[8/4/2006 11:29:36 AM] [Entrance] [MODERATOR: "Welcome to the “Silent Treatment: Addiction in America” web chat, where we’ll discuss addiction issues featured in the “Silent Treatment” newspaper series and and www.silenttreatment.info. It’s my pleasure to introduce Dr. Tom McLellan, who appeared as a subject in the second in a series of stories examining addiction treatment and recovery funded by the Robert Wood Johnson Foundation and now appearing in newspapers nationwide. Tom, a foremost expert on addiction treatment, is working on applying medical research in practical ways to help those in need. He’s here to help answer questions on the latest advancements in treatment, so fire away by entering your message in box at bottom."

[8/4/2006 11:31:20 AM] [Entrance] [MODERATOR: "This question came in yesterday from Rachael: Hi Tom: My question primarily has to do with educating myself about methamphetamine addiction in the U.S., for the purposes of understanding the lives of the growing numbers of meth users who, either by choice or by state mandate, are relinquishing their children to social services/foster care. Do you agree with the Drug Enforcement Agency's recent categorization of methamphetamine addiction as a national epidemic? Why or why not? "

[8/4/2006 11:31:52 AM] [Entrance] [Alexandre laudet: "I am really attending this to see what questions other people are going to ask to inform my work as to what is relevant to the field among clinicians and other stakeholders."

[8/4/2006 11:32:10 AM] [Entrance] [sherri Roff: "Hi Dr. McLellan, thank you for responding to my email on suboxene showing up on drug screen for women involved with CPS"

[8/4/2006 11:32:34 AM] [Entrance] [MODERATOR: "YES I DO AGREE THAT IT IS AN EPIDEMIC. IN OFFICIAL TERMS AN EPIDEMIC PERTAINS TO THE PREVALENCE OF A DISEASE OR A HEALTH RELATED CONDITION WHEN THERE IS AN INCREASE OF OVER 10% AND THAT INCREASE IS NOT CONFINED TO A SPECIFIC GEOGRAPHIC OR DEMOGRAPHIC GROUP. IN THIS SENSE METH QUALIFIES. THE MAGNIFYING EFFECTS OF THIS ARE THE FACT THAT FOR MANY OF THE MIDWESTERN STATES NOW FEELING THE EFFECTS OF IT – THEY HAVE NEVER HAD THE KIND OF URBAN, INNER-CITY EPIDEMICS THAT EASTERN AND WESTERN STATES HAVE HAD. I THINK IT MAKES IT MORE SCARY. SECOND – WHILE METH IS NOT QUALITATIVELY WORSE AS A DRUG OR A DRUG PROBLEM THAN ALCOHOL, HEROIN, OXYCONTIN AND MANY OTHERS – IT IS BAD – MAKE NO MISTAKE. UNLIKE HEROIN METHAMPHETAMINE USE OVER LONG PERIODS OF TIME IS ASSOCIATED WITH SIGNIFICANT DETERIORATION IN MENTAL AND ALL TYPES OF PHYSICAL FUNCTION – IT PRODUCES PROBLEMS AND THOSE PROBLEMS CAN BE VERY LONG TERM.

[8/4/2006 11:33:27 AM] Tom McLellan: "Hi Sherri - hope it was helpful"

[8/4/2006 11:34:18 AM] sherri Roff : "I found out some other information from a drug lab and was told that it depends on the panel used by the drug court, some panels will not detect & others will"

[8/4/2006 11:35:43 AM] Tom McLellan: "That is interesting to me - I would think that any analysis for opioids would be positive - just a question of which opioid would come up. If Bup is not detectable on some analyses that is actually a problem"

[8/4/2006 11:34:27 AM] Tom McLellan: "Hi Alexandre - good idea to do this, will help make all our work more relevant"

[8/4/2006 11:34:51 AM] Alexandre laudet: "Could we have a bit of a discussion as to what place people see treatment has in the recovery process or this this way off topic?"

[8/4/2006 11:38:32 AM] MODERATOR: "From Rachael: Science has demonstrated that the neuroscience of methamphetamine usage differs greatly from that of other drugs such as cocaine, heroine and marijuana. Meth produces a longer and stronger high, and dismantles dopamine receptors, resulting in severe depression and an inability for users to experience pleasure. It is thought that this deep chemical depression cements the user's addiction in a way that other drugs may not. It also makes recovery a longer and more difficult process. Could you comment on the possible ways that the specific neuroscience of methamphetamines may be altering current generational addiction patterns, and how it might end up producing unique and specific generational addiction patterns in the future? Thanks. "

[8/4/2006 11:39:59 AM] MODERATOR: "FROM TOM: I’LL ANSWER THIS IN TWO PARTS: WHILE FUNDAMENTALLY YOUR INFORMATION AND YOUR INFERENCES ARE CORRECT BASED ON CURRENT STATE OF KNOWLEDGE, I THINK IT IS PREMATURE TO THINK OF GENERATIONAL PROBLEMS OR EVEN THAT THIS VERY SERIOUS PROBLEM IS SOMEHOW UNLIKE ALL OTHERS. REMEMBER FOR EXAMPLE THE HORROR STORIES THAT ATTENDED THE VERY SERIOUS PROBLEMS WITH “CRACK BABIES” AND HOW THEY WERE ALMOST CERTAIN TO GROW UP IN A VERY IMPAIRED WAY – THIS HAS NOT BEEN THE CASE AT ALL. SIMILARLY – IT WAS SAID – BASED ON PRETTY SOUND INFORMATION AT THE TIME – THAT USERS OF LSD WOULD ALMOST CERTAINLY HAVE AFFECTED GENETIC TRANSMISSION OF THEIR TRAITS – AGAIN, SEEMINGLY NOT SO. SO – JUST SOME CAUTION. NOW THERE ARE REASONS FOR REAL CONCERN. SINCE ROUTE OF TRANSMISSION IS OFTEN (AT LEAST AFTER SOME TIME) INJECTION – YOU HAVE ALL THE INFECTIOUS DISEASE PROBLEMS THAT ARE COMMON TO OTHER DRUGS OF INJECTION. SECOND – SINCE SEX (USUALLY UNPROTECTED AND OFTEN WITH MULTIPLE PARTNERS) IS A FREQUENT PART OF THE DRUG USE SCENE – ADDITIONAL MECHANISMS FOR TRANSMISSION OF DISEASE AND TO A SET OF INDIVIDUALS THAT ARE OUTSIDE THE INJECTION POPULATION – MAKING IT MORE OF A THREAT TO THE REST OF SOCIETY"

[8/4/2006 11:40:03 AM] Tom McLellan"Alexandre - As you know better than almost any other researcher, this is a very big question. While the definition of recovery is still being debated it is certainly more than simply the reduction of primary symptoms - such as opioid use. Recovery goes well beyond that to enable affected individuals to lead productive and happy lives. It is an open question how much society wants to invest in simply reducing the symptoms of a disease - any disease - or whether they want to go beyond that to invest in the kind of pro-health lifestyle that should prevent re-occurrence of illness. This is particularly true in the case of addictions but also in many other areas of healthcare. I hope that is at least the start of an answer"

[8/4/2006 11:40:58 AM] [Entrance] [Leigh: "Dr. McLellan - thanks for agreeing to chat. As a research and scientist, how confident are you overall in the data on addiction as a national or even global problem? To what extent has the lack of reliable data hindered research and what can be done to address that? Thanks "

[8/4/2006 11:42:05 AM] MODERATOR: "FROM TOM: PART II, for RACHEL: THERE ARE ALSO – AS YOU POINT OUT – VERY SERIOUS AND POSSIBLY (NOT CERTAINLY) UNIQUE ASPECTS TO METHAMPHETAMINE USE BECAUSE OF THE POWERFUL MANNER IN WHICH IS AFFECTS THE DOPAMINE REWARD SYSTEM. WHILE OTHER DRUGS OVERCOME THE DOPAMINE SYSTEM AND LEAD TO DOWN REGULATION OF THE NATURAL NUMBER OF RECEPTORS (WHEN NEW SOURCES OF DOPAMINE COME INTO THE BRAIN THE BRAIN SHUTS DOWN THE CREATION OF NEW RECEPTORS IN RESPONSE) – AMPHETAMINE ACTUALLY DESTROYS DOPAMINE TERMINALS –SEEMINGLY BURNS THEM OUT LEAVING EVEN WORSE DEPLETIONS. ALL OF THIS IS DOSE AND TIME DEPENDENT OF COURSE. THERE ARE SOME PRETTY CLEAR IMPLICATIONS FROM THIS TYPE OF PATHOLOGY – SCHIZOPHRENIA BEING ONE OF THEM. ANIMAL AND HUMAN STUDIES HAVE ALL SHOWN THE PRODUCTION OF SCHEZOPHRENIC SYMPTOMS IN THE SHORT TERM THROUGH HIGH DOSES OF METHAMPHETAMINE – AND THERE ARE A NUMBER OF REPORTS OF EMERGENCE OF SCHIZOPHRENIC SYMPTOMS AMONG HEAVY USERS – AND WORSE, THAT THOSE SYMPTOMS DO NOT REMIT FOR LONG PERIODS OF TIME FOLLOWING CESSATION (AT LEAST ONE YEAR). IN SUMMARY – METHAMPHETAMINE DOES HAVE SOME UNIQUE CHARACTERISTICS THAT MAKE IT PARTICULARLY DANGEROUS – BUT IT SHARES MANY CHARACTERISTICS WITH OTHER DRUGS OF ABUSE THAT MAKE IT AMENABLE TO THE SAME KINDS OF INDIVIDUAL AND PUBLIC HEALTH AND SAFETY RESPONSE THAT HAVE BEEN EFFECTIVE WITH OTHER DRUG EPIDEMICS."

[8/4/2006 11:44:26 AM] Tom McLellan: "Leigh - There is no doubt that the addiction field suffers from lack of accurate, timely epidemiological data on drug use types and frequencies. Now most epidemic reports come from newspaper accounts. Moreover, some drugs (e.g. club drugs) are quite prevalent in certain groups but not widely beyond those groups. That said - it is tough to hide drug abuse and while there may be (likely are) many more individuals affected than we know (Type 1 error) I am confident that those we do see are really suffering from the problems. In other words - low Type 2 error rates. The real question is how do we get better, faster data so that policies can be put into play to avert some of these problems."

[8/4/2006 11:45:07 AM] Tom McLellan: "Hi Mike - thanks for joining"

[8/4/2006 11:46:15 AM] [Entrance] Mike Boyle: "Hi Tom, I'll just listen a bit and get caught up"

[8/4/2006 11:46:59 AM] [MODERATOR: "Tom, there's a lot of research into heredity and genetics as basis of addiction -- why is it still considered sketchy science to some people?"

[8/4/2006 11:47:34 AM] Leigh: "Thanks. A quick follow up. Drug companies have been very aggressive the past five or 10 years in marketing directly to consumers (lipitor, nexium, ambien, lunesta). Do you think at some point the drug companies will pursue a similar approach for anti-addiction drugs and how could this kind of mass marketing program affect treatment overall?"

[8/4/2006 11:48:15 AM] Alexandre laudet: "Could this be because there is still a large porportion of the general public who viewed addiction as a moral weakness or a bad choice? we speak of 'hard core' users for addict, no one speaks of hard core hypertensive or diabetics."

[8/4/2006 11:50:35 AM] Mike Boyle: "It's not just the general public but a lot of folks in the addiction treatment field. We say it is a "disease" and then punsih those who come for us for help. For example, we discharge people for confirming their diagnosis."

[8/4/2006 11:51:35 AM] Alexandre laudet: "and as researchers we basically adopt the same paradigm (the pathology-based one)"

[8/4/2006 11:51:40 AM] MODERATOR: "In the Silent Treatment series, that the biggest surprise to reporters -- that people still don't see addiction as disease, and you do wonder what has to happen for that to become the norm. "

[8/4/2006 11:52:30 AM] Tom McLellan: "Alexandre and Mike, This is a good question and I think you are right that people diminish the import of this information. I think it is because the manifestations of addiction - the ones that are so clear to the public - do not look like any of the traditional manifestations of other genetic traits such as blue eyes or being left handed. But the science is quite clear not only on the amount of heritability for most addictions (~50% for alcohol and heroin; ~40% for cigarettes,cocaine) but also the mechanisms by which that heredity occurs. In the case of alcohol for example - what is actually being inherited is 1) enhanced tolerance - the ability to drink much more alcohol than most people - without getting intoxicated - over 70% of tolerance is inherited, not learned; and 2) alcohol metablolism - some people (slow metabolizers - have normal "next day" responses to heavy alcohol use - but fast metabolizers (Asians particularly) have very profound and almost immediate negative effects from drinking alcohol - an almost immediate hangover) Not surprisingly there are far fewer cases of alcoholism among Asians. The fact of heritability does not eliminate personal responsibility - it just informs it."

[8/4/2006 11:53:54 AM] Alexandre laudet: "perhaps we can use mental health as a model field, I am not sure how they did it because I have not been in the US that long but they have done a really good job as working on destigmatization and as a result I believe more suffering people have sought help, the first thing for treatment to be helpful is people have to go...there is such stigma in the addictions and Mike is right, it is very pervasive, a big part of guilt and shame among substance users as well, may contribute to not seeking help (not acknowledging the issue, what SAMHSA called "the growing denial gap")"

[8/4/2006 11:55:39 AM] Rachael: "Hi Tom, Thank you for your responses to my questions regarding methamphetamines and their usage. I especially appreciate your defining the term "epidemic" for me. I also think that it is interesting to look at the larger phenomenon of "hyping epidemics" in this country at the same time that we manage to ignore or deprioritize addiction treatment and rehabilitation. Which is related to the most current comments by Alexandre, Mike and yourself. Who "hypes" drug addiction and why? Who simultaneously ignores it, and why? They hype and the silence equally benefit some folks."
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[8/4/2006 11:56:45 AM] Tom McLellan: "The issue of addiction as a disease is still pretty unsettled in the minds of most of the public and I believe it is because in most of the rest of medicine - having a disease (and oh yeah having a genetically transmitted disease) means the individual is in some way "not at fault" for their disease. The public simply doesn't buy this in the case of alcohol and other drugs. Neither do I for that matter. But I also don't buy it for most diseases - hypertension, diabetes, asthma - almost all adult onset cases are due to lifestyle problems not just genetics or environment. But the idea that a condition is a disease also suggests that medicine and healthcare should be able to fix it - that you wouldn't go to a Priest or Rabbi if you have a disease. Again - the public has seen the moral emptiness and the antisocial problems associated with addiction and assumes that there are deep moral deficiencies at work"

[8/4/2006 11:58:59 AM] Tom McLellan: "Rachael - not sure what to say there - I think it's a "Gotcha." There are people who appear to revel in the continuing emergence of drug problems - hopefully there are not many. My guess - and it is only a guess - is that some of the hype comes from those who are in the middle of drug related problems - when your world is affected in that way it is hard to see that you may not be in the majority. Again - this is just a guess"

[8/4/2006 12:01:35 PM] Alexandre laudet:  "The issue with this is especially central in light of the survey that came out last week I think whereby a lot of the public feels that folks whose behavior contributes to a disease should pay more in health insurance... as a tax payer and a health insurance customoer it may be attractive but it also runs the risk of contributing to elected officials who are not that likely to push for treatment funding, we are in a climate where supply reduction gets more $ than does demand reduction (which includes treatment)"

[8/4/2006 12:03:38 PM] MODERATOR: "Just want to mention here the group FAVOR -- Faces and Voices of Recovery --an advocacy group that publicly and actively pushes for anti-discrimination for addiction. They are worth looking into."

[8/4/2006 12:04:21 PM] Alexandre laudet: "http://www.facesandvoicesofrecovery.org/main/index.php"

[8/4/2006 12:04:44 PM] MODERATOR: "thanks!"

[8/4/2006 12:05:42 PM] Mike Boyle: "FAVOR site also has a contact list of all mutual aid groups for addictions and mental health."

[8/4/2006 12:05:54 PM] Tom McLellan: "Leigh - good question about the drug companies. Yes I do think there will be mass marketing. In general I think it is a sign that medicine (not just addiction medicine) has reached the point where it is an understandable commodity to those who are direct consumers. Thanks to the internet, the healthcare reporting and things like this - patients are now true consumers - for patients who have rare diseases, they often know more than their doctors about their symptoms and the latest research - again thanks to the internet. What this means is that sooner or later a physician will become an adviser - much like a financial advisor. Sure - some people do not want to learn about finances and turn decisions over to their broker - BUT - if they lose their money the broker is not responsible - the consumer is. I see this coming in medicine. Second point - I think it is a very good idea to advertise EFFECTIVE, FDA-ApPRoved medications directly to consumers in our field. Here's why - only a tiny fraction of affected people now go for help - part of the reason is that they don't like the options they are offered. Another part of the reason is that they can't go to a normal health care facility - they have to go to a specialty care programs that says Drug TREATMNT on it. I think that more options will bring more people into treatment and more physicians into direct care"

[8/4/2006 12:07:18 PM] Tom McLellan: "Alexandre - good point - lots of "unintended consequences" that could emerge"

[8/4/2006 12:09:30 PM] Rachael: "Alexandre, thanks for your comments. Tom, who in the field might disagree with your opinions on marketing drugs directly to consumers, and why? Docs perhaps?"

[8/4/2006 12:11:32 PM]Tom McLellan: "Moderator - There has been a lot of work trying to figure out whether the manifestations of a condition resemble those of other diseases - this is how we have come to think something is or is not a disease. I think the real question is which area of society or commerce will take responsibility for correcting the problem. For example, if the real estate industry says that addiction is fundamentally a problem of homelessness and they can provide shelter and help to the point that addiction is reduced - i am going to conclude addiction is a real estate problem. Criminal justice basically has been asked to do this and for a long while it has been labeled as a CJS problem - only every cop and judge will tell you they can't solve it. Now it is medicine's turn - if we can come up with medications, interventions and services that reduce or eliminate the problem then everyone will see addiciton as a medical problem"

[8/4/2006 12:13:50 PM] Alexandre laudet: Tom - OK that is a good point. the question is that as I see it one charatceristic of this disease as opposed to some other chronic conditions is the denial issue, how do we get people to take the effective FDA approved medication? do you believe that some of the folks who need but do not seek treatment for the reasons you mentioned (it is not attractive to them) would go for the pills?"

[8/4/2006 12:14:35 PM] Tom McLellan: "Rachael - I think the FDA and particularly the insurance companies will disagree - FDA correctly, doesn't want patients asking for meds that may be inappropriate - this is a worry as for example antibiotics for flu. Insurance companies are more sinister - as in the case of every drug there has ever been, more and easier availability (e.g. marketing) will make for more demand and use - thus expenditures - sorry to be cynical"

[8/4/2006 12:14:45 PM] MODERATOR: "Just to pick up on Mike's observation about people in the field, how much of the problem is that?"

[8/4/2006 12:15:06 PM] Leigh: Not to sound cynical but you left out profit motive. Do you know if the big drug companies are pursuing anti addiction medication with same aggressiveness as other areas? Perhaps drug company executives need convincing as well...maybe they believe addiction is primarily a behavioral driven disability. "

[8/4/2006 12:15:43 PM] Rachael: "Not cynical, folks. Skeptical. Healthy skepticism.:-)"

[8/4/2006 12:18:22 PM] Tom McLellan: "Moderator - I am sorry to say that I think our field has become too close minded about other options. Of course we are wise to be cautious about recommending new "cures" and new theories about addiction. But the simple fact is that the great majority of people affected (and their families) are not in any kind of care. When asked about why - most patients do not want the product - even if it is good for them. Now I have thought about this as some form of denial and in fact it may be. But if you look at the industry as a whole - we have very few product lines, very few ways for people to get a service that might benefit them. In that climate, I am much more likely to be open to a new option - such as a medication, or a new type of intervention or a new type of technological effort. The old ways are not always the best ways"

[8/4/2006 12:18:54 PM] Alexandre laudet: "there was a recent survey by peter heart where they ask general public and physicians perceived causes of addiction, 9% of physicians endoresed moral weakness and another 34% endorsed moraal weakness and disease "both equally" that's a lot of docs!"

[8/4/2006 12:20:25 PM] MODERATOR: "which i guess would beg the question of what kind of training is being worked on to help educate the docs about addiction? Is there a model or pilot project for that?"

[8/4/2006 12:22:34 PM] Tom McLellan: "Leigh - I am going to sound like a shill for drug companies (I do consult for Alkermes by the way) but taking the case of depression - it is a fact that over three times the number of people are in treatment for depression following the release of Prozac and related drugs - than before. Is it the drug - not quite - it is the delivery system - over 70% of all depression episodes are now diagnosed by primary care physicians in their offices - because 1) the drugs are safer - you don't have to be an expert to manage them and 2) direct marketing - patients are asking for them. Also - there are more referrals to specialty care now (psychiatrists) than ever before - when first line treatments do not work the docs send patients for specialty care. In our field less than 4% of all referrals to specialty care come from any member of a medical establishment. So I guess the profit motive happens in our field too."

[8/4/2006 12:23:49 PM] Rachael: "So, it's a vicious cycle. There are many manifestations of stigmatization of addiction that prevent/deter folks from seeking or accepting treatment long term. Stigmatization happens at the institutional level (media; government; corporations. PRISONS), at the level of the docs and hospitals, and thus, within the addict's life and mind. I am also interested to learn more about any growing or large-scale movements to rethink addiction as a different sort of problem or issue besides a medical "disorder" or "disease." Does the FAVOR group endorse destigmatization and reframing of addiction issues, for example?"

[8/4/2006 12:24:54 PM] Alexandre laudet: "Also, with the lowering of stigma for depression, people on prozac are more likely to tell others about being on it, its effectiveness and I think that reinforces the effectiveness idea for the public, that it's not just ads in magazines but someone they know

[8/4/2006 12:27:36 PM] Mike Boyle: "Picking up on Tom's comment, I really think we need new technologies, particularly in ongoing support and monitoring; what I call Recovery management and what I believe Tom refers to as outcome monitoring. Also, the existing treatment system must become much more engaging and welcoming. I am proposing that treatment should be "fun". A place where I could enjoy developing my dreams and learning how to achieve them.,"

[8/4/2006 12:28:17 PM] MODERATOR: "FAVOR is big into policy, legislation and grassroots public change, like Recovery Walks. They definitely want to reframe the issue so as to begin to change things, like laws, insurance coverage (parity) and workplace discrimination. Which is a whole 'nother issue. "

[8/4/2006 12:28:30 PM] Tom McLellan: "The training of physicians in addiction is a difficult situation. Until 1992 there were just two medications approved for use by docs - so many docs said if i can't prescribe something - what exactly am I being trained to do (this is the current situation facing docs that are asked to screen for family violence). Now that there are meds and possibly a growing belief that healthcare can help addiction - I think there will be an honest willingness to screen and treat addiction. Also - an angle that has not been explored - is the fact that alcohol particularly and to a lesser extent other drugs - are very big complicating factors in the treatment of many chronic illnesses. our group is doing systematic reviews of the effects of alcohol and drugs (below diagnostic levels) on the management of cancer, pain, sleep disorders, hypertension etc. Now that 13 systematic reviews have been published showing that docs are missing an opportunity to improve chronic care treatment for many illnesses simply by including alcohol adn other drug use information in their questioning - we have been asked by the four largest medical societies in the country (220,000 physicians) to start alcohol interest and practice groups for their members. Never underestimate the power of enlightened self interest!"

[8/4/2006 12:30:36 PM] MODERATOR: "Tom had to leave us to come up with new treatments. Thanks so much for joining us. This chat will be archived if others would like to check it out later. Thanks again, and come back Monday for Darla Bardine for discussions on disparity."