Sunday, February 25, 2007

Sober Housing is a Potent, Cost-Effective Treatment for Addiction

A Report to AODAAC, Treatment Committee
Steven T. Coulter, MD, Chairman
October, 2006

The October 2006 issue of The American Journal of Public Health includes a DePaul University study on the effectiveness of Oxford House placement for graduates of addiction treatment programs (Jason et al, 2006). An Oxford house is a group home of people recovering from addiction. There is no staff; residents supervise each other's recovery. Since the only major cost for this arrangement is the rental expense of the house, this is a low-cost, long-term approach to supporting sobriety for those addicted to alcohol or other drugs.

The Oxford House movement was born here in Montgomery County. In the 1970's, a county-funded halfway house lost its budget. The residents decided the house was working too well for them to leave, and so they simply started paying the landlord rent on their own. The arrangement worked well, despite the lack of any staff. With some evangelical zeal, they started a non-profit organization to spread the concept. Today, there are 1200 Oxford houses in the US (see

Clinicians "in the field" have long recognized that such living arrangements can be a highly effective support to those in recovery. Until the publication of the study mentioned above, however, there was no published measure of the effectiveness of such placements. The results of the study are impressive enough to put many (far more expensive) treatment options to shame. At 24 months:

- rates of substance abuse were lower, at 31.3%, versus 64.8%, a 52% reduction
- monthly income was higher, $ 989, versus $ 440, more than doubled
- incarceration rates were lower, 3%, versus 9%, only a third as many were incarcerated.

This "treatment" approach is inexpensive; these results are too good to ignore. Investing a modest amount of money to create placement slots in such housing could enhance the operations of other aspects of our county's "continuum of care." Many of the existing operations suffer from long waiting lists. For some of our clients on waiting lists, an Oxford house-like placement would suffice, permitting better access for others that need higher intensity care. Those individuals placed here would clearly be less likely to relapse; therefore reducing the numbers of repeat clients who cycle through our system over and over. In addition, some of our programs have great difficulty placing clients at discharge. A set of dedicated, low-cost placement slots would allow shorter lengths of stay (at, e.g., ARTC or ARCC), thus permitting these existing services to treat more patients per year.

In such an arrangement, clients in such housing would presumably pay rent on a sliding scale according to income, up to a maximum of the market value of the housing they occupy. This should provide revenue to offset the bulk of the operating expense, while ensuring that clients who are or become disabled or unemployed are not made homeless.

The closest comparable program we currently run is probably Lawrence Court. With a typical census of around 20 at Lawrence Court and an annual budget of $336,000, a placement there costs roughly $1,400 per client per month (which does not include any rental expense, since the property is owned by the county). Even though an Oxford house-like placement would presumably entail rental expense, the net cost after revenue should be well under $300 per client per month.

At least two local non-profits have been operating sober housing under this model for several years already. Community Ministries of Rockville (CMR, has been running Hope Housing with a HUD grant. Community Ministry of Montgomery County (CMMC, has been operating a parallel program. The funding stream for these programs is through Montgomery County Coalition for the Homeless ( These three organizations are already partners with Montgomery County in providing services to the needy.

Estimates of benefits for relapse, income, and incarceration in the Hope Housing programs seem to match or exceed the results from the DePaul University study. The CMR program operates with a single full-time manager/director/case-manager for a census of about 21 clients, with some administrative support from the rest of the organization.

Options for incorporating this model into the County's continuum of care might include replicating the Hope Housing model, assisting with the creation of new Oxford houses (existing Oxford houses in the county tend to operate at full occupancy already), or contracting with an agency such as CMR to expand existing operations to include county-funded beds. The treatment committee suggests that DHHS should consider issuing an RFP (request for proposals) to implement one or more of these options for providing sober housing. The Chairman of this Committee will be happy to assist with advising the County Council on the merits of funding this proposal.


Jason, LA et al. Communal Housing Settings Enhance Substance Abuse Recovery. American Journal of Public Health. October, 2006. Vol 96, No 10. Pp 1727 - 1729. Abstract at:

This document on the web:

Friday, February 23, 2007

From the Archives of Addict-L

Jerry Costley


We have a director of a local Methadone clinic who has his doctoral degree in social work. He teaches substance abuse counselor (LSAC) courses at the local university. He is hung up on diversion possibilities and doesn't allow anyone take-home privileges for the first several months--he prides himself that his clinic is open seven days a week, 365 days a year. After two years someone can earn up to one week take-home privileges, max. I have asked him about trying to accommodate for people's employment, noting that research has suggested a good job is a huge predictor of success, and his response has been that individuals need to decide what is more important, employment or treatment, as though they are mutually exclusive. He also prides himself on never having applied for a federal exception for an individual. His clinic serves largely people who are on Medicaid or receive public assistance, so they don't have much of a choice. Most of the public dollars go to his clinic because the public funders feel more comfortable with the "tight ship" he is running….



To Jerry and the List:

What you describe of this methadone clinic is the kind of bullshit, counter-productive, paternalistic, humiliating crap that methadone accreditation was supposed to prevent. A well-written letter to the accrediting body may be the most effective way to fix such defunct practices. The vast majority of methadone programs are accredited either by JCAHO or by CARF. For CARF, the way to submit a complaint is at:

or just

For JCAHO, it's at:

or just

Each site has a directory to see if a given program is accredited with them.

Best wishes,

Steve Coulter, MD
SteveMDFP -at- gmail -dot- com

Hi Steve,

Sorry to say the accreditation bodies service the providers, not the patients. Their words, not mine.
As for clinic policies, the Federal regulations are the most lenient, but the states can impose additional
restrictions and the individual clinics, even more restrictions. While some methadone clinics have
come around and are doing excellent work under difficult circumstances others just demonstrate
control, control and more control. Exactly what complaint would you file against the clinic director?


Howard S. Lotsof, President
Dora Weiner Foundation
46 Oxford Place
Staten Island, NY 10301

Dir. Tel: 1 718 442-2754
Dir. Fax: 1 718 442-1957


To Howard and the List:

I really don't share your cynicism about accreditation bodies. They do get their income from the organizations being accredited, but my experience is that they take their work very seriously, and consider their chief customer to be the public at large. A few years ago, a well-regarded local hospital came very close to shutting its doors because of a complaint filed with JCAHO. My hunch is that they receive very few well-written complaints, especially from programs serving the poor and uninsured.

Accredited methadone programs must meet the federal accreditation guidelines, and any additional requirements of their particular accreditation body. The federal guidelines are at:

An excerpt:

1. Patients have the right to treatment that:
a. is given with full informed consent;
b. is individualized and participatory;
c. responds adequately to patient needs;
d. promotes dignity and is humane;
e. promotes autonomy and patient responsibility;
f. protects confidentiality;
g. protects and promotes overall health and well-being.
2. Program administration obtains and is responsive to patients' feedback concerning their care.

The approach to take-home doses is supposed to be individualized. A policy of "we don't give anyone more than two days of take-homes" violates the accreditation standards. I'd be very surprised if the accreditation body didn't pursue a well-written complaint.

Best wishes,

Steve Coulter, MD
SteveMDFP -at- gmail -dot- com


"High" Howard! (official addictions treatment salutation)

I would like to chime in here briefly. I believe that I could speak for JCAHO but I will not since I am not directly involved with them. I have been a CARF accreditation surveyor for many years now & was involved with the "Opioid Treatment Program accreditation project" almost from inception. I conducted the two initial pilot tests of the study of whether or not accreditation was a viable model for improving patient care for "methadone programs" & I have consulted with or surveyed many U.S. "OTP's" since that time having worked with them since the early 1970's. I ensure you that patient-focused/centered care & client rights are a HUGE part of accreditation. There are many mechanisms built in an accreditation survey to determine whether or not the organization and program is in conformance to the standards surrounding and underlying these rudimentary practices. I cannot imagine that a complaint such as the one listed in this thread would not be taken VERY seriously by an accreditation body. If I were an accreditation surveyor visiting this organization, I would certainly pay close attention to this issue and it would have a SIGNIFICANT impact upon my findings and report. If this organization is accredited by CARF and you or anyone else would like to file a complaint, you should contact Bettye Harrison at . Patients can, and should file complaints as well. Another good place to check is .

Director of Operations
Addiction Recovery Systems
Three Mill Road, Suite #200
Wilmington, DE 19806
904-307-6548 Mobile


On 2/22/07, <> wrote:

I'm with Howard, here, MIke. I also have been involved with the OTP accreditation process from the beginning, and from my view, all accreditation has done is increased costs to patients and made more "make work" for already overburdened clinic staff. ARM has filed complaints to both CARF and JCAHO and unless the complaint meets an "accreditation element" (most of which have nothing to do with quality treatment) they do not do anything to help. In fact, the accreditors have never resolved a complaint that we have filed, we ALWAYS have to go all the way to the Feds at CSAT.

And remember Betty Harrison refers to herself as the "Queen of Forms" and thats exactly what CARF accreditation is......a TON of paperwork.

The intent of the accreditation system was good, but from the patients perspective it has been a huge failure.

Chris Kelly


Advocates for Recovery through Medicine

Washington DC CHapter


To Chris and the List:

I certainly can't argue with your experience on this matter. I'm surprised and outraged. Respectful, individualized, compassionate, flexible methadone treatment that enhances autonomy, employment and larger recovery are "accreditation elements." If JCAHO and CARF are not enforcing these accreditation elements, then these organizations themselves are subject to complaints filed at SAMHSA's CSAT. I would urge anyone with specific information to send such a letter. A cc to one's Senators and Representative tends to multiply the effectiveness of efforts to get federal agencies to do the jobs they're supposed to. An additional cc to JCAHO and CARF would be useful, too.

Really, you're describing failure of federal licensees (CARF and JCAHO) to fulfill their contractual obligations. I believe the Inspector General of HHS has authority to investigate failure of contractors to perform their obligations.

So, the specific people to inform would be:

Center for Substance Abuse Treatment
Division of Pharmacologic Therapies
Substance Abuse and Mental Health Services Administration
Attention: OTP Certification Program
1 Choke Cherry Road, Suite 2-1073
Rockville, MD 20857

Phone and e-mail would seem to be:
Telephone: 1-866-INFO OTP (463-6687); e-mail:





And, for one's congress-critters, you can look up your own Representatives and Senators at:

The laws, regulations, and standards are all already in place. All that's needed is a little dogged determination to make various people do the jobs they're paid to do. I think Addict-L has enough dedicated people to fix this problem.

Best wishes,

Steve Coulter, MD
SteveMDFP -at- gmail -dot- com





I have been a "lurker" on the list for some time now, quietly observing from the shadows & I have been GREATLY impressed and inspired by the depth of some participant's passion and knowledge. This is a topic on which I can & will speak. While I cannot & will not address others' experiences I will share the accounts of my own adventures over the past decades, which have been many.

I have worked in the field of "medication assisted treatment" for over 30 years. I have also had a great deal of additional experience but for the purposes of this thread I will focus on my work with opioid treatment programs. We have been under the regulatory control of the DEA & FDA since "the beginning of time", which focused on the control of the medication itself. The decision to transition away from the FDA & to move programs under the auspices of CSAT was a shift in the right direction in my opinion. The desire to finally instill some national standards for patient care was long overdue. I can tell you many "horror stories" of programs I have visited through the years where the words "patient care" could not be used in the same sentence. Too often rules & regulations came first & patients/families came second at best.

My experience as an accreditation surveyor (& I do emphasize that this is MY experience) has been extremely positive. The programs I have worked with as a consultant & as a surveyor have consistently reported that the accreditation process has significantly improved the quality of patient care as demonstrated by measurable outcomes & based upon solicited feedback from the organizations' various stakeholders. We worked together to streamline systems so that redundancy was reduced so that resources are better allocated to patient needs & in some instances, paperwork was cut rather than increased. Patients consistently report that they are more empowered and engaged in their programs because that is something we measure as heightened participation is a desirable positive outcome. Barriers were reduced or eliminated altogether and bridges were constructed so that accessibility to services was increased. We know this because we measured it & we used that data in an on-going effort to improve at what we do. Wait-time for services was reduced and employee retention was increased as staff competencies were improved. Counseling services focused on use of effective therapeutic "tools" (discussed here) such as cognitive behavioral therapies, motivational enhancement/interviewing techniques, brief intervention, etc. & this was reflected in progress noting and treatment planning so that it could be clearly seen. ETC.

I don't know if I'm being very clear as I'm doing too many things right now to write as well as many of you on this list who post on a regular basis but I hope that I've made my point in at least a satisfactory manner. I agree with Dr. Steve's post [above]. If you have complaints, PLEASE COMPLAIN as that's the only way that the system stands any chance of getting adjusted. I promise you that when I see/find problems that I fuss & fume loud & long because the bottom line is that the bad stuff has an adverse impact on patients & their families. However, when you see something that works to help patients & families, take a little time to "give it a little push" as well.

Director of Operations
Addiction Recovery Systems
Three Mill Road, Suite #200
Wilmington, DE 19806
904-307-6548 Mobile



Hi Mike,

My experience as a member of the Board of Directors of the National Alliance of Methadone Advocates and an observer of patient/clinic activities is that there was a rash of improvement in clinics during the accreditation process. Patient committees were supported. Things were spruced up around the clinic but for the most part once accreditation was achieved the clinics withdrew support for many of the activities they paraded in front of CARF and JCAHO during accreditation visits. My experience is that the accreditation organizations so distanced themselves from patient issues as to be of no value to patients at all. I must admit I haven't been on the front lines of these matters for 18 months or so but, I have heard nothing exemplary as to CARF and JCAHO from a patient perspective either.

Wednesday, February 21, 2007

To: "Academic and Scholarly Discussion of Addiction Related Topics." <>
From: SteveMDFP -at- gmail -dot- com
Subject: Re: Brief Intervention Insufficient for Medical Inpatients With Unhealthy Alcohol Use

To Fred and the List:

In my mind, the most interesting question about Brief Intervention (BI) is why it works. From a perspective borne of counseling work, it doesn't make any sense to expect significant behavior change from something that lasts only a few minutes. Where's the quality of relationship that's been proven to facilitate such change? How could there possibly be the development of therapeutic rapport, empathy, or even the conveyance of an understanding of what the problematic behavior is, exactly? Doesn't make sense.

Then I went to see a doctor myself for a minor chronic condition I'd been neglecting. I got appropriately scolded and given very directive, but appropriate, instructions. It had a significant psychological impact, somehow, and I found myself doing better at what I'd already known I should have been doing all along.

Did this behavior change depend on empathy? Nope. A deep understanding of the problematic behavior? No. It derived from being the explicit instructions of a trusted authority figure.

Our species is a social animal. That doesn't mean only that we like being around other people, to a variable degree. It also means, I think, that our brains are "hard-wired" to carry out specific social functions. One of those functions is to "follow the herd." We tend to adjust our behavior to fit in with the behavior of those around us whom we identify with.. This can be in dress, speech, mannerisms, and it happens with almost no conscious thought or deliberation.. Look at any gang or cult to see the power of this effect. I suspect group therapy, and maybe even individual therapy, work in part from this "drive to conformity."

I think BI taps into a different facet of being a social species. I think we're "hard-wired" also to dutifully follow the orders of recognized authority. History and social psychiatry provide an abundance of examples of people blindly following authority, despite knowing the orders are wrong or stupid. We do it anyway.

I wonder if BI works less well for inpatients because the trappings of the interaction undermine the perceived authority of the clinician. In a medical office visit, the experience has some similarity to having an audience with the King. You're kept waiting, attended to by a sequence of underlings, and then brought into his chamber. In contrast, in a hospital, the clinician is just another of a string of more or less anonymous visits. Also, the clinician is lowering himself to come to the client, not the other way around. Who would follow the orders of a king like that?

Food for thought.

Best wishes,

Steve Coulter, MD
SteveMDFP -at- gmail -dot- com

On 2/21/07, Fred Rotgers, Psy.D., ABPP <> wrote:

The problem here is that the target of the intervention was wrong! I ran
such a program for a number of years at Rutgers, where our goal was to
stimulate thinking about change, not actual change itself. These
interventions are opportunistic ones done with people who have little
thought of changing their drinking until the clinician approaches them.
It is grossly unrealistic to expect that a motivational intervention
(the content of which, I suspect, did NOT include formal feedback about
medical condition and its association with drinking, although this press
article does not specify that). In addition, this was very sloppy
research, and its conclusions are certainly open to question, on that
basis alone!


Frederick Rotgers, Psy.D.,ABPP, Associate Professor of Psychology
Department of Psychology
Philadelphia College of Osteopathic Medicine
4190 City Avenue
Philadelphia, PA 19131-1693
Phone: 215-871-6457
Fax: 215-871-6458

"Harm reduction is keeping them alive until the miracle happens" Sarz
Maxwell, MD, 5/7/06

To view the article with Web enhancements, go to:

This activity is supported by funding from WebMD.

Medscape Medical News
Brief Intervention Insufficient for Medical Inpatients With Unhealthy Alcohol Use CME

News Author: Laurie Barclay, MD
CME Author: Charles Vega, MD, FAAFP

Complete author affiliations and disclosures, and other CME information, are available at the end of this activity.

Release Date: February 12, 2007; Valid for credit through February 12, 2008
Credits Available
Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™ for physicians;
Family Physicians - up to 0.25 AAFP Prescribed credit(s) for physicians

All other healthcare professionals completing continuing education credit for this activity will be issued a certificate of participation.
Physicians should only claim credit commensurate with the extent of their participation in the activity.

February 12, 2007 — In a group of medical inpatients defined as risky alcohol drinkers, a 30-minute intervention was not effective, according to the results of a randomized controlled trial reported in the February 6 issue of the Annals of Internal Medicine.

"The efficacy of brief intervention in reducing alcohol consumption is well established for selected outpatients but not for medical inpatients," write Richard Saitz, MD, MPH, of the Boston Medical Center and Boston University in Boston, Massachusetts, and colleagues. "The unmet need for alcohol screening and intervention and opportunities for implementation underscore the importance of determining the efficacy of brief intervention in medical inpatients with unhealthy alcohol use. In addition, evaluating its effectiveness and practicality in real-world settings is critical to help clinicians make informed decisions when treating their patients."

On the medical service of an urban hospital, 341 medical inpatients who were drinking risky amounts of alcohol were randomized to receive a 30-minute session of motivational counseling given by trained counselors during hospitalization (n = 172) or to usual care (n = 169). Risky amounts of alcohol drinking were defined as more than 14 drinks per week or 5 or more drinks per occasion for men and more than 11 drinks per week or 4 or more drinks per occasion for women and persons 66 years or older. Of the 341 patients, 77% had alcohol dependence as defined by the Composite International Diagnostic Interview Alcohol Module.

Self-reported primary outcomes were receipt of assistance with alcohol misuse, such as specialty treatment of alcohol disorders, by 3 months in dependent drinkers and change in the mean number of drinks per day from enrollment to 12 months in all patients.

In alcohol-dependent patients, the intervention was not significantly associated with receipt of alcohol assistance by 3 months (adjusted proportions receiving assistance, 49% for the intervention group and 44% for the control group; intervention-control difference, 5%; 95% confidence interval [CI], -8% to 19%). Furthermore, the intervention was not significantly associated with drinks per day at 12 months among all patients (adjusted mean decreases, 1.5 for patients who received the intervention and 3.1 for patients who received usual care; adjusted mean group difference, -1.5; 95% CI, -3.7 to 0.6). Statistical models predicting drinks per day revealed no significant interaction between the intervention and alcohol dependence (P = .24).

Study limitations include baseline imbalances between randomized groups, 10% of patients lost to follow-up, lack of blinding of research associates and patients, primary outcomes were self-reported, change in screening criteria early in the study, and patients who received usual care were assessed and advised that they could discuss their drinking with their clinicians.

"The high prevalence of unhealthy alcohol use among medical inpatients has important implications for acute and long-term patient care," the authors conclude. "As a matter of policy, efforts focused on screening and brief intervention in hospitals should be directed elsewhere, possibly toward more intensive interventions, follow-up care, or on subgroups of patients who are more likely to benefit. Additional research must identify the most effective interventions to address unhealthy alcohol use, particularly dependence, among hospitalized patients."

The National Institute on Alcohol Abuse and Alcoholism and the National Center for Research supported this study. The authors have disclosed various financial relationships with Fusion Medical Education and/or the National Institute on Alcohol Abuse and Alcoholism.

In an accompanying editorial, Patrick G. O'Connor, MD, MPH, of the Yale University School of Medicine in New Haven, Connecticut, discusses current recommendations from the National Institute on Alcohol Abuse and Alcoholism for identifying patients with problem drinking and treating them individually according to their pattern of alcohol use.

"What should clinicians do when one of their inpatients is a problem drinker?" Dr. O'Connor writes. "The key principle is to link inpatient treatment in a continuous manner to ongoing outpatient treatment — either brief interventions for nondependent drinkers or more specialized treatment for patients with alcohol dependence. Medical hospitalization can be a hook with which to engage the problem drinker."

Dr. O'Connor has disclosed no relevant financial relationships.

Ann Intern Med. 2007;146:167-176, 223-225.

Tuesday, February 20, 2007

Re: How one woman got hooked on happy pills

To Al and the List:

Since I've prescribed a lot of SSRI antidepressants in my day, I should offer a few comments:

1. It's unfortunate that the article describes Kirsty's experience as being "hooked." Addiction is a dysfunctional pattern of behavior, not a physiologic dependence on a substance. One can have either without the other, or they can occur together. As Maia and I have both pointed out here, one can have severe, even life-threatening withdrawal from a variety of substances which are simply not addictive, such as some blood pressure medicines and most anti-convulsants. Try taking Tegretol for a pain syndrome for six months and then stop suddenly. Well, don't, the convulsion could be fatal. Similarly, don't suddenly stop your beta-blocker for blood pressure. You could have a fatal rise in blood pressure, causing stroke or heart attack.

2. Yes, a scattering of people will have awful withdrawal symptoms when coming off SSRI's. Paxil and Effexor seem to have the worst reputations, but I suspect any of them could.

My hunch about this is that the sufferers arise mostly among those overly-compliant patients who take their prescribed medications every single day, exactly as prescribed. I''ve never accomplished a task like this myself without herculean efforts, or without supervision. I suspect that most people who are prescribed such medications end up skipping a day or two per week, mostly by accident, and that the little "drug holidays" keep the severity of withdrawal symptoms to a minimum when they discontinue the medication. I've seen lots of cases where "non-compliance" or spotty compliance was the wisest thing a patient could do.

3. She describes clear bipolar (manic-depressive) symptoms while tapering her SSRI dose. It's quite possible she's truly bipolar. Though the textbooks (and George, too) say that anti-depressants will reliably swing a bipolar patient into mania (and they surely can), I've known of a few bipolar patients who seemed to be stable on an SSRI alone. These folks run into mood trouble when they stop the SSRI. Sounds like this woman.

4. My own limited experience with PTSD and anti-depressants is that these wonderful medications are not very helpful for this condition at all. It's not surprising this woman considers the downside of her experience to be greater than any benefit. I'm not aware of much progress in the realm of psychopharmacology for PTSD. I wonder if cannabinoids might prove useful; rarely does one want to impair memory function, but this may be what PTSD sufferers need most.

5. The whole subject of SSRI antidepressants and addiction shouldn't go by without pointing out that some research indicates benefit from SSRI's for treatment of alcoholism, even with no other psychiatric diagnosis. One handy study on this:

Fluvoxamine and alcoholism

Best wishes,

Steve Coulter, MD
SteveMDFP -at- gmail -dot- com

On 2/20/07, Al Turner MS CADC <> wrote:

How one woman got hooked on happy pills

[Published: Tuesday 13, February 2007 - 13:02]

Kirsty Morrison was on one of the London Tube trains hit by terrorist bombs on 7 July 2005. Tormented by flashbacks, she was prescribed antidepressants - and that's when her problems really began

On the morning of 7 July 2005, I stepped on to a Piccadilly Line Tube train and began my regular subterranean journey across London. Little did I know that this was to be the start of a journey that has not yet found its end. It was the Tube train on which a 19-year-old man decided to blow himself up, killing 26 innocent people and injuring hundreds of others.

I was one of the "lucky" ones. I was physically unscathed and walked away from that scene of devastation intact, or so I thought. The psychological injuries were buried deep within my brain and went unnoticed for weeks. Something in my mind had snapped during those 30 long minutes buried in a dark, smoke-filled carriage. The moment responsible for the lasting damage was a split second in which I had thought I might die. I contained the turmoil for two months, but finally it escaped, exploding and screaming in the middle of the night. The horrors emerged and took over my days. I sat at home trembling, unable to sleep, eat or work.

I started to see a psychiatrist who diagnosed me with post- traumatic stress disorder (PTSD). He explained the mechanisms inside my head that were causing the chaos. With comprehension came relief - I couldn't stop it, but I could, at least, understand.

Initially, I hoped it would pass within weeks. But for two months, I was unable to work. Then my shrink dropped the bombshell. "It will be at least a year until you get back to your old self; and even then, you might not be the same," he said. He suggested that perhaps I should try some antidepressants. "Your brain will sort itself out in the background and they will take away the pain," he said. I contemplated for a week, then succumbed to the temptation of a quick-fix solution. The pressure was on to get back to work and I was desperate to retrieve a semblance of normality. His professional opinion was swallowed without question along with a daily dose of 20mg of Citalopram, one of a group of drugs called selective serotonin reuptake inhibitors (SSRIs), which includes Prozac and Seroxat.

Naively, I was hoping to be bouncing off the walls within weeks. Instead, I was plunged into life-questioning darkness. Later, I read that this can be common during the first weeks of taking SSRIs; some people even try to kill themselves. I mentioned it to my shrink. He thought it was unrelated.

One year on and an anniversary later, I felt in control of my life and ready to ditch the drugs. The side effects had been minimal, but I wouldn't feel that I had won this fight until I was doing it unaided. "Take it slowly," everyone said, "you can't just suddenly stop." Over three long months, I cut down by five milligrams at a time. Each reduction was followed by an identical cycle. Two weeks of nothing, then an exponential week of spiralling mania. I was then plummeted into two familiar weeks of self-loathing and misery. My own little manic-depressive cycle, condensed into less than a month.

Initially, I thought that the PTSD was back, but my GP was reassuring. "It could be a recurrence, but it is more likely to be the side effects of reducing the medication," he said. The only advice that he had to offer was to increase the dose if it all became too much. But the decision had been made - I was on this road to stay, and a diversion into the sunshine was never an option. So, sticking to the lowered dose, I battened down the hatches and waited for the storm to pass. Eventually, the clouds lifted and stability returned to my battered brain. Three five-milligram reductions later, I was shattered but undeterred. The time had come to hit zero.

I took my last pill and waited with trepidation. I had no idea of what was to come - no one had ever warned me. Two weeks went by and I nervously wondered whether I had already been through the worst. Quietly, though, the heavy head returned and I sensed the drug-fuelled apathy. There was going to be a final hurdle after all.

On the Monday, I began to feel weary and cold, and the chill found its way to my bones. I couldn't concentrate or keep still; I was shivering to my core. The week continued with lethargy and exhaustion and my appetite started to fade. On Wednesday night, I woke suddenly, startled by a shudder. It was freezing and dark and my body was convulsed with fitful shakes. I hauled myself out of bed and piled on the layers - jumpers, socks and even a hat. I turned the heating up high and flung a blanket over my bed, all to no avail. This was the cold turkey of heroin addicts; it felt like a scene from a movie. Eventually, it subsided, but it was quickly replaced with biting nausea. I forced myself from my nest, staggered to the bathroom and was violently sick.

I warmed up slowly over the next few days, but the nausea and fatigue remained. I was snappy and irritable. My head thumped with relentless pain. When I moved, it took me a moment to catch up. I forced myself to eat, although I had no urge, but usually it passed through me without touching the sides.

There was small comfort. They were clearly not caused by PTSD. It was not a recurrence - it was my body in shock, trying to cope without the presence of the drugs.

My curiosity got the better of me and I wanted to know whether others had been through the same. If so, how many, and why had I not been warned? When I examined the information leaflet, I found it listed reams of possible side effects when taking the drugs , but only a scant few lines warning of "mild" withdrawal symptoms such as headaches, dizziness and nausea. There was no detailed guidance, either, on how to come off them.

The potential side effects caused by coming off Seroxat are well documented. In a Panorama programme in 2000, Dr David Healy, an expert on Seroxat, said: "If they [SSRIs] aren't the right drug for you, they can cause problems. They can make you suicidal, or throw you into a state of mental turmoil. And even if they are the right drugs for you, in some cases they can leave you hooked." The makers of Seroxat, GlaxoSmithKline, deny that the drug is addictive, but their patient leaflet does contain a detailed warning about possible withdrawal symptoms.

Professor David Taylor is head of pharmacy at the Maudsley Hospital and runs a national medication helpline. From statistics gathered over the past 10 years, he has become convinced that all antidepressants cause some level of withdrawal. A controlled study in 2000, by Dr David Michelson of Lilly Research Laboratories, showed that the incidence of SSRI discontinuation syndrome ranged from between 35 per cent and 86 per cent. Taylor admits that it is difficult to get accurate figures since many cases go unreported, but he believes it is more than 50 per cent for some drugs.

He said that one of the key reasons for this lack of information is that, in order to be granted a licence, manufacturers are only obliged to study any side effects that occur while taking the medication. Hence, nine out of 10 clinical trials do not look at the effects of stopping the medication, despite the fact that they can be far more distressing for patients than the ones that they warn about.

When I contacted Professor Taylor's helpline, they reassured me that my symptoms were "completely normal" when coming off SSRIs. They said that doctors could be wary of talking about withdrawal in case it put people off taking medication that could help them.

Professor Taylor says there is truth in this, but he thinks that there is also a lack of awareness. He believes that "patients should be allowed to weigh up the benefits for themselves". He stresses that withdrawal "can be extremely unpleasant, especially when people are exposed without any prior warning". He thinks that the lack of information is because of pharmaceutical firms' incompetence rather than an effort to hide the facts. When SSRIs were launched, he told me, there was no research into withdrawal. When problems were identified, he says, "we just didn't shout loud enough".

Three weeks on and I hope that I am through the worst of it. But the exhaustion continues and I am still can't hold down much food.I can't say whether I would have taken Citalopram had I been told of the risks. Neither do I know whether it helped me in my recovery from PTSD. What I do know is that I would rather have been made aware of all the risks before I decided to put those pills into my mouth.

Sunday, February 18, 2007

McCardell Proposes a New Legal Drinking Age

The Middlebury Campus
Sonja Pedersen-Green
Original URL:
Issue date: 2/14/07
Media Credit: Dina M. Magaril

Since stepping down from the presidency to resume teaching, McCardell has become a vocal opponent of current minimum drinking age laws. Now he plans to take his criticisms even further.

President Emeritus John M. McCardell, Jr. is preparing to launch a national campaign for legislation that would effectively lower state minimum drinking age laws to 18 for young adults who passed alcohol education courses. To support the campaign, McCardell and his student research team plan to work under the umbrella of a newly-incorporated not-for-profit organization named Choose Responsibility.

The campaign and the new organization come after more than a year of research by McCardell's team, which granted The Campus an interview and preview of their findings just before the Feb break.

"We don't want to be a bunch of people beating our spoons on a highchair saying we want beer," said McCardell, who stressed the "commonsense" logic of his group's proposal.

Rather than simply lowering the national legal drinking age from 21 to 18, Choose Responsibility advocates that states launch alcohol education programs to teach young adults about responsible purchase, possession and consumption. Upon successful completion of an alcohol safety course, a participant could receive a new license granting them full adult privileges to use alcohol at age 18, according to a draft copy of Choose Responsibility's proposal.

The license would be legal in the state in which the 18-year-old is a resident, and in the state in which he or she attends college, if they attend out of state. Individuals who drank illegally before turning 21 or before receiving the 18 year-old license, would delay or jeopardize their eligibility for the privilege.

Grace Kronenberg '06, one of Choose Responsibility's student researchers, equated the program to that of driver's education.

"Learning to drive a vehicle and learning to drink responsibly are remarkably similar processes," said Kronenberg.

Supporters of existing drinking age laws had yet to see Choose Responsibility's proposal, but were skeptical of any campaign to lower the current minimum age.

"We do not think that lowering the drinking age is a good idea," said Barbara Cimaglio, Vermont Deputy Commissioner for Alcohol and Drug Abuse, about the state of Vermont.

Cimaglio said that because the brain develops into the twenties, the possibility for developmental problems arises when alcohol is consumed at a young age.

The Commissioner also cited a Vermont survey on youth and drinking from which she worried that "lowering the drinking age opens up the possibility for more binge drinking."

In a draft summary of Choose Responsibility's research that was released to The Campus, McCardell's researchers outlined a number of reasons they had found current laws ineffective: from an argument that widespread violation of the drinking age breeds disrespect for other laws, to the inconclusive link between the drinking age and drunk driving fatalities.

Citing a National Highway Transit Safety Authority (NHTSA) study, Student Research Assistant Amanda Goodwin '07 said that Choose Responsibility found "there was no demonstrable cause and effect relationship between the 21 year-old drinking age and the decline in alcohol-related traffic fatalities, but rather, that the decrease in drunken driving fatalities could be attributed to a composite of other factors."

"More important contributing factors include safer motor vehicles, more vigorous law enforcement, shifts in societal trends and fluctuations in the population of relevant age cohorts," said Goodwin.

The decline in traffic fatalities following the lowering of the drinking age is one of the main reasons opponents give for maintaining the current drinking age.

Goodwin said that according to NHTA data, "More lives have been saved in the last two years from seat belts and airbags than in the entire history of the 21-year-old drinking age."

The major challenge Choose Responsibility cites for the importance of its research is the prevalence of binge drinking from college campuses to high schools.

"It's more important how one consumes alcohol than the age at which one consumes alcohol," said Scott Guenther '06.5, another student researcher.

In the draft summary of its report, Choose Responsibility cites statistics that show the mean age of alcohol initiation for young adults has dropped to 14 years of age since the legal age of 21 was implemented. And according to the data, only two of 1,000 underage drinkers are caught violating the law.

McCardell's research team hopes that a well-designed curriculum could teach 18-year-olds who chose to drink, to do so responsibly. An important component of that education, they argue, is the parent.

"The 21-year-old drinking age marginalizes the role of parents in drinking," said Kronenberg. "If the drinking age were 18, then parents would able to play a larger role in teaching 18-year-olds how to drink responsibly."

McCardell's research began with a 2004 New York Times op-ed in which he criticized the United States' 21-year-old minimum drinking age. Following the publication of the op-ed, McCardell and Middlebury College received a grant from the Robertson Foundation.

Since receiving their first grant, the researchers have used College facilities and resources to carry out their work. The group finished a "white paper" this summer and delivered the project to the Robertson Foundation last fall, after which it was given additional grant money to produce more research.

Now working as Choose Responsibility, McCardell's team plans to move out of College facilities and hire more employees to continue its work. McCardell explained that the group's decision to leave the College was made because his team "felt that this is not something the College should take a position on at this time."

The first mission of the non-profit, beyond continued research, will be to test public opinion on the possibility of lowering the legal drinking age to 18 and to raise funds to campaign for supporting legislation. Along with their research, the organization will undertake a fundraising component as well. McCardell said he plans to "broaden their acquaintances" to gauge public reaction and collect feedback.

McCardell suggested the principal opponent to their research could be Mothers Against Drunk Driving (MADD), whose Web page McCardell he said was "more about the evils of drinking than about the evils of drinking and driving." But he also stressed that his organization does not advocate drunk driving, and that proposals for teaching responsible choices should not be at odds with groups like MADD.

Requests for comment from several MADD offices were not returned.

To see their proposal realized in law, Choose Responsibility envisions a grassroots movement. Choose Responsibility has planned a two-step approach for releasing their study and beginning their campaign. The group plans to launch a Web site in mid-March, which it hopes will become the "go-to place" for people wanting to learn about the legal drinking age. Choose Responsibility will then release its full research and report on the current drinking age in the fall.

"There is very little the states can do without changes in Congress," said McCardell, who recognized that there is no state would change its drinking age until the federal government no longer denies highway funding to states that set legal drinking ages lower than 21 years of age. If Vermont were to change its legal drinking age to 18, the state could stand to lose $17 million a year in highway funds.

McCardell has already engaged some policymakers and professors to understand their perspectives on current drinking age laws, and said that those he spoke with reacted positively to his data and seemed welcome to change.

"It's time," Kronenberg, "for a change in the drinking culture of young adults today."

[To submit letters to the editor, comments or questions about this article, please e-mail]

Thursday, February 15, 2007

From: Mike Ashton <>
Date: Feb 15, 2007 5:48 AM

There was reference recently to Australian research on
naltrexone. Don't know if this (see below) is what was being
referred to but I have to say I found it shocking. If you
tell a patient that they face a near 1 in 10 chance of
dieing within 3 months of starting this treatment, how many
would take it up? This is real-world data as opposed to from
experimental research so we don't know what preparation and
support these patients had. One of the worries with implant
and depot naltrexone, especially in legally coerced
patients, is that these preparations enforce (not entirely
but pretty well) abstinence without the the patient and
those around them having to make the life changes and have
the motivation which would otherwise be needed. Hopefully
those changes will be made anyhow so the person comes out
the end with a viable and attractive alternative drug-free
life, but short-changed programmes may not make that kind of
investment. Similarly with respect to inpatient
detoxification - by 'artificially' enabling people to
complete withdrawal (and loss of tolerance) who would
otherwise not have not been able to do so, does it leave
them more vulnerable when they go back outside? (Strang J.
et al. "Loss of tolerance and overdose mortality after
inpatient opiate detoxification: follow up study." British
Medical Journal: 2003; 326: p. 959-960.). And similarly too
with rapid detox under anaestheia or deep sedation - yes
more patients complete and start on naltrexone than after
conventional detoxes, but more then relapse leaving no
long-term benefit (Krabbe P.F.M. et al. "Rapid
detoxification from opioid dependence under general
anaesthesia versus standard methadone tapering: abstinence
rates and withdrawal distress experiences." Addiction
Biology: 2003, 8(3), p. 351-358. McGregor C. et al."A
comparison of antagonist-precipitated withdrawal under
anesthesia to standard inpatient withdrawal as a precursor
to maintenance naltrexone treatment in heroin users:
outcomes at 6 and 12 months." Drug and Alcohol Dependence:
2002, 68, p. 5-14. Collins E.D. et al. "Randomized
comparison of buprenorphine, clonidine and
anesthesia-assisted heroin detoxification and naltrexone
induction." Drug and Alcohol Dependence: 2002, 66, S2-S202,
p. S35.)

None of this of course is to argue against these
'technologies' - in our magazine we have consistently
reported on developments in rapid detox and implant and
depot preparations despite the sceptics, and they certainly
have potential if used to create a space during which lives
can be turned around. But some caution is needed - take away
someone's tolerance without the props necessary to sustain
abstinence and you might put them at greater risk than if
you had done nothing.


In Australia patients trying to avoid relapse by taking the
opiate-blocking drug naltrexone had at least a 1 in a 100
chance of dieing within about three months, usually from
opiate overdose in the weeks following the end of treatment.
The true figure may be as high as 8 in a 100, many times the
risk of death related to substitute prescribing. In contrast
to methadone, naltrexone blocks the effects of opiates,
reducing tolerance levels to practically zero and leaving
patients vulnerable to overdose if they stop taking the
medication. Together with very poor retention in treatment
and the high rate of post-treatment relapse, it mean the
attempt to promote abstinence by prescribing opiate blockers
is potentially extremely risky.

The study behind these figures found that in the years 2000
to 2003, per 1000 episodes of treatment with the three
drugs, there were 10 deaths related to oral naltrexone,
virtually none to buprenorphine, and just under three to
methadone.1 All but five of the naltrexone deaths occurred
in the two weeks following the end of treatment. In the same
period there was just one death after methadone treatment.
Instead, the high risk period was the first week of
treatment. Nevertheless, over an equivalent time, the death
rate in the high risk period for naltrexone (post-treatment)
was over seven times higher than during the high risk period
for methadone (induction). Naltrexone implants were not
included in the calculations and have not yet been
associated with an elevated death rate.

For several reasons, the disparity between the death rate
per episode of oral naltrexone treatment compared to
substitute prescribing is likely to have been even greater.
Most important is that since deaths typically occur after
naltrexone has been cleared from the system, a possible
relationship with prior treatment is often omitted from
official records. In one Australian state, the death rate
related to naltrexone treatment was over seven times higher
than the study was able to identify. If this was the case
nationally, 8% of patients starting naltrexone treatment
would die within three months.

1 Gibson A. et al. Mortality related to naltrexone in the
treatment of opioid dependence: a comparative analysis.
NDARC Technical Report 229. [Australian] National Drug and
Alcohol Research Centre, 2005. Summary at , full report from NDARC,
University of New South Wales, Sydney NSW 2052, Australia.

Mike Ashton

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