dose kicks in, you get a wave of energy and you want to listen to loud music and you're well... you're on speed, albeit a medical dose.

There is a documentary on Netflix I watched recently called Take Your Pills all about ADHD meds and how they're overprescribed in the US, with Adderall in particular being the big one. Found it pretty interesting and it also dispelled the myth I addressed above. Although we don't have the overprescription issue in the UK. It's exactly the opposite here, getting an ADHD assessment on the NHS can take years so unless you go private you will have a hard time even seeing the right doctor. In the US you can get a script off your GP. Much more liberal with the scripts over there.

As for Nutt I live in the UK and the situation is a little more complex than many realise. Nutt used experts to rate drug harms and showed those ratings differed markedly from the legal classification of some drugs (e.g., alcohol is very harmful both acutely and chronically, but legal in the UK, whereas MDMA, which probably causes far less damage and indeed might be used therapeutically in some psychiatric contexts, is a Class A drug with the highest penalty for illegal possession). If Nutt had limited himself to making the one point that expert opinion and legal classification mismatch in some cases, he would have been fine.

The study you are referring to, where he compared drug harms and proposed a new classification system, was conducted after he was sacked.

What he was sacked for was stating that MDMA is statistically safer than horse riding. He made this comparison to highlight how society accepts certain risky activities yet stigmatises drug use. It was also because a patient of his had suffered severe brain injury after a horse riding accident.

So in fact he did just make that one point about MDMA while chair of the ACMD. That was enough for the government to sack him. It was only after he got sacked that he started a drug research charity and began conducting further research independently. He was recently involved in clinical trials on magic mushrooms for depression.

His research on relative drug harms has also been independently replicated by a European research team who looked at drug use across the whole of the EU and came to the same conclusions as Nutt did.

You might find this interesting reading:


The bizarre fact is the public vote with their wallets and buy drugs of all sorts, but paradoxically elect officials who present drugs as a moral law-and-order issue rather than a public health issue. Someday I hope both will change.

It's not too bizarre really. The simple fact is neither of the two main parties have drug reform as policy. I do expect that by the time the next election rolls around, the issue of cannabis will come up, particularly as the government finally accepted it's a medicine - although getting a prescription, in reality, remains extremely difficult.

When MAPS gets MDMA approved as a medicine in the US I think that'll be huge news that will have ripple effects across the world too.

The drugs issue is something that's been burnt into our culture for so long that change has to be slow and gradual for people to accept it. Full cannabis legalisation (medical and recreational) would have to be the first step and I think public opinion will force the issue particularly as our politicians simply cannot ignore the rest of the world's progress forever. It's ridiculous the police are out arresting people for selling weed when the rest of the world is heading to full legalisation and I find it particularly hilarious the NHS will hand out speed and morphine, every corner shop and supermarket sells booze and baccy, but cannabis is just too risky!
 
For any substance not truly capable of fatal withdrawal directly, one could also argue to the effects of psychological withdrawal can lead to suicide... which is not exactly uncommon. This is especially true when you have concurrent psychological disorders (depression, bipolar, etc). This is why detoxes are usually built to psych ward standards and follow similar rules like restricting razor blades, shoe laces, drawstringed clothing etc. The detox in my hospital actually had to ban peanut butter because a guy in detox with a peanut allergy once tried to commit suicide by eating it.

This is a fair point, but I'd argue you have put the horse before the cart. People are often driven to addiction in the first place because of suicidal depression and other mental illness symptoms rather than withdrawal causing those mental illness symptoms. There's been quite a bit of research to back this one up and it was certainly true in my own experience. I used oxy as a crutch because it was, at the time, readily available to me and it numbed me to my emotional pain.

When I tapered off I did feel depressed for a bit as I mentioned on the last page. But not suicidal depression, more just like not feeling any emotion at all. I couldn't enjoy anything, I had no drive, it was... well depressing.

Once this passed I was feeling much better, but this also overlapped with me getting a new job and I was over the moon about it. This had me very happy, I felt I had more purpose and self-worth and all that good stuff, and that was about a year ago. Since then the hype has obviously died down and I've had mild episodes here and there but nothing I couldn't deal with on my own and I've never felt the urge to get back on oxy again.

However I can say with virtually 100% certainty that if I quit oxy only to go back to my old menial boring low paid dead end job I'd probably have been chewing OC's again in no time because the reason for my depression getting as bad as it did, and the driver for me to enter such a dark place in my life, would not have changed.

And this is the rub really. It's all well and good quitting an addiction but you need a plan for what you're going to do next. If your life was crappy before you got addicted, and nothing has changed in the meantime, it'll still be crappy when you quit. People tend to turn to addictions as self-medication or a coping mechanism or both so they either need treatment for the underlying condition or an actual route to improving their lives or both. One tends to lead to the other. If this isn't taken care of, there's nothing keeping them from spiralling again.

That includes depression as well. If someone was already depressed, got hooked on drugs to self-medicate, and went to rehab... unless the underlying issue of depression is also treated, whether it be circumstantial or clinical, they will relapse in no time. I'm sure if you've been involved in addiction treatment you will have seen it yourself. The underlying causes of addiction are far too often ignored and then apparently it's a mystery why the patient relapses.

In my observation it depends on the patient. Generally speaking, mild-moderate cases will have the traditional stimulant, euphoric, prosocial, effects. For those severely affected, that’s when you see the paradoxical effects.

Reactions to specific medications certainly depend on the dose and the patient. My point really is the common belief that only people with ADHD benefit from stimulants because the drugs somehow "work differently" is an idea without any basis in science.

I do notice that I am less hyperactive when I am on amphetamine. But this is less a paradoxical reaction and more a natural result of being on a drug that makes you focus quite heavily on one task. It does mean that stimulants have this benefit that appears exclusive to those who are hyperactive, but it doesn't mean that stimulants won't also help others focus.

After all even medicine recognises this as there are two forms of ADHD - inattentive and hyperactive. The inattentive diagnosis indicates a lack of hyperactivity symptoms, yet both are treated with stimulants, often successfully.

That said ADHD is way over diagnosed and narcotic stimulants are way over prescribed and dosed inappropriately.

For example, I work with a psychiatrist that drives me nuts. He’ll give patients multiple high doses of Adderall or Vyvanse (lisdexamphetamine) daily with a history of anorexia and then wonder why they’re not eating. It’s negligent and stupid.

Yes in the US it seems ADHD is very overdiagnosed and stimulants overprescribed. This seems to me partly because the DSM-V criteria is very lax compared to the ICD-10 and partly because you don't need to even be a psychiatrist to diagnose ADHD in the US which is just... crazy to me.

We have the opposite problem in the UK where ADHD is underdiagnosed and undertreated. The primary reason for this is because ADHD can only be diagnosed by a psychiatrist who is also an ADHD specialist and seeing any psychiatrist on the NHS is difficult enough as it is. These specialists are small in number so the wait list to see one is very long (I'm talking years) and getting an assessment becomes extremely difficult unless you can get yourself assessed privately. If you can afford this, you can be diagnosed by a specialist within a few days. But you need to pay out of pocket because ADHD is not covered by private health insurance in the UK as it's considered chronic. Additionally, ADHD and adult ADHD are treated as separate conditions, so an adult with a childhood diagnosis has to go through that process all over again.

The intentions are good here I'm sure - this certainly prevents the issues the US has with overdiagnosis and overprescription - but it also means that unless you can afford to see a fancy private specialist you will have a long wait to get assessed for ADHD. This is already a problem for NHS mental health services in general, but especially so for ADHD since you must see a specific type of psychiatrist.

I was diagnosed with ADHD as a child but was never medicated. I got myself reassessed privately as an adult so I could get the medication if I still showed symptoms. It's helped me a lot. But I have never abused my meds and have never had any problem controlling my use when it comes to stimulants. I just don't find them moreish at all and in higher doses they just give me bad anxiety. But used correctly, they help me function.

Curiously there's also been research done on drug use and ADHD patients which shows those who are medicated are less likely to have substance abuse issues. This makes a lot of sense to me since obviously the meds are working if they make you less impulsive. And if they treat the symptoms there's no reason to self-medicate.
 
If you have never taken a stimulant before, i.e. you have no tolerance, a low dose is still going to induce euphoria.

I have never taken amphetamine-like stimulants. I don't want to go there if I can avoid it. I'll take your word for it, and honestly I do not find it surprising. Volkow initially claimed that Ritalin at prescribed doses did not activate reward-related circuits like addictive drugs do, but even she seems to have changed her tune. Perhaps my initial suspicions about the risks of Ritalin were correct. Thank you for bringing up the subject.

The study you are referring to, where he compared drug harms and proposed a new classification system, was conducted after he was sacked.

The paper to which I refer is 2007 (see https://doi.org/10.1016/S0140-6736(07)60464-4 ). That apparently caused friction that culminated in his sacking in 2009 (see https://www.theguardian.com/politics/2009/oct/30/drugs-adviser-david-nutt-sacked ). Also, the final straw that broke the camel's back was mostly focused on Nutt's claims about cannabis reclassification (see https://theconversation.com/david-nutt-i-was-sacked-i-was-angry-i-was-right-19848 ). I remember the day he was sacked, and honestly I think it was due to an interview he did on the radio where he suggested that the legal classification should be based on scientific evidence. The problem for him was, of course, it is absolutely right that not just scientists get a say in how society is run. Again, he overstepped. He was not elected.

FWIW I am scientist and I too find it frustrating when governments ignore or distort data. However, it is the height of hubris to think that all laws should be based on scientific data alone, particularly when scientists are not representative of the general population in terms of minority status, gender, or wealth. Known biases exist in science as a result, particularly in the fields related to behaviour, like addiction. All we can do is try to convince politicians and the public of the scientific data and them let them act as they see fit.
 
This is a fair point, but I'd argue you have put the horse before the cart. People are often driven to addiction in the first place because of suicidal depression and other mental illness symptoms rather than withdrawal causing those mental illness symptoms. There's been quite a bit of research to back this one up and it was certainly true in my own experience. I used oxy as a crutch because it was, at the time, readily available to me and it numbed me to my emotional pain.

When I tapered off I did feel depressed for a bit as I mentioned on the last page. But not suicidal depression, more just like not feeling any emotion at all. I couldn't enjoy anything, I had no drive, it was... well depressing.

Once this passed I was feeling much better, but this also overlapped with me getting a new job and I was over the moon about it. This had me very happy, I felt I had more purpose and self-worth and all that good stuff, and that was about a year ago. Since then the hype has obviously died down and I've had mild episodes here and there but nothing I couldn't deal with on my own and I've never felt the urge to get back on oxy again.

However I can say with virtually 100% certainty that if I quit oxy only to go back to my old menial boring low paid dead end job I'd probably have been chewing OC's again in no time because the reason for my depression getting as bad as it did, and the driver for me to enter such a dark place in my life, would not have changed.

And this is the rub really. It's all well and good quitting an addiction but you need a plan for what you're going to do next. If your life was crappy before you got addicted, and nothing has changed in the meantime, it'll still be crappy when you quit. People tend to turn to addictions as self-medication or a coping mechanism or both so they either need treatment for the underlying condition or an actual route to improving their lives or both. One tends to lead to the other. If this isn't taken care of, there's nothing keeping them from spiralling again.

That includes depression as well. If someone was already depressed, got hooked on drugs to self-medicate, and went to rehab... unless the underlying issue of depression is also treated, whether it be circumstantial or clinical, they will relapse in no time. I'm sure if you've been involved in addiction treatment you will have seen it yourself. The underlying causes of addiction are far too often gnored and then apparently it's a mystery why the patient relapses.

In some cases, many cases, depression is a factor- particularly with a lack of healthy coping mechanisms. Suicidal ideation isn't the case with everyone. A lot of cases are attributed to anxiety or other mental health conditions. In my opinion, the case of someone using drugs "just for fun" and getting caught up is very rare with no other psychiatric component in the long run. The confounder is that when people are regularly using substances of abuse they're screwing up in their natural neurochemistry, so when they stop using things are generally worse than before they started... which perpetuates the use cycle. So I don't think its as cut and dry as everyone who uses does so out of depression.

I absolutely agree that a lot of rehab facilities don't focus enough on the underlying mental health problems... I imagine that's often due to many not being actual medical facilities and only being licensed to treat addiction directly. I work for a very highly regarded psych hospital so we thankfully have a very well-rounded approach and specific programs for different types co-occuring disorders that make things far more complex like personality disorders, trauma, OCD, etc. We also have probably the best diagnostic program in the country to determine what co-occuring disorders are there, as this can be very hard to sort out, especially in the context of active addiction/early recovery. As you said, if you don't treat the underlying mental health problems, its hard to treat the addiction when its the primary coping mechanism.

I'm not sure this is so much that case outside of the US, but here there's a ton of programs still operating like it's the mid-20th century focusing on 12-step philosophy, which I believe has valuable attributes, but isn't compatible with everyone and doesn't address the underlying conditions. These programs also tend to be against medicated assisted treatment (ie Buprenorphine/Suboxone, Methadone) and indoctrinate people into opposing them... but they have no problem loading them on a dozen psychotropic medications that only seem to hinder progress more. I'm a firm believer in the less is more when it comes to any type of pharmacotherapy. Its very common with some psych prescribers to fall into this trap of if something "doesn't work" not discontinuing it.

Yes in the US it seems ADHD is very overdiagnosed and stimulants overprescribed. This seems to me partly because the DSM-V criteria is very lax compared to the ICD-10 and partly because you don't need to even be a psychiatrist to diagnose ADHD in the US which is just... crazy to me.

We have the opposite problem in the UK where ADHD is underdiagnosed and undertreated. The primary reason for this is because ADHD can only be diagnosed by a psychiatrist who is also an ADHD specialist and seeing any psychiatrist on the NHS is difficult enough as it is. These specialists are small in number so the wait list to see one is very long (I'm talking years) and getting an assessment becomes extremely difficult unless you can get yourself assessed privately. If you can afford this, you can be diagnosed by a specialist within a few days. But you need to pay out of pocket because ADHD is not covered by private health insurance in the UK as it's considered chronic. Additionally, ADHD and adult ADHD are treated as separate conditions, so an adult with a childhood diagnosis has to go through that process all over again.

The intentions are good here I'm sure - this certainly prevents the issues the US has with overdiagnosis and overprescription - but it also means that unless you can afford to see a fancy private specialist you will have a long wait to get assessed for ADHD. This is already a problem for NHS mental health services in general, but especially so for ADHD since you must see a specific type of psychiatrist.

I was diagnosed with ADHD as a child but was never medicated. I got myself reassessed privately as an adult so I could get the medication if I still showed symptoms. It's helped me a lot. But I have never abused my meds and have never had any problem controlling my use when it comes to stimulants. I just don't find them moreish at all and in higher doses they just give me bad anxiety. But used correctly, they help me function.

Curiously there's also been research done on drug use and ADHD patients which shows those who are medicated are less likely to have substance abuse issues. This makes a lot of sense to me since obviously the meds are working if they make you less impulsive. And if they treat the symptoms there's no reason to self-medicate.

Well, in my opinion the APA who writes the DSM is much more susceptible to political pressure and pharmaceutical companies. There's a lot of finical conflicts of interest with authors/board members involved in writing it and making changes. ICD-10 has it's own problems, largely with their diagnosis codes being convoluted, but that's what we end up billing to insurance anyways. It's funny too because everyone still talks about the 4 Axises that the DSM-V removed.

There's actually chronically a shortage of Adderall, especially Adderall XR because the FDA limits manufacturing and the prescribing just keeps going up and up. There's a lot of parents who want their kids to have an edge and manipulate doctors, usually primary care docs, into prescribing it. In my observation, most of the stimulant abuse in the country has to do academic performance and seeking out the euphoric effects is less common. Certainly Opioid, Benzo, Alcohol, Cocaine are much more common problems.

The US has huge access problems to mental health treatment. The problem is reimbursement rates are not good, especially with medicare/medicaid (30-60% less than private insurance). If you have insurance chances are you're going to be on a waiting list for a while, unless you pay out-of-pocket for a private-pay psychiatrist, which around here is generally $400-600/hr.

I am also a partner in a dual-diagnosis (psych + addiction) residential program. It's private-pay... $12,500/month+ with 3 month minimum. Average stay is 6-8 months. You can't get private insurance to pay for residential programs, though we send an itemized bill so some of the services can potentially be reimbursed if the patient has out-of-network coverage, which is becoming more and more rare. We're a "premium" facility so obviously there is some extra cost there and the cost self-selects for a certain level of clientele, but when you consider a luxury rehab is $40-80,000 for a 28 days I'd argue we're a much better deal- especially because we're actually integrating people back into the real world and can provide very individualized attention. I do feel bad for those on medicaid as many addicts are, the options generally aren't great, nor is a lot of staffing, nor is the programming. Most people with private insurance will end up having to pay ~50% unless they are part of a union that seem to pay endless amounts of money.
 
I have never taken amphetamine-like stimulants. I don't want to go there if I can avoid it. I'll take your word for it, and honestly I do not find it surprising. Volkow initially claimed that Ritalin at prescribed doses did not activate reward-related circuits like addictive drugs do, but even she seems to have changed her tune. Perhaps my initial suspicions about the risks of Ritalin were correct. Thank you for bringing up the subject.

Hey no problem. Methylphenidate (Ritalin) has a very different mechanism of action to amphetamines and in fact is more similar to cocaine than anything else. You've probably seen tabloids call it "kiddie crack" which is obviously hyperbole but I imagine that's where it comes from. The pharmacological mechanism of action of methylphenidate and cocaine are very similar. As I'm sure you can imagine, if you do a small line of coke, you are going to feel something even if it's not the full high.

The paper to which I refer is 2007 (see https://doi.org/10.1016/S0140-6736(07)60464-4 ). That apparently caused friction that culminated in his sacking in 2009 (see https://www.theguardian.com/politics/2009/oct/30/drugs-adviser-david-nutt-sacked ). Also, the final straw that broke the camel's back was mostly focused on Nutt's claims about cannabis reclassification (see https://theconversation.com/david-nutt-i-was-sacked-i-was-angry-i-was-right-19848 ). I remember the day he was sacked, and honestly I think it was due to an interview he did on the radio where he suggested that the legal classification should be based on scientific evidence. The problem for him was, of course, it is absolutely right that not just scientists get a say in how society is run. Again, he overstepped. He was not elected.

Firstly thank you for those links. I was previously unaware of the 2007 paper.

But as for your views on the roles of scientists, I think perhaps you are interpreting his words as him acting like an elected politician and conflating his independent scientific research with his role in the government at the time.

He was hired by the government to head up the ACMD. The job of the ACMD is to review current scientific knowledge and use this knowledge to make recommendations to the government regarding drug policy. What the government then does with those recommendations is up to the elected officials. But the recommendations of the ACMD should be based on science, not politics.

The frustration felt by Nutt was that even though this was the case, the ACMD itself was expected to toe the political line rather than to do its actual job of conducting and reporting on drug related scientific research.

The reason he was sacked was really nothing to do with his work at the ACMD, which he'd been a member of for about 10 years before being put in charge of it without issue. He got sacked because the government did not like his personal views reflected in his independent research. That 2007 paper for example - it was not conducted on behalf of the ACMD or any other government body, it was conducted by him as a scientist.

The real question that should be asked is why did the government sack a perfectly well qualified scientist from a scientific position simply because his personal views and independent scientific research happened to not be aligned with current government policy?

And if it's simply to be expected that you either toe the line or get sacked, however will progress be made?

His job was never to further anyone's political interests. His job was to provide the government his professional opinion based on scientific research. Instead he was sacked because the science didn't match up with the government agenda.

FWIW I am scientist and I too find it frustrating when governments ignore or distort data. However, it is the height of hubris to think that all laws should be based on scientific data alone, particularly when scientists are not representative of the general population in terms of minority status, gender, or wealth. Known biases exist in science as a result, particularly in the fields related to behaviour, like addiction. All we can do is try to convince politicians and the public of the scientific data and them let them act as they see fit.

When it comes specifically to the issue of drugs, I think science should take precedent above political games, don't you? I'd say the same of climate change for example. There are particular areas of policy within which we simply must consult science and follow the best research available, otherwise we end up with bad policy.

The reason we (as in the UK) have a bad drugs policy now - the failed so-called "war on drugs" - is because we ignored doctors and bowed to political pressure from the US. As a result, we saw a huge rise in drug use and subsequent addiction following the institution of prohibitionist policy. Meanwhile, Portugal decriminalised personal use of every single drug and began treating addiction as a health concern in 2001, and ever since has had reduced rates of drug use and one of the lowest overdose rates in the world. A study conducted by the Coalition government showed that there is no correlation at all between strict drug laws and levels of drug use. The facts tell us time and time again our current policy does not work.

That being as it is, perhaps it is time our politicians listened more to science where it is called for. Science may be imperfect and subject to biases, but it is certainly based on a lot more solid foundations than political posturing. The "war on drugs" comes entirely from politics, specifically from American politics driven by racial moral crusades, and has never had absolutely anything to do with science or public health or the NHS or anything else.

As for your last point, I believe that is exactly what Nutt was trying to do, and continues to do independently through his organisation Drug Science. He was never acting as if it was his job to create policy. But he was hired to make recommendations on drug policy to the government. He did so based on scientific research and got sacked because he didn't toe the line. I ask again how will progress ever be made if you cannot disagree with the status quo?

In my opinion, the case of someone using drugs "just for fun" and getting caught up is very rare with no other psychiatric component in the long run.

I agree entirely.

The confounder is that when people are regularly using substances of abuse they're screwing up in their natural neurochemistry, so when they stop using things are generally worse than before they started... which perpetuates the use cycle. So I don't think its as cut and dry as everyone who uses does so out of depression.

This depends highly on the substance in question. As I understand it most addictive drugs do not actually cause permanent damage to the brain. The primary exception being meth due to the neurotoxicity. MDMA is also neurotoxic but rarely addictive. But heroin or oxy or other opiates for example do not cause brain damage, opiates in general are ironically physically safe drugs if not taken in overdose. In fact most opiate related overdoses are a result of a combination of opiates and other downers (benzos, alcohol, etc) while overdoses from opiates alone, provided they're not cut with fentanyl, are compartivately rare.

What every addictive drug does do is cause the addicted individual to prioritise getting high beyond other things in life, but this is why I stress the importance of having real changes in day-to-day life as well as a support network after quitting, otherwise the chances of lasting recovery become very slim. The psychological element has to be dealt with by ensuring that person has new goals in life that don't revolve around getting high.

There's also social factors that are extremely important. Often drug addicts surround themselves with other drug addicts. If your whole social circle is based around doing drugs, if you want to quit you need a new social circle. Leaving all your friends behind as well as leaving your crutch and trying to change your circumstances all at once is no easy task. In my case it was my "friends" who decided to leave me when I quit. Thankfully I have better friends now. But being socially isolated on top of all the other struggles can be very difficult as I'm sure you'll agree.

I absolutely agree that a lot of rehab facilities don't focus enough on the underlying mental health problems... I imagine that's often due to many not being actual medical facilities and only being licensed to treat addiction directly. I work for a very highly regarded psych hospital so we thankfully have a very well-rounded approach and specific programs for different types co-occuring disorders that make things far more complex like personality disorders, trauma, OCD, etc. We also have probably the best diagnostic program in the country to determine what co-occuring disorders are there, as this can be very hard to sort out, especially in the context of active addiction/early recovery. As you said, if you don't treat the underlying mental health problems, its hard to treat the addiction when its the primary coping mechanism.

Exactly. Which is why I don't think rehab on its own is very helpful to most people. Really addiction treatment should be provided by mental health facilities - as addiction is, after all, recognised as a disorder - who are better equipped to treat the underlying causes of the addiction.

Since as you correctly point out, a dedicated rehab facility is not a mental health facility, they cannot really provide enough help to most people. At the very most, they are only one piece of a much bigger puzzle. But yet they are not treated as such.

I'm not sure this is so much that case outside of the US, but here there's a ton of programs still operating like it's the mid-20th century focusing on 12-step philosophy, which I believe has valuable attributes, but isn't compatible with everyone and doesn't address the underlying conditions. These programs also tend to be against medicated assisted treatment (ie Buprenorphine/Suboxone, Methadone) and indoctrinate people into opposing them... but they have no problem loading them on a dozen psychotropic medications that only seem to hinder progress more. I'm a firm believer in the less is more when it comes to any type of pharmacotherapy. Its very common with some psych prescribers to fall into this trap of if something "doesn't work" not discontinuing it.

This is an interesting discussion in its own right as many countries around the world have very different approaches to treating addiction. In the UK our drugs services tend to just give out methadone or buprenorphine (the latter being preferred these days) but we do not use Suboxone, only Subutex and its generics (so, no naloxone combinations). I imagine the way these are dispensed is similar to how they are in the US - new patients have to come into the pharmacy for daily collections while patients who have been in the system long enough without showing signs of deviating from their plans eventually get given takehomes, more so with bupe than methadone for obvious reasons.

We do have NA over here but I've never heard of 12 step programmes being compulsory and we do not share the same stigma about being on maintenance = not actually being clean. At least not within the actual medical community. Socially, many people do hold those views. But addiction treatment is not going to stigmatise maintenance.

On the UK private system (as opposed to the NHS) addiction clinics can prescribe virtually anything within reason for maintenance. I've heard of people getting 1000mg bottles of Oramorph 10mg/5ml oral solution every month to maintain. I've also heard of cocaine addicts being prescribed amphetamine from private clinics, but this has been very controversial as there's a lack of scientific evidence to suggest it is effective.

In Germany, Denmark, and Switzerland the state will provide clean pharma grade heroin as Britain used to do. In Canada there are supervised injection rooms but you must bring your own dope. Any type of supervised injection facility is a good idea imo. They are clearly a successful harm reduction approach.

And yes I absolutely agree about doctors being all too willing to just shove people on cocktails of various psych meds. This is an issue in general not just in addiction and it's a big one. People end up being on pills to treat the side effects of their pills. I've had a psychiatrist try to force all sorts of crap on me including Seroquel for the treatment of GAD. This is, in my opinion, simply poor medical practice. Antipsychotics should not be taken lightly and they have serious adverse effects. Yet docs are happy to hand them out for anxiety. Usually to avoid writing a benzo script.

Now that's a whole other thing I could go on about as the way the NHS and NICE have made it so difficult to obtain legitimate benzo scripts in the UK has simply lead to a booming black market of dangerous counterfeit Valium and Xanax flooding the streets, often containing super-potent and unresearched NPS such as flubromazolam and flualprazolam.

The issue is that while benzos do indeed have risks, the simple fact is they do not yet have a replacement that is as effective. SSRIs work for some but are far from the miracle drugs doctors wish they were - and SSRIs are extremely overprescribed in both the UK and US and this is mostly overlooked simply because you cannot abuse them. But this doesn't make them any less dependence forming.

Of course the pharma companies would rather you ignore SSRI withdrawal. They even invented a new name for it: "discontinuation syndrome."

Well, in my opinion the APA who writes the DSM is much more susceptible to political pressure and pharmaceutical companies. There's a lot of finical conflicts of interest with authors/board members involved in writing it and making changes. ICD-10 has it's own problems, largely with their diagnosis codes being convoluted, but that's what we end up billing to insurance anyways. It's funny too because everyone still talks about the 4 Axises that the DSM-V removed.

This is what I have heard as well. The DSM is often influenced by outside interests. And it is of course beneficial to the pharma companies if conditions that are treated with the meds they make are overdiagnosed.

Interestingly in the UK psychiatrists tend to consult both the DSM-V and the ICD-10 when making a diagnosis, but they will usually favour the ICD and they always use the names given in the ICD rather than the DSM. For example EUPD rather than BPD is the term used here (although, unofficially, everyone calls it BPD anyway).

There's actually chronically a shortage of Adderall, especially Adderall XR because the FDA limits manufacturing and the prescribing just keeps going up and up.

Why is manufacturing limited? Is it to combat overprescription? If so surely more regulations on the doctors would be a more sensible approach? At the very least it seems to me common sense that only a psychiatrist rather than a GP should be able to diagnose ADHD.

The US has huge access problems to mental health treatment. The problem is reimbursement rates are not good, especially with medicare/medicaid (30-60% less than private insurance). If you have insurance chances are you're going to be on a waiting list for a while, unless you pay out-of-pocket for a private-pay psychiatrist, which around here is generally $400-600/hr.

Doesn't sound like the grass is much greener on the other side then.

I do quite like our healthcare system in the UK although I clearly do have criticisms of it.

That said, having used both the NHS and private specialists, I am also very happy I have access to the private system. I tend to use the NHS for basic things that only require a GP. If I need to see any type of specialist (whether it's due to mental health or needing surgery or whatever) I get a private referral. I had to have surgery and I got it arranged in a week. By contrast my girlfriend has been waiting about six months and counting to get an operation on the NHS. Doesn't seem fair to me that I get to be seen to much more rapidly just because of the job I have, but there you go.

I am also a partner in a dual-diagnosis (psych + addiction) residential program. It's private-pay... $12,500/month+ with 3 month minimum. Average stay is 6-8 months. You can't get private insurance to pay for residential programs, though we send an itemized bill so some of the services can potentially be reimbursed if the patient has out-of-network coverage, which is becoming more and more rare. We're a "premium" facility so obviously there is some extra cost there and the cost self-selects for a certain level of clientele, but when you consider a luxury rehab is $40-80,000 for a 28 days I'd argue we're a much better deal- especially because we're actually integrating people back into the real world and can provide very individualized attention. I do feel bad for those on medicaid as many addicts are, the options generally aren't great, nor is a lot of staffing, nor is the programming. Most people with private insurance will end up having to pay ~50% unless they are part of a union that seem to pay endless amounts of money.

Those are crazy sums of money but yes compared to a luxury rehab, a service that actually offers psychological help is clearly superior. Then again it's just a shame only wealthy people can access such services to begin with. Not a criticism of the US as the same is true here, although I don't think the costs are quite so high, the price of a private rehab is still not within the reach of most people.
 
I have seen and felt things I haven't seen since I was a boy. The beauty of the stars at night. Learning and cooking new recipes. The small pleasure of taking a walk and sharing a smile with a neighbor. I am getting glimpses of what life is really about when you aren't powerless.

There will be more like this. Count on it.

I've been alcohol-free for 34 years.
 
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The frustration felt by Nutt was that even though this was the case, the ACMD itself was expected to toe the political line rather than to do its actual job of conducting and reporting on drug related scientific research.

I understand his frustration, but picking a public fight with the government was going to result only one outcome, and that wasn't going to be a rational change in policy.

...
When it comes specifically to the issue of drugs, I think science should take precedent above political games, don't you? I'd say the same of climate change for example. There are particular areas of policy within which we simply must consult science and follow the best research available, otherwise we end up with bad policy.

I think we all aspire to a rational policy about drugs, but what if the public wants an irrational policy? Do scientists get to overrule them? I believe the answer is no. We can only present information and try to change minds. The moment we go beyond that into activism is the moment we get sucked into the political vortex and get accused of bias.

...
Meanwhile, Portugal decriminalised personal use of every single drug and began treating addiction as a health concern in 2001, and ever since has had reduced rates of drug use and one of the lowest overdose rates in the world. A study conducted by the Coalition government showed that there is no correlation at all between strict drug laws and levels of drug use. The facts tell us time and time again our current policy does not work.
...

I was invited to a debate by the Mayor of Oporto to discuss this when it was being proposed. I got the distinct impression that we scientists were being managed by the politicians (and possibly other interests). No questions from journalists were allowed after my talk, which emphasised the structural and functional changes in the nervous system after taking drugs. We were given no free time at all from 7AM until 10PM and we were assigned a handler that followed us everywhere. There's politics on all sides of this issue.

On my part I would like to see recreational drugs decriminalized but regulated. I really would like to see governments institute a drug user's license (including for nicotine and alcohol). That means you get to choose whatever drug you want once you are of age, but risk losing your license if you engage in drug-fueled violence, criminality, reckless behaviour that endangers others, or if you have a health problem that would be complicated by drug-taking. I find it appalling that people caught driving while drunk often get banned from driving, which often entails impacts on employment and family life, but are still allowed access to alcohol. It makes no sense whatsoever.
 
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This depends highly on the substance in question. As I understand it most addictive drugs do not actually cause permanent damage to the brain. The primary exception being meth due to the neurotoxicity. MDMA is also neurotoxic but rarely addictive. But heroin or oxy or other opiates for example do not cause brain damage, opiates in general are ironically physically safe drugs if not taken in overdose. In fact most opiate related overdoses are a result of a combination of opiates and other downers (benzos, alcohol, etc) while overdoses from opiates alone, provided they're not cut with fentanyl, are compartivately rare.

Any chemically addictive substance is going to have neurological effects, which causes most of the psychological effects in the first place. See “disease model of addiction”. The changes in the brain are not permanent in the way they were once believed, but the brain is never really going to “forget” how drugs benefited itself which is generally why people quickly fall back into addiction, even after years of abstinence.

Opioids for such terribly addictive drugs indeed do have little long term consequences on the body. But with dependence opioids flood the brain (nucleus accumbens in particular, like all euphoric addictive or dependence forming substances) with dopamine (which probably has effect on other neurotransmitters like serotonin down the line). The body gets used to this and down regulates naturally occurring neurotransmitters and/or receptors to try and get back to homeostasis. When someone with addiction/dependence stops taking the opioids regularly (or any other abusable drug), it takes time for the the body to re-regulate itself. So this is why I say even if someone didn’t have conditions like anxiety and depression going into their drug use, between the brain learning drugs are a coping mechanism and the withdrawal effects, people usually end up with at least temporary psych issues when coming off.

Just speaking to psychiatric effects:
Long term opioid use can suppress the endocrine system, including testosterone, which can effect males and can be psychologically detrimental directly and indirectly, though this tends to reverse itself.

Marijuana is generally considered not very addictive, though I believe the numbers are quite underestimated. THC, especially used during adolescence and teenage years, may have a long term effect on learning/memory and potentially other cognitive factors. It can also induce psychosis in the predisposed (which may or may not have happened otherwise naturally) and worsen psychotic disorders in those already with them.

Benzodiazepines, again not considered the most addictive drugs, even at therapeutic levels there is some evidence they may cause long term memory issues. Abuse levels would likely lead to worse effects.

Stimulants like cocaine and meth like THC can induce/exacerbate psychotic disorders. They can also affect longterm cognitive skills. they can induce seizure disorders. Really long term use can cause Parkinson-like symptoms from burning out dopamine receptors. The profound cardiovascular effects can result in brain hemorrhages, heart attacks, and stroke which of course can cause a myriad of forms of neurological damage.

MDMA is related to stimulants and has similar effects, so I would imagine it would fall into the category above. MDMA is rarely pure (at least in the US) and often contains other stimulants and sometimes opioids as it is. Some claim it is not addictive, but think that’s willful ignorance unsupported by research- and I’ve seen many cases of MDMA addiction.

LSD, DMT, Peyote, and most hallucinogens are generally not considered addictive, but can have damaging effects on the psyche long term depending on how well individuals tolerate their trips. They do risk inducing/exacerbating psychosis. In heavy users, there is also the risk of persistent hallucinations (“flashbacks”), though there isn’t a ton of data on this condition and it’s prevalence estimates vary widely. Chronic use of such drugs isn’t particularly common though.

It is true opioids generally have minimal physical impact on the body beyond risk of overdose, impacted bowel, and potential longterm anti-androgenic effects. I believe about 30% of opioid overdoses involve benzos and IIRC alcohol+opioids isn’t reported by our govt, but I’d imagine at least another 30%... though I’m sure many of the Benzo cases also involve alcohol too.

I would be careful not to discount how dangerous all opioids are even without other benzos or alcohol. Many of people die from pharmaceutical opioids alone every year.

In short, long term effects on the brain by drugs are not just related to neurotoxicity (damaging neurons directly). Any drug that has an effect in the brain (intended or not) can potentially have long lasting effects. For example, old people given anesthesia can wreak havoc and take months to recover if ever. Even Benadryl given to an old person, especially with dementia, can cause anticholinergic toxicity (incl. delirium) and potentially have longterm consequences.
 
Exactly. Which is why I don't think rehab on its own is very helpful to most people. Really addiction treatment should be provided by mental health facilities - as addiction is, after all, recognised as a disorder - who are better equipped to treat the underlying causes of the addiction.

Since as you correctly point out, a dedicated rehab facility is not a mental health facility, they cannot really provide enough help to most people. At the very most, they are only one piece of a much bigger puzzle. But yet they are not treated as such.

After watching perhaps thousands of people go through rehab and hearing their experiences (generally multiple other rehab experiences), I have some opinions on the matter.

1) Detox - clearly medically necessary for some drugs (opioids, Benzos, alcohol) but really should be offered to drugs (like stimulants) for those who need extra support to stop using the substance. Unless you pay privately, insurance will only cover "medically necessary" detox.

2) Rehab - generally 21-30 day inpatient programs - the quality of these programs range greatly. Even the "best" programs, of which are minority, are probably only useful once or twice in terms of a crash course in addiction/recovery education. A lot of people go to rehab after rehab after rehab, but other than segregating them from society to keep them safe, after the first rehab or two there is not much to gain.

The exception to this are true dual-diagnosis programs that are actually equipped to deal with addiction occurring in patients with severe mental health conditions. As we both agree you can't effectively treat the addiction without treating the psych issues, this is especially true with more severe forms of mental illness.


3) Residential programs - generally 90 days minimum, not covered by private insurance. I find this is the most effective form of treatment since it integrates real life responsibilities with recovery. Going to rehab is like living in a bubble.

4) Outpatient group programs - they can work for well stabilized patients, but generally for people without much intense treatment under their belt are highly unsuccessful
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The idea that people can go to detox +/- rehab (or simply outpatient programs) and then magically be cured is insane. Going back to the same environment, with the same people, with the stress of everything that existed beforehand is a recipe for disaster, yet this is what nearly all insurances expect to happen. Not surprisingly the long term success rate of these short stints are very, very low.

There's also a lot of families that send their loved ones to rehab, but the individual isn't yet ready to for recovery. This is especially true of teenagers and young adults. I've seen a lot of young people sent to rehab for smoking pot or drinking (in a non-addictive fashion) and frankly it just causes resentment and exposes these kids to people with far worse drug habits and is probably more detrimental than beneficial.

There has been an argument for some time about treating all substance abusers together or separating treatment by substance. While the underlying fundamentals are similar, I would argue at the very least treatment ideally should be separated by severity- at least in young people. But even adults can pick up new things in rehab...

I am aware of an instance of a middle-aged man who was abusing OxyContin but switched to fentanyl as it was far cheaper. He was eating the fentanyl, which allows for very little absorption. In rehab he learned if he snorted the fentanyl he could use less and get higher. Less than two week after leaving rehab he had relapsed and fatally overdosed on fentanyl. Had he never gone to rehab and just kept eating the fentanyl he'd probably still be alive.
 
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Why is manufacturing limited? Is it to combat overprescription? If so surely more regulations on the doctors would be a more sensible approach? At the very least it seems to me common sense that only a psy
chiatrist rather than a GP should be able to diagnose ADHD.
You'd be correct regulating prescribing would be more effective than limiting production, but the government also has pretty limited ability to restrict doctor's prescribing. It doesn't make a ton of sense, but it's what they do. I agree PCP's shouldn't be prescribing Adderall (or any psych drugs), but given the wait times to see a psychiatrist (especially for those on Medicaid, especially children on Medicaid), I suppose it becomes a healthcare access issue.


Those are crazy sums of money but yes compared to a luxury rehab, a service that actually offers psychological help is clearly superior. Then again it's just a shame only wealthy people can access such services to begin with. Not a criticism of the US as the same is true here, although I don't think the costs are quite so high, the price of a private rehab is still not within the reach of most people.
The same is true pretty much everywhere. Psych funding is generally the last concern of most healthcare systems, particularly addiction. There's little incentive for hospitals to provide psych programs and little incentive for psychiatrists to take insurance when the reimbursement rates are so low (thus not many med school students become psychiatrists). Why accept $130/hr from an insurance company when you have a line of people willing to pay $400+/hr cash... plus you don't need to deal with the hoops of the insurance company and hire extra staff to handle claims?
 
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I understand his frustration, but picking a public fight with the government was going to result only one outcome, and that wasn't going to be a rational change in policy.

I guess we differ in perspective here. I personally don't really see conducting independent research, unconnected from his duties within the ACMD, as "picking a fight with the government."

The issue here seems to be with how the government acts and expected him to act rather than anything else. They hire experts - and Nutt is extremely well qualified in his field - but expect those experts to only tell them what they want to hear and sack them if they say anything that deviates from the party line.

In other words the government doesn't actually want scientific recommendations, which is ostensibly the function of the ACMD. All they really want is their existing views to be echoed back to them by scientists to lend more credibility to their current policies.

If an expert they hire dares to contradict government policy, even on their own time and separately to their government work, they will be removed.

I can only ask again - how will any change happen if even scientists are not allowed to contradict existing government policy when advising the government?

I think we all aspire to a rational policy about drugs, but what if the public wants an irrational policy? Do scientists get to overrule them. I believe the answer is no. We can only present information and try to change minds. The moment we go beyond that into activism is the moment we get sucked into the political vortex and get accused of bias.

I'm curious, in what way do you believe Nutt was attempting to overrule the politicians?

He did not start his own party, or a political movement, or become an activist, or anything of the sort. He did his job as a scientist, which is to review and conduct research and report his findings.

Further, much of what the government took issue with was research he conducted independently of his governmental duties. It had nothing (or very little) to do with how he conducted his actual job as chair of the ACMD.

I simply do not see how anything he did was attempting to remove control of policy from politicians.

As for your point about the public - this is valid of course, and understandably political parties have to take public opinion into account if they are to be reelected, but why does this mean an expert government advisor who presents alternate views on the matter has to be sacked? The government are not bound by ACMD recommendations, and again most of what the government took issue with was independent research to begin with.

Perhaps if Nutt was able to stick around and have a voice in government, the public would be more likely to become exposed to rational views. At the moment, unless someone happens to take a particular interest in the issue of drug use, all most of the public hears is the same lines trotted out again and again in the mainstream media. Minds don't change if they're never presented with new information.

Thankfully public opinion is slowly changing on a generational basis. Young adults view cannabis as safer than alcohol - which is factually correct. But the government had to be pushed by a very public PR nightmare to even admit cannabis has medical benefits, despite much research already proving this for years and years prior. They simply do not want things to change.

To quote a great philosopher:

“One lied, mendaciously inventing reasons for these laws, simply to avoid admitting that one had become used to these laws and no longer wanted things to be different.”

I was invited to a debate by the Mayor of Oporto to discuss this when it was being proposed. I got the distinct impression that we scientists were being managed by the politicians (and possibly other interests). No questions from journalists were allowed after my talk, which emphasised the structural and functional changes in the nervous system after taking drugs. We were given no free time at all from 7AM until 10PM and we were assigned a handler that followed us everywhere. There's politics on all sides of this issue.

Absolutely there are. But don't you think that's rather absurd? Politics trumps science every time. I'm simply arguing this isn't how things should be. It is irrational and illogical to put political point scoring above scientific evidence.

On my part I would like to see recreational drugs decriminalized but regulated. I really would like to see governments institute a drug user's license (including for nicotine and alcohol). That means you get to choose whatever drug you want once you are of age, but risk losing your license if you engage in drug-fueled violence, criminality, reckless behaviour that endangers others, or if you have a health problem that would be complicated by drug-taking. I find it appalling that people caught driving while drunk often get banned from driving, which often entails impacts on employment and family life, but are still allowed access to alcohol. It makes no sense whatsoever.

I would be fully on board with this policy, sounds very sensible to me. Nutt effectively suggested a similar type of system (many years after he got sacked) whereby most drugs (aside from "light" ones like cannabis) would only be available from a pharmacy, people would only be able to buy limited amounts, there would be plain packaging and a ban on advertising, and there would be a database to keep track of use.

In case you're curious:


Clearly neither of these proposed systems (yours or Nutt's) would stop a motivated addict from obtaining their drug of choice by other means, but they'd keep the majority of the public within safe limits.

The way I see it, if the public can be trusted with open access to a drug as dangerous and addictive as alcohol, and most of them end up not dying or becoming alcoholics, they can be trusted with controlled supplies of most other substances.

The body gets used to this and down regulates naturally occurring neurotransmitters and/or receptors to try and get back to homeostasis. When someone with addiction/dependence stops taking the opioids regularly (or any other abusable drug), it takes time for the the body to re-regulate itself. So this is why I say even if someone didn’t have conditions like anxiety and depression going into their drug use, between the brain learning drugs are a coping mechanism and the withdrawal effects, people usually end up with at least temporary psych issues when coming off.

Of course, this is why tolerance builds for basically any substance and withdrawals happen for drugs that develop physical dependence. No argument here. This is also why rushed tapers or cold turkey detox is a bad idea. You need to wean the person off the drug slowly to avoid (or at least reduce) severe withdrawals, rebound symptoms, and so on.

Particularly if you consider alcohol and benzos. Rapid withdrawal from those can easily lead to seizures in cases of severe abuse.

Long term opioid use can suppress the endocrine system, including testosterone, which can effect males and can be psychologically detrimental directly and indirectly, though this tends to reverse itself.

Yep opiates absolutely lower testosterone levels. But typically once you begin to taper off you notice the sex drive come roaring back.

Marijuana is generally considered not very addictive, though I believe the numbers are quite underestimated. THC, especially used during adolescence and teenage years, may have a long term effect on learning/memory and potentially other cognitive factors. It can also induce psychosis in the predisposed (which may or may not have happened otherwise naturally) and worsen psychotic disorders in those already with them.

Again I am in full agreement. I don't think cannabis should be used by teenagers with developing brains - a very good argument for legalisation and regulation - and yes if someone is already predisposed to or is experiencing psychosis cannabis may well trigger it or make it worse.

It does also seem quite possible that in many cases people with psychotic illness are using cannabis to self-medicate however. The high number of schizophrenic patients who smoke tobacco is also very interesting. I'm not saying either is a good idea, but rather that in many cases it is very possible the psychosis came first and cannabis (as well as tobacco) was then used as self-medication.

Benzodiazepines, again not considered the most addictive drugs, even at therapeutic levels there is some evidence they may cause long term memory issues. Abuse levels would likely lead to worse effects.

Benzodiazepines certainly are very addictive if abused. If used therapeutically under medical supervision the risk of a psychological addiction is greatly reduced (although unless used prn you of course always get physical dependence as with any psych med). But when people abuse benzos they commonly increase their doses as tolerance develops and the withdrawal symptoms are notoriously severe.

However based on the research I've read, therapeutic dose ranges of benzos do not cause permanent brain damage, only excessive doses do. The research I looked at was on diazepam though and it may well be the more potent benzos such as alprazolam pose more of a risk. There's no conclusive link to therapeutic benzo use and reduced cognitive function even after the medication has been discontinued as far as I'm aware.

Even if such a link was proved, as you'd be talking about therapeutic use, the question would be is symptom relief worth the tradeoff? For many the answer could well be yes. For others it'd be no. Depends on if alternate treatments work for that specific patient and how severe their condition is to begin with.

Personally I find comfort just in knowing I have a small amount of benzos I can use if they're needed. But I don't use them daily and instead use cannabis whenever possible. Often cannabis provides comparable anxiety relief if it's the right strain for the job. But if the anxiety is more severe, a benzo is the only option for me personally.

Stimulants like cocaine and meth like THC can induce/exacerbate psychotic disorders. They can also affect longterm cognitive skills. they can induce seizure disorders. Really long term use can cause Parkinson-like symptoms from burning out dopamine receptors. The profound cardiovascular effects can result in brain hemorrhages, heart attacks, and stroke which of course can cause a myriad of forms of neurological damage.

Absolutely. But on the flipside of this, we have almost a century of data showing that therapeutic levels of pharmaceutical amphetamine or methylphenidate do not carry these risks to nearly the same degree. Not only due to the lower doses, but also because amphetamine is fundamentally a safer drug than meth (which is neurotoxic) or cocaine (which is cardiotoxic).

Abusing pharma stims can still cause psychosis, psychological addiction, and a host of other bad things, but if used correctly there's very little risk even in long-term use.

So as with most substances really, it comes down less to is the drug itself inherently harmful and more to is it being abused in a way likely to cause harm?

MDMA is related to stimulants and has similar effects, so I would imagine it would fall into the category above. MDMA is rarely pure (at least in the US) and often contains other stimulants and sometimes opioids as it is. Some claim it is not addictive, but think that’s willful ignorance unsupported by research- and I’ve seen many cases of MDMA addiction.

MDMA is a substituted amphetamine indeed. I cannot speak for the US, but in the UK and Europe in general MDMA is highly pure. The Dutch labs pump out virtually 100% pure MDMA and it is dirt cheap. I can get a gram of pure MDMA for £10. I know it's pure because I can get it lab tested using GC/MS. It's very rare for MDMA to be cut with anything here because there's simply no point.

When droughts have occurred, caused by law enforcement interfering with supply as happened in 2009-2010 for instance, this is the only time MDMA purity became an issue here. But then precisely for that reason we (in the UK) stopped using MDMA and started using mephedrone (4-MMC) instead. By the time mephedrone was made illegal the MDMA supply began to return and purity has only been climbing ever since.

As for its addictive potential, the research is quite clear that it is low. I can dig up sources if you wish. The big thing with MDMA is it's not a drug you wake up the next morning wanting another hit of, as you might do with heroin, but rather it's a drug with a comedown you have to ride out for about a week, while the next morning the positive feelings associated with the experience stick with you if it's good stuff. You don't really feel like doing more. And if you do take it too frequently, it simply stops getting you high and you only get the negative effects - after all, your brain can only produce so much serotonin. It's really quite a difficult drug to become addicted to.

Mephedrone on the other hand was far more addictive than MDMA. It was very moreish in a way that MDMA simply isn't and the comedown far less severe and far more short lived compared to MDMA too.

Just to make one last point here, the only reason the MDMA in the US is impure is quite obviously due to the black market nature of its supply. Were it to be legal and regulated, it would of course be pure. If MAPS is successful in getting it FDA approved in a couple of years you will have legally prescribed pharma grade MDMA. It'll be used to assist in psychotherapy, which is exactly what Shulgin promoted it for in the first place when he synthesised it.

LSD, DMT, Peyote, and most hallucinogens are generally not considered addictive, but can have damaging effects on the psyche long term depending on how well individuals tolerate their trips. They do risk inducing/exacerbating psychosis. In heavy users, there is also the risk of persistent hallucinations (“flashbacks”), though there isn’t a ton of data on this condition and it’s prevalence estimates vary widely. Chronic use of such drugs isn’t particularly common though.

Classic psychedelics are overall very safe drugs. As you correctly point out, the primary risk for an already healthy individual comes from the lingering psychological effects of bad trips. This is where the importance of set and setting comes into play.

Other than that, yes, the only real dangers are to people already predisposed to or suffering from psychosis.

Chronic HPPD is extremely rare to the point where there's so little data on it, it's debatable whether or not it's real. Even temporary HPPD is very rare except perhaps for the next day after a strong trip.

The fact so little data can be gathered on it speaks volumes to how small of a risk it is considering how long psychedelics have been in use by humans (in the case of mushrooms, pretty much since we have existed).

And they're certainly not prone to addiction. For one thing tolerance to most psychedelics builds instantly and takes a couple weeks to reset. And for another, as with MDMA, you simply do not wake up the next morning desiring more. A trip is an intense experience. You typically want time to chill and mentally recover while you process everything and regain your energy.

I did some 2C-B with a few friends in a park last night, topped off with a couple bumps of ketamine and a joint being passed around. Had a great time. As 2C-B is short lasting and not very intense mentally (it's a primarily visual experience) I got up this morning and began work as usual.

If I had been drinking all night instead I'm quite certain the resulting hangover would have rendered me much less functional. I'm also quite sure I'd have done much more damage to my brain and body.

Let's not forget that mainstream medicine is finally catching up to the therapeutic benefits as well. Two pharma companies are running clinical trials on ketamine products for depression treatment hoping to beat the other to market. MAPS is set to get MDMA approved by the FDA as early as 2023. Ongoing research into LSD and mushrooms is yielding very promising results. It's my belief psychedelics are the future of mental health treatment. Clearly I'm not the only one who holds this view.

I would be careful not to discount how dangerous all opioids are even without other benzos or alcohol. Many of people die from pharmaceutical opioids alone every year.

Certainly. I'm not downplaying the dangers of opioids in other aspects at all. The primary danger, in my opinion, is the severe psychological addiction. There's a reason I kicked oxy and decided I'm better off smoking weed and tripping/rolling instead. Far better for my mental health, in fact I would argue I've had trips and rolls that have been outright therapeutically beneficial to my mental health, more so than any prescription psych meds.

In short, long term effects on the brain by drugs are not just related to neurotoxicity (damaging neurons directly). Any drug that has an effect in the brain (intended or not) can potentially have long lasting effects. For example, old people given anesthesia can wreak havoc and take months to recover if ever. Even Benadryl given to an old person, especially with dementia, can cause anticholinergic toxicity (incl. delirium) and potentially have longterm consequences.

Anything that alters brain function can have effects on the mind especially if used chronically and especially in vulnerable groups, for sure.

The questions though are about balancing risk and reward. For instance, are these harms likely to occur in the majority of the public? Are they less than the harms of already legal and socially acceptable intoxicants and medications such as alcohol and opioids? Are there risk factors we can look at to determine who is most likely to be at risk of harm?

It seems to me the answers there are quite clear cut and show no reason that many drugs such as cannabis and psychedelics should not be legal for recreational and medical use. Certainly, to use a very relevant real world example in the US right now, cannabis for pain relief is proving to be a lot safer than the use of opioids. No one has ever in the history of the universe overdosed on cannabis.

The idea that people can go to detox +/- rehab (or simply outpatient programs) and then magically be cured is insane. Going back to the same environment, with the same people, with the stress of everything that existed beforehand is a recipe for disaster, yet this is what nearly all insurances expect to happen. Not surprisingly the long term success rate of these short stints are very, very low.

I agree with this and everything else you wrote in this particular comment 100%.

You'd be correct regulating prescribing would be more effective than limiting production, but the government also has pretty limited ability to restrict doctor's prescribing.

Does the DEA not have that power? I was under the impression that the DEA is being very strict in regulating opioid prescriptions in recent years for instance.

The same is true pretty much everywhere. Psych funding is generally the last concern of most healthcare systems, particularly addiction.

Sadly very true.
 
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I am aware of an instance of a middle-aged man who was abusing OxyContin but switched to fentanyl as it was far cheaper. He was eating the fentanyl, which allows for very little absorption. In rehab he learned if he snorted the fentanyl he could use less and get higher. Less than two week after leaving rehab he had relapsed and fatally overdosed on fentanyl. Had he never gone to rehab and just kept eating the fentanyl he'd probably still be alive.

Sorry to hear this. :(

Personally, I'd like to make all the pharmaceutical and healthcare people who knowingly pushed opiates onto patients as though they were nonaddictive through a gauntlet of people who have lost family members due to opiate addiction that started with legal medications.
 
One day I just decided to quit, to NOT light a cigarette any more. That first step, it really was that simple and it basically was the desire to be free. The struggle then was to not fall victim to those bad old habits again.

Exactly my story also! Former attempts to quit smoking did not work but one day, I realised that the cigarettes had control over me, my time, my will... and I started to dislike it. Freedom!
It wasn't so easy, of course. For a while, I still did my "routines" of having a break, leaving the room/the house but no longer for smoking. Just went outside because I had that habit :) Stood around the corner, people began to think if I would sell illegal drugs or if I were a policeman in disguise, because why should one stand outside and do nothing for a couple of minutes staring around?
Helpful for me was that a dude in the internet had written, do not count the days you are not smoking. You are a non-smoker from now on and forever, so the number of days does not matter.
But I remember the year. 14 years since the last cigarette (of my life, I think).
 
However based on the research I've read, therapeutic dose ranges of benzos do not cause permanent brain damage, only excessive doses do. The research I looked at was on diazepam though and it may well be the more potent benzos such as alprazolam pose more of a risk. There's no conclusive link to therapeutic benzo use and reduced cognitive function even after the medication has been discontinued as far as I'm aware.

Even if such a link was proved, as you'd be talking about therapeutic use, the question would be is symptom relief worth the tradeoff? For many the answer could well be yes. For others it'd be no. Depends on if alternate treatments work for that specific patient and how severe their condition is to begin with.

I guess what you consider large doses. No guideline recommends daily, routine Benzo use for more than 2-4 weeks... yet people (at least here in the US) end up taking them for months, more of then years on end.

I have severals bankers boxes stuffed with studies... when I get a chance I can link you to some. I know there’s at least one meta analysis in there. Certainly mega doses would also have detrimental cognitive effects

Benzos are though, they’re very useful in the short term but tend to be disastrous in the long run, at the least in the end providing no benefit or making things worse (rebound effect). Clinically speaking I’m generally not a fan except when used very sparingly or to help manage rare, serious seizure disorders when nothing else is adequately effective.

As with any anxiety disorder though, Benzos are not a great tool in the long run. SSRI’s seem to have more utility in the long run. But in reality, cognitive behavioral therapy has demonstrated to be the best tool in managing such conditions. Benzos can provide so short term, rapid relief. SSRI’s and some other drugs can act as a booster to therapy. But drugs alone are not the answer, the research is pretty clear on that. One has to alter how they process reality on a cognitive level.


Anything that alters brain function can have effects on the mind especially if used chronically and especially in vulnerable groups, for sure.

The questions though are about balancing risk and reward. For instance, are these harms likely to occur in the majority of the public? Are they less than the harms of already legal and socially acceptable intoxicants and medications such as alcohol and opioids? Are there risk factors we can look at to determine who is most likely to be at risk of harm?

It seems to me the answers there are quite clear cut and show no reason that many drugs such as cannabis and psychedelics should not be legal for recreational and medical use. Certainly, to use a very relevant real world example in the US right now, cannabis for pain relief is proving to be a lot safer than the use of opioids. No one has ever in the history of the universe overdosed on cannabis.
Basically every single drug regardless of what it does carries risks. There’s a lot of drugs that have psychotropic effects that people don’t even consider as they’re not classified as such- like some antibiotics.

I’m not a fan of recreational drugs. Im
Somewhat libertarian and believe people can make their own choices, but I don’t really like the government and signing off on it... basically just to get tax money. What actually bothers me the most is the lack of responsibility the government (and pot stores have) around providing informed consent of the possible dangers. If people want cannabis to be a legal drug it should be treated like one as much as reasonably possible. I don’t deny medical marijuana has some benefits in a LIMITED Number of circumstances, but we all know many “medical” users are using it just to get high, treating conditions not proven to benefit (or worse, proven to exacerbate the issue). Further, I am have a grave concern of people going to their head shop to seek medical advice from clearly unqualified individuals, meanwhile forgoing actual medical treatment, potentially worsening their situation.

That said, I also find a huge problem with the war on drugs and punishing drug use and addiction as a criminal matter rather than a mental health matter. I understand very well the interplay between drugs and criminality (ie robbing a bank to get $$$ for heroin), but I’d prefer quality rehabilitation was actually the focus... especially when it comes to matters like simple possession and truly victimless crimes. Besides, from what I understand if jail, it’s not hard for one sustain their drug use while incarcerated.

What annoys me too is the claims that big pharma is squashing marijuana (and other “natural medications). If and when a natural product can be used pharmaceutically big pharma jumps in, makes a product, and throws a patent on it. We have several THC and CBD pharmaceuticals available. Morphine and Digoxin are also naturally occurring products. There’s a huge marijuana and “natural health” industry that plays the same game of trying to make money. The difference is they’re unfortunately held to a much lower standard.

That’s not to say all natural medicines are bad an don’t work, but generally they require more frequent dosing and/or have more side effects. Most pharmaceuticals are modifications of naturally occurring substances in order to improve effectiveness, convenience, etc while reducing side effects.

I’m on the same page about the overuse of opioids, particularly in the US where things really got out of hand. I consult frequently on utilizing techniques to reduce or avoid opioids in pain patients. My hospital network also has employees nurses trained in mindfulness and “alternative therapies” (mostly related to relaxation) to help mitigate pain. It’s quite amazing 10 years ago prescribers would throw opioids at people, now newly graduated MD’s are terrified to write a script for 5mg of hydrocodone in people in serious shape. There should be a balance, but we have a lot of alternatives now and thankfully the medical-academic-research job is doing a better job at teaching them. This is especially true in chronic pain. For acute pain (post trauma or surgery) we’ve been able to drastically avoid opioids by using nerve blocks or reduce them with low dose ketamine. For chronic pain we use SSRIs, muscle relaxers (usually avoiding carisoprodol), TENS, NSAIDs, etc. Ketoralac is a wonder drug, it’s a NSAID- non-narcotic, but equanalgesic powers to morphine. The only problem is you can only take it for several days before it kills your stomach and ruins your kidneys (esp those with renal insufficiency)... but for healthy people it’s fantastic.

Methadone is also a great opioid painkiller, sadly stigmatized for its use in opioid addiction. It has very long, slow, stable pharmacokinetics that make it far less addictive and easier to discontinue. Gabapentin and pregabalin/Lyrica can also be phenomenally effective in the right cases and most people discontinue easily cold turkey. Those who don’t are usually fine after a relatively short taper. Though there is a small minority that seems to have difficulty and find it addictive.

The issue with marijuana, like opioids, in the context of pain management, especially for chronic pain is that the goal is to get people functional. Being high is counter productive, as is being lazy. Granted, between heavy opioids and cannabis I’d rather not see someone sucked into the hellhole of opioid dependence. But cannabis doesn’t treat all types of pain.

I’ve had 2 herniated discs in my back since... actually more like 2.5. I’ve taken everything from opioids to antidepressants to muscle relaxers to NSAIDs to PT to chiropractors, to acupuncture, to message therapy, to acupuncture, to other obscure treatments. In the end, getting back into swimming (I was raised competitive swimming, pre-Covid managed 3-4,000yrds/day x 4-5x/week + yoga has helped me more than anything. Some drugs I found actually made the pain worse. Everyone is different of course... but too often people want an answer in a pill and expect an immediate 100% return to normalcy, which 95% of the time is not realistic.


Chronic HPPD is extremely rare to the point where there's so little data on it, it's debatable whether or not it's real. Even temporary HPPD is very rare except perhaps for the next day after a strong trip.
In all my years of working, I have yet to hear this reported, so I too question it’s legitimacy, at least to any significant prevalence. I’d say it’s just as likely these people have unlocked a mild psychosis that pops up here and there or are experiencing PTSD from something traumatizing in their trip.

I’ve had a number of patients who did copious amounts of LSD for years. It’s hard to say what they were like before their usage, but many do seem to have a subtle cognitive deficit and motivational impairment. Again, hard to say whether it was the chicken or the egg, but I can imagine frequent, prolonged breaking with reality is healthy for the psyche. Brain aside, there seems to be no other physical effects.

Does the DEA not have that power? I was under the impression that the DEA is being very strict in regulating opioid prescriptions in recent years for instance.
Yes the DEA regulates controlled substance production... not sure if I said FDA before... though they may also play a role in it.
 
Sorry to hear this. :(

Personally, I'd like to make all the pharmaceutical and healthcare people who knowingly pushed opiates onto patients as though they were nonaddictive through a gauntlet of people who have lost family members due to opiate addiction that started with legal medications.

It is very sad, he was a really nice guy and always put a smile on everyone’s face.

In this specific case this guy was actually never prescribed opiates in the first place medically. IIRC he had aches and pains from a lot of manual labor in life. He had a friend prescribed Oxy (diabetes related? :rolleyes: ) who had him try it out and ended up selling up some of the ridiculously massive quantities he was prescribed (100’s of mg per day). When the govt started cracking down, the friend’s prescriptions got cut back and the patient was told he couldn’t supply him anymore. So he found a fentanyl connect and the rest is history. Very sad.

I’ve had at least 7 patients I knew we’ll die since January. 3 overdoses, 2 suicides, 1 “suspcious circumstance” (I suspect suicide but I also suspect the local PD smoothed it over to comfort his newly ex-wife and young children), and 1 freak accident. And those are just the cases I know about. Working in a hospital it can take months to find out about these things. :(
 
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