Raw Story [based on the Wall Street Journal] is reporting good news on the “drug war” front. It looks like the administration will finally end the 40-year old war on drugs and create, instead, a campaign to help -people and communities ravaged by drugs:
“The Obama administration’s new drug czar says he wants to banish the idea that the U.S. is fighting ‘a war on drugs,’ a move that would underscore a shift favoring treatment over incarceration in trying to reduce illicit drug use,” the Wall Street Journal reported Thursday.
“Regardless of how you try to explain to people it’s a ‘war on drugs’ or a ‘war on a product,’ people see a war as a war on them,” he told the paper. “We’re not at war with people in this country.”…
“The Obama administration is likely to deal with drugs as a matter of public health rather than criminal justice alone, with treatment’s role growing relative to incarceration,” the paper summarized Kerlikowske as saying.
This is great news to all of us who’ve worked in the substance abuse treatment and prevention fields and know the need to replace the militarized law enforcement perspective with public health approaches.
May 14th, 2009
I’ve been dissapointed that the Obama administration, like its predecessors, has not drawn its “Drug Czar” from the ranks of substance abuse professionals. In Obama’s case, he chose Seattle Police Chief Gil Kerlikowske, who does at least have some committment to treatment and prevention, along with fighting the long ago lost “War on Drugs” at the borders.
It is, however, exciting to hear that Thomas McCellan has been chosen as Deputy Czar. McCellan is one of the top two or three substance abusetreatment researchers in the country. he developed the most important single research tool in the substance abuse area, the Addiction Severity Index (ASI). McCellan also has long experience working wioth policy makers. Hopefully McCellan’s selection is a harbinger of a major commitment to making expanded treatment national policy and a decisive turn away from the imprisonment on demand policy of the last decades.
Now if we could only stop fighting that lost war and develop comprehensive prevention policies that work, at least in dramatically reducing the risks associated with the substance use that will inevitably remain.
April 14th, 2009
Many of us who have worked in the substance abuse field know that US drug policies are a failure. We know that major reforms re needed. It is surprising how many drug abuse professionals will express support, or at least interest, in drug decriminalization approaches when they discuss these things privately, over a bottle of wine. Yet, very few will ever mention the possibility of decriminalization in the sober light of day, when colleagues and potential funders may hear.
Glenn Greenwald [yes, the same Greenwald I'm always quoting on torture and civil liberties] has recently produced a major report on drug decriminalization in Portugal. Evidently Portugal decriminalized all drugs in 2001, making possession an administrative, rather than a criminal matter. Drug dealing is still a crime. Greenwald finds that the effects are overwhelmingly positive, while potential negative effects did not materialize.
Possible drug decriminalization in the US may have different effects than it did in Portugal. It is likely that drug use, in its complex intersection with class and race, may be somewhat different in this country. Certainly our attitudes toward the criminal justice system are far different, mostly for the worse I suspect. But any reasoned discussion of drug policy should carefully study and evaluate the Portuguese experience.
A Scientific American reporter recently heard Greenwald speak on his report and produced this brief article on the issue:
5 Years After: Portugal’s Drug Decriminalization Policy Shows Positive Results
Street drug-related deaths from overdoses drop and the rate of HIV cases crashes
By Brian Vastag
In the face of a growing number of deaths and cases of HIV linked to drug abuse, the Portuguese government in 2001 tried a new tack to get a handle on the problem—it decriminalized the use and possession of heroin, cocaine, marijuana, LSD and other illicit street drugs. The theory: focusing on treatment and prevention instead of jailing users would decrease the number of deaths and infections.
Five years later, the number of deaths from street drug overdoses dropped from around 400 to 290 annually, and the number of new HIV cases caused by using dirty needles to inject heroin, cocaine and other illegal substances plummeted from nearly 1,400 in 2000 to about 400 in 2006, according to a report released recently by the Cato Institute, a Washington, D.C, libertarian think tank.
“Now instead of being put into prison, addicts are going to treatment centers and they’re learning how to control their drug usage or getting off drugs entirely,” report author Glenn Greenwald, a former New York State constitutional litigator, said during a press briefing at Cato last week.
Under the Portuguese plan, penalties for people caught dealing and trafficking drugs are unchanged; dealers are still jailed and subjected to fines depending on the crime. But people caught using or possessing small amounts—defined as the amount needed for 10 days of personal use—are brought before what’s known as a “Dissuasion Commission,” an administrative body created by the 2001 law.
Each three-person commission includes at least one lawyer or judge and one health care or social services worker. The panel has the option of recommending treatment, a small fine, or no sanction.
Peter Reuter, a criminologist at the University of Maryland, College Park, says he’s skeptical decriminalization was the sole reason drug use slid in Portugal, noting that another factor, especially among teens, was a global decline in marijuana use. By the same token, he notes that critics were wrong in their warnings that decriminalizing drugs would make Lisbon a drug mecca.
“Drug decriminalization did reach its primary goal in Portugal,” of reducing the health consequences of drug use, he says, “and did not lead to Lisbon becoming a drug tourist destination.”
Walter Kemp, a spokesperson for the United Nations Office on Drugs and Crime, says decriminalization in Portugal “appears to be working.” He adds that his office is putting more emphasis on improving health outcomes, such as reducing needle-borne infections, but that it does not explicitly support decriminalization, “because it smacks of legalization.”
Drug legalization removes all criminal penalties for producing, selling and using drugs; no country has tried it. In contrast, decriminalization, as practiced in Portugal, eliminates jail time for drug users but maintains criminal penalties for dealers. Spain and Italy have also decriminalized personal use of drugs and Mexico’s president has proposed doing the same. .
A spokesperson for the White House’s Office of National Drug Control Policy declined to comment, citing the pending Senate confirmation of the office’s new director, former Seattle Police Chief Gil Kerlikowske. The U.S. Drug Enforcement Administration (DEA) and the U.S. Department of State’s Bureau of International Narcotics and Law Enforcement Affairs also declined to comment on the report.
April 10th, 2009
As a health researcher, I am a strong advocate of increasing the research-base guiding our clinical efforts. Among other things, I help develop systems to assess the outcomes of psychosocial interventions in order to use the resultant knowledge to improve the quality of treatments that are delivered to our clients. Yet, as a clinician, I am a skeptic regarding the quality of our current knowledge and its ability to appropriately guide our practice. Do we really know enough? And what about the large element of clinical expertise that cannot, with our current tools anyway, be quantified.
This is a tension I have lived with and explored throughout my professional career. I even co-edited a book — Reconciling Empirical Knowledge and Clinical Experience: The Art and Science of Psychotherapy — on the interface between research and clinical practice.
I have just been sent this new Wall Street Journal op-ed by Jerome Groopman and Pamela Hartbrand that makes the case that rigid guidelines can be wrong, and even dangerous. Groopman and Hartbrand argue that these guidelines, based as they are on what is believed to be best practices, can, in the current state of our knowledge, easily turn out to be suboptimal or even harmful. As one of the examples they give illustrates:
One key quality measure in the ICU became the level of blood sugar in critically ill patients. Expert panels reviewed data on whether ICU patients should have insulin therapy adjusted to tightly control their blood sugar, keeping it within the normal range, or whether a more flexible approach, allowing some elevation of sugar, was permissible. Expert consensus endorsed tight control, and this approach was embedded in guidelines from the American Diabetes Association. The Joint Commission on Accreditation of Healthcare Organizations, which generates report cards on hospitals, and governmental and private insurers that pay for care, adopted as a suggested quality metric this tight control of blood sugar.
A colleague who works in an ICU in a medical center in our state told us how his care of the critically ill is closely monitored. If his patients have blood sugars that rise above the metric, he must attend what he calls “re-education sessions” where he is pointedly lectured on the need to adhere to the rule. If he does not strictly comply, his hospital will be downgraded on its quality rating and risks financial loss. His status on the faculty is also at risk should he be seen as delivering low-quality care.
But this coercive approach was turned on its head last month when the New England Journal of Medicine published a randomized study, by the Australian and New Zealand Intensive Care Society Clinical Trials Group and the Canadian Critical Care Trials Group, of more than 6,000 critically ill patients in the ICU. Half of the patients received insulin to tightly maintain their sugar in the normal range, and the other half were on a more flexible protocol, allowing higher sugar levels. More patients died in the tightly regulated group than those cared for with the flexible protocol.
This example illustrates both the difficulty with rigid guidelines and the need to be able to use judgment and flexibility in treating patients.
I concur with their concerns. We are far from knowing with any degree of certainty the correctness of most of our clinical guidlines. Yet I also believe that clinical care independent of research is increasingly problematic. While Groopman and Hartbrand are right about the need for clinical flexibility, the ignore the opposite problem whereby the treatment a patient receives depends in an arbitrary manner of which doctor or hospital they go to, or where they live. Thus, enormous geographic variability has been found for certain surgical procedures with no evidence that the variability is based upon anything but custom.
Thus, I believe that health care systems need to measure their outcomes and use the resultant data to improve care. Yet, they also need to avoid the rigid guideline problem.
One way of reconciling these conflicting impulses is to implement outcomes monitoring in a quality improvement framework.That is, the goal is to identify practices and health providers who have superior outcomes and find how to tap their knowledge and expertise and communicate it to those whose outcomes are inferior. A successful quality improvement framework is based upon the assumption that the vast majority of healthcare workers want to deliver quality care. Thus, they will be open data-driven quality improvement efforts, as long as these are conducted in a collaboarative and respectful manner, fully valuing the expertise of healthcare workers while providing them with the information and tools to improve their efforts.
One important aspect of such a quality improvement perspective is that healthcare workers, doctors and others, should be part of team that selects outcome measures and quality improvement implementation procedures. Especially in “fuizzy” areas like mental health, the ability to control the outcomes that are measured is a powerful influence on the nature of treatment that is delivered.
To take one example with which I am intimately familiar, if substance abuse treatment outcomes included measures of such lifetsyle factors as having housing and jobs, as well as improved mental health, then these life domains are likely to be included in treatment planning. However, if substance abuse outcomes only include measurements of substance use, then large aspects of substance abusing clients’ lives will ultimately be given short shrift when planning and conducting treatment.
By the way, similar issues arise in a number of other areas than healthcare. Thus, much of the current efforts to measure “outcomes” in education could similarly benefit from a quality improvement perspective. If teachers and parents, not to mention students, were more integrated into the vast apparatus now assessing educational outcomes through standardized testing, there would likely be less grousing among teachers, with its acompanying drop in morale and loss of experienced teachers to early retirement.
Here is the complete Groopman and Hartbrand article:
Why ‘Quality’ Care Is Dangerous
The growing number of rigid protocols meant to guide doctors have perverse consequences
By Jerome Groopman and Pamela Hartbrand
The Obama administration is working with Congress to mandate that all Medicare payments be tied to “quality metrics.” But an analysis of this drive for better health care reveals a fundamental flaw in how quality is defined and metrics applied. In too many cases, the quality measures have been hastily adopted, only to be proven wrong and even potentially dangerous to patients.
Health-policy planners define quality as clinical practice that conforms to consensus guidelines written by experts. The guidelines present specific metrics for physicians to meet, thus “quality metrics.” Since 2003, the federal government has piloted Medicare projects at more than 260 hospitals to reward physicians and institutions that meet quality metrics. The program is called “pay-for-performance.” Many private insurers are following suit with similar incentive programs.
In Massachusetts, there are not only carrots but also sticks; physicians who fail to comply with quality guidelines from certain state-based insurers are publicly discredited and their patients required to pay up to three times as much out of pocket to see them. Unfortunately, many states are considering the Massachusetts model for their local insurance.
How did we get here? Initially, the quality improvement initiatives focused on patient safety and public-health measures. The hospital was seen as a large factory where systems needed to be standardized to prevent avoidable errors. A shocking degree of sloppiness existed with respect to hand washing, for example, and this largely has been remedied with implementation of standardized protocols. Similarly, the risk of infection when inserting an intravenous catheter has fallen sharply since doctors and nurses now abide by guidelines. Buoyed by these successes, governmental and private insurance regulators now have overreached. They’ve turned clinical guidelines for complex diseases into iron-clad rules, to deleterious effect.
One key quality measure in the ICU became the level of blood sugar in critically ill patients. Expert panels reviewed data on whether ICU patients should have insulin therapy adjusted to tightly control their blood sugar, keeping it within the normal range, or whether a more flexible approach, allowing some elevation of sugar, was permissible. Expert consensus endorsed tight control, and this approach was embedded in guidelines from the American Diabetes Association. The Joint Commission on Accreditation of Healthcare Organizations, which generates report cards on hospitals, and governmental and private insurers that pay for care, adopted as a suggested quality metric this tight control of blood sugar.
A colleague who works in an ICU in a medical center in our state told us how his care of the critically ill is closely monitored. If his patients have blood sugars that rise above the metric, he must attend what he calls “re-education sessions” where he is pointedly lectured on the need to adhere to the rule. If he does not strictly comply, his hospital will be downgraded on its quality rating and risks financial loss. His status on the faculty is also at risk should he be seen as delivering low-quality care.
But this coercive approach was turned on its head last month when the New England Journal of Medicine published a randomized study, by the Australian and New Zealand Intensive Care Society Clinical Trials Group and the Canadian Critical Care Trials Group, of more than 6,000 critically ill patients in the ICU. Half of the patients received insulin to tightly maintain their sugar in the normal range, and the other half were on a more flexible protocol, allowing higher sugar levels. More patients died in the tightly regulated group than those cared for with the flexible protocol.
Similarly, maintaining normal blood sugar in ambulatory diabetics with vascular problems has been a key quality metric in assessing physician performance. Yet largely due to two extensive studies published in the June 2008 issue of the New England Journal of Medicine, this is now in serious doubt. Indeed, in one study of more than 10,000 ambulatory diabetics with cardiovascular diseases conducted by a group of Canadian and American researchers (the “ACCORD” study) so many diabetics died in the group where sugar was tightly regulated that the researchers discontinued the trial 17 months before its scheduled end.
And just last month, another clinical trial contradicted the expert consensus guidelines that patients with kidney failure on dialysis should be given statin drugs to prevent heart attack and stroke.
These and other recent examples show why rigid and punitive rules to broadly standardize care for all patients often break down. Human beings are not uniform in their biology. A disease with many effects on multiple organs, like diabetes, acts differently in different people. Medicine is an imperfect science, and its study is also imperfect. Information evolves and changes. Rather than rigidity, flexibility is appropriate in applying evidence from clinical trials. To that end, a good doctor exercises sound clinical judgment by consulting expert guidelines and assessing ongoing research, but then decides what is quality care for the individual patient. And what is best sometimes deviates from the norms.
Yet too often quality metrics coerce doctors into rigid and ill-advised procedures. Orwell could have written about how the word “quality” became zealously defined by regulators, and then redefined with each change in consensus guidelines. And Kafka could detail the recent experience of a pediatrician featured in Vital Signs, the member publication of the Massachusetts Medical Society. Out of the blue, according to the article, Dr. Ann T. Nutt received a letter in February from the Massachusetts Group Insurance Commission on Clinical Performance Improvement informing her that she was no longer ranked as Tier 1 but had fallen to Tier 3. (Massachusetts and some private insurers use a three-tier ranking system to incentivize high-quality care.) She contacted the regulators and insisted that she be given details to explain her fall in rating.
After much effort, she discovered that in 127 opportunities to comply with quality metrics, she had met the standards 115 times. But the regulators refused to provide the names of patients who allegedly had received low quality care, so she had no way to assess their judgment for herself. The pediatrician fought back and ultimately learned which guidelines she had failed to follow. Despite her cogent rebuttal, the regulator denied the appeal and the doctor is still ranked as Tier 3. She continues to battle the state.
Doubts about the relevance of quality metrics to clinical reality are even emerging from the federal pilot programs launched in 2003. An analysis of Medicare pay-for-performance for hip and knee replacement by orthopedic surgeons at 260 hospitals in 38 states published in the most recent March/April issue of Health Affairs showed that conforming to or deviating from expert quality metrics had no relationship to the actual complications or clinical outcomes of the patients. Similarly, a study led by UCLA researchers of over 5,000 patients at 91 hospitals published in 2007 in the Journal of the American Medical Association found that the application of most federal quality process measures did not change mortality from heart failure.
State pay-for-performance programs also provide disturbing data on the unintended consequences of coercive regulation. Another report in the most recent Health Affairs evaluating some 35,000 physicians caring for 6.2 million patients in California revealed that doctors dropped noncompliant patients, or refused to treat people with complicated illnesses involving many organs, since their outcomes would make their statistics look bad. And research by the Brigham and Women’s Hospital published last month in the Journal of the American College of Cardiology indicates that report cards may be pushing Massachusetts cardiologists to deny lifesaving procedures on very sick heart patients out of fear of receiving a low grade if the outcome is poor.
Dr. David Sackett, a pioneer of “evidence-based medicine,” where results from clinical trials rather than anecdotes are used to guide physician practice, famously said, “Half of what you’ll learn in medical school will be shown to be either dead wrong or out of date within five years of your graduation; the trouble is that nobody can tell you which half — so the most important thing to learn is how to learn on your own.” Science depends upon such a sentiment, and honors the doubter and iconoclast who overturns false paradigms.
Before a surgeon begins an operation, he must stop and call a “time-out” to verify that he has all the correct information and instruments to safely proceed. We need a national time-out in the rush to mandate what policy makers term quality care to prevent doing more harm than good.
**********
Dr. Groopman, a staff writer for the New Yorker, and Dr. Hartzband are on the staff of Beth Israel Deaconess Medical Center in Boston and on the faculty of Harvard Medical School.
April 8th, 2009
Psychologist Andrew Tatarsky has released the following press release objecting to Obama’s potential selection of Republican Congressman Jim Ramstad for a major position in drug policy. We cannot afford another right-wing ideologue in charge of drug policy:
For Immediate Release:
Contact: Andrew Tatarsky, PhD (212) 633-8157
Monday, December 22, 2008
Possible Obama Pick for “Drug Czar” or head of SAMHSA Criticized by Hundreds of Substance Abuse and Mental Health Treatment Professionals, Researchers and Academics
Ramstad’s Positions on Syringe Exchange, Sentencing Reform, Medical Marijuana and other Issues Unscientific and Harmful Say Experts
Leading Substance Abuse and Mental Health Experts Suggest Six Positions that Leaders of ONDCP and SAMHSA Should Support
A growing number of professionals have expressed concern about reports in the media that President-elect Obama may be considering appointing Republican Congressman Jim Ramstad (R-MN) either as the next “Drug Czar”, director of the Office of National Drug Control, or as director of SAMHSA, the Substance Abuse and Mental Health Services Administration. In a letter to President-elect Obama released today, over 250 clinicians working with patients with substance use problems and nearly 150 researchers, academics and other concerned citizens warn that Ramstad is not the man for either of these jobs because his record suggests that his perspective is ideologically based and at odds with science.
The letter applauds Rep. Ramstad’s support for expanding access to drug treatment and improving addiction awareness and it honors his own personal triumph over addiction. However, in spite of these contributions, Ramstad has supported unscientific faith-based treatment while opposing evidence-based practices such as methadone maintenance and syringe exchange, two of the most effective interventions for addiction and transmission of infectious disease that save lives. He has also consistently opposed congressional efforts to stop the arrest of patients with HIV/AIDS, cancer and other illnesses who use prescribed medical marijuana in states where it is legal and he has failed to co-sponsor legislation that would eliminate sentencing disparity between crack cocaine and powder cocaine, despite the fact that there were three different crack/powder reform bills in the 110th Congress. These positions clearly conflict with President-elect Obama’s stated positions on these issues.
These professionals call for President-elect Obama to select leaders for these critically important positions who are committed to reducing the harms associated with both drugs and punitive drug laws and who will base their decisions on science rather than politics or ideology.
They call for leaders who will support evidence-based treatment across the spectrum including:
- Non-abstinence based interventions like Motivational Interviewing, opiate substitution treatment and abstinence oriented treatment for appropriately matched patients
- Integrated treatment for patients with co-occurring disorders
- Syringe exchange programs to halt the spread of HIV and hepatitis-C
They also call for leaders who will treat substance abuse and dependence as health issues rather than as criminal issues and be committed to:
1. Sentencing reform
2. Better educating criminal justice professionals associated with drug courts in the complexities of substance use problems and their treatment and
3. More fully involving clinical staff in decisions about individuals mandated by drug courts to treatment
The letter concludes, “There are many roads to recovery and recovery can take different paths…these views are in the best interests of individuals struggling with substance use disorders and all Americans9 D.
For a copy of the letter and a complete list of signatories, go to www.andrewtatarsky.com
December 23rd, 2008
The Boston Globe editorialized against a potential Obama Drug Czar. We don’t need our drug policy to handed over to right-wingers who refuse to use needle exchjange, a proven technique, to fight AIDS.
Beyond needle exchange, we need a radical turn from the decades-long emphasis on ineffective and punitive supply-side law enforcement to a demand-side emphasis on treatment and prevention.There is no excuse for continuing locking up hundreds of thousands of people on relatively minor drug offenses. It isn’t clear where Ramstad stands on this. but any new druf policy officials must be committed to fundamentally transforming drug policy.
The Globe:
Wrong kind of drug czar
By Boston Globe
REPRESENTATIVE Jim Ramstad, a Republican from Minnesota, is said to be a candidate for drug czar in the Obama administration. This would take bipartisanship one step too far, at the expense of public health.
Ramstad, who is retiring after 18 years in office, gets high marks for working with a Democratic colleague, Patrick Kennedy of Rhode Island, to require insurers to cover mental health and addiction treatment (the two men are alcohol recovery partners). But Ramstad has also voted repeatedly against federal funding for needle exchange programs for drug users to fight the spread of HIV/AIDS. Washington’s paralysis on this issue goes back to when President Clinton let his drug czar, Barry McCaffrey, sabotage funding efforts by Donna Shalala, then secretary of Health and Human Services. McCaffrey hyperbolically called clean-needle programs “magnets for all social ills.” In 2002, Clinton admitted that “I was wrong” not to lift the funding ban.
A study this fall in The Lancet found that only 1.5 percent of injecting drug users in Australia have HIV, compared with 16 percent in the United States. “That’s largely because we acted very quickly in the 1980s to implement methadone programs and needle exchange programs when other countries like the US were dragging their heels,” study author Bradley Mathers of Australia’s National Drug and Alcohol Research Center told the Associated Press. Anthony Fauci, director for infectious disease at the National Institutes of Health, flatly says, “needle exchange programs work. There’s no doubt about that.”
The Centers for Disease Control says the national HIV infection rate is now 40 percent higher than previously thought. Injection drug use causes 12 percent of new infections. Obama, a supporter of needle exchange, has no time to thread the needle with his drug czar.
December 13th, 2008
Phillip Leveque, M.D., takes on the army’s denial or deceipt about the extent of PTSD-realted drug abuse in an article in the Salem-News:
PTSD and Psychosis Among Army Psychiatrists
Dr. Phillip Leveque Salem-News.com
Phillip Leveque has spent his life as a Combat Infantryman, Physician, Toxicologist and Pharmacologist.
(MOLALLA, Ore.) – I was a combat infantryman for about 18 months in WWII where things were really crazy with various levels of officers demanding of their underlings (anyone of lower rank) that such and such a military objective be taken even if it killed every attacking soldier.
If that isn’t psychosis, what is?
I was also stationed in General Eisenhower’s headquarters for about six months. Of about 15,000 personnel, half officers, half enlisted, they acted like there wasn’t a war.
If such a psychic denial isn’t psychosis, what is?
The current seeming denial of PTSD and drug use on the highest army medical levels MUST BE a further example of psychosis.
I was absolutely flabbergasted that on ABC News 20/20 Col. Elspeth Ritchie, the psychiatry consultant to the U.S. Army Surgeon General, implied that there is no battle-induced PTSD causing drug use by soldiers, but like all other people using drugs, there were other “reasons”.
I was reminded that in WWI the Army swept it under the rug too, naming PTSD as “homesickness” or saying that the soldiers “missed their mothers”. What comes to my mind is SNAFU, FUBAR and even JANFU.
The VA’s own information says up to half of all PTSD patients treated also have a substance abuse problem.
Colonel Ritchie would only say that PTSD is a “risk factor” for the abuse of drugs and alcohol, but that the Army has not been able to quantify how strongly the two are linked. She said she was unaware of cases of soldiers turning to drugs to cope with the trauma of their experiences in Iraq.
She said, “That has not been my experience. My psychiatrists and social workers who see soldiers report to me of their experiences with soldiers all the time, and none of them are seeing that particular explanation.”
The Army actually goes so far to say there has been NO increase in the rate of illegal drug use among soldiers since the beginning of the wars in Iraq and Afghanistan.
Who do they think they’re fooling?
I presume Dr. Ritchie got her MD from a real medical school, but I have heard that the Armed Forces has its own medical school. I was embarrassed as a physician at her comments.
Was she lying to maintain her quest for one star, or was she really ignorant about PTSD? It’s hard to believe she got to where she is today without intelligence, so that leaves: CHOICE. She is choosing her future star over the welfare of our troops.
Even other army spokespersons and the VA people say to expect about 20% of battle veterans to have PTSD. Paul Sullivan, Gulf War veteran, a former project manager at VA who monitored the disability claim activity of Iraq and Afghanistan war veterans, and now is the executive director of Veterans for Common Sense (VCS), said PTSD was a big problem. His reaction to the Army psychiatrist? “Shame on her!”
Some of the most pitiful comments were given by a woman described as the director of substance abuse programs, apparently with the U.S. Army. She spoke about their success. The 20/20 program didn’t indicate her rank, or even if she was a physician, but she obviously didn’t understand that a battle-scarred PTSD veteran will use anything he can get his hands on to remove the PTSD devils from his soul and mind, even if it is heroin, booze, or at the very least, cannabis.
Ten times the number of soldiers are using drugs now compared to when the Iraq war began. That’s the military’s number, a complete contradiction to what Col Richie said.
Hundreds of veterans have told me that cannabis works better than any prescription drug. It’s about time for a serious trial of cannabis for PTSD.
Some soldiers are breaking the rules and turning to drugs to give them relief from the consequences of trauma in war. We can help them seek the best treatment by not living in the psychosis of denial.
I have also heard that many VA psychologists are trying “fake battle sounds” as treatment. God preserve us.
We PTSD guys are trying to stay as far from that as possible.
December 16th, 2007
As the U.S. has filled its prisons with millions of, mostly young minority males, many on often minor drug charges. While the War on Drugs has been a total failure at addressing the extent of substance abuse in our society, it has been ripe with abuses. The symbol of this abuse in recent years has been the extreme sentencing discrepancy between those arrested for selling crack, as opposed to powered cocaine. Those of us in substance abuse treatment know that there is essentially no difference between crack and cocaine, except for the common differences in who sells and uses them: crack — poor blacks; cocaine — middle class to wealthy whites. As all attempts to reform theses sentencing disparities have failed, federal judges have taken to using modest discretion in interpreting sentencing guidelines. The Bush administration, terrified by the humanity exemplified by the judges actions, tried to get the Supreme Court to put a stop to judicial discretion. Today, in a 7-2 decision, the SCOTUS said “NO” to the Bush administration. Adam B at Daily Kos explains:
SCOTUS: Let judges be merciful
Derrick Kimbrough is, no doubt, a bad man. In 2004 he pleaded guilty to four offenses: conspiracy to distribute crack and powder; possession with intent to distribute more than 50 grams of crack (he acknowledged 56 grams); possession with intent to distribute powder (92.1 grams); and possession of a firearm in furtherance of a drug-trafficking offense. His plea subjected him to a minimum term of 15 years and a maximum of life, with the guidelines reccomending 19-22.5 years. The trial judge thought that such treatment exemplified the “disproportionate and unjust effect that crack cocaine guidelines have in sentencing,” noted that if Kimbrough had possessed only powder cocaine, his Guidelines range would have been far lower: 8-9 years. So the judge did the best he could, and sentenced him to the minimum of 15 years.
The Bush Administration didn’t like this and appealed, claiming that the judge should have had no discretion to consider the crack/powder disparity in sentencing him.
In a 7-2 opinion by Justice Ginsburg handed down this morning, the Supreme Court rebuked the Bush Administration and has given judges permission to deviate downwards from the draconian federal guidelines to consider the disparity in treatment between crack and powder cocaine.
Under the federal sentencing guidelines, a drug trafficker dealing in crack cocaine is subject to the same sentence as one dealing in 100 times more powder cocaine. These were guidelines drawn up in 1986 at the dawn of the crack epidemic, but they yield bizarre, unjust results. As the bipartisan U.S. Sentencing Commission had explained to Congress, “Although chemically similar, crack and powder cocaine are handled very differently for sentencing purposes. The 100-to-1 ratio yields sentences for crack offenses three to six times longer than those for powder offenses involving equal amounts of drugs.” More:
“[T]he Commission concluded that the crack/powder disparity is inconsistent with the 1986 Act’s goal of punishing major drug traffickers more severely than low-level dealers. Drug importers and major traffickers generally deal in powder cocaine, which is then converted into crack by street-level sellers. … But the 100-to-1 ratio can lead to the ‘anomalous’ result that ‘retail crack dealers get longer sentences than the wholesale drug distributors who supply them the powder cocaine from which their crack is produced.’
“Finally, the Commission stated that the crack/powder sentencing differential ‘fosters disrespect for and lack of confidence in the criminal justice system’ because of a ‘widely-held perception’ that it ‘promotes unwarranted disparity based on race.’ [] Approximately 85 percent of defendants convicted of crack offenses in federal court are black; thus the severe sentences required by the 100-to-1 ratio are imposed ‘primarily upon black offenders.’ ”
The Sentencing Commission has repeatedly urged Congress to act and amend this disparity; it has failed to do so. In the meantime, the sentencing guidelines have shifted from mandatory to advisory on trial judges (long story), so the question remained whether deviating from this 100:1 ratio was something that judges could do on their own. Today’s ruling says yes, they can, and you can read it here, along with much discussion of how LSD sentencing works in America.
Justices Thomas and Alito dissented, with Thomas venting about how he doesn’t like the Court’s whole approach to the sentencing guidelines, and Alito briefly arguing that the guidelines were entitled to more weight.
In a second 7-2 opinion today, the Court further extended judicial discretion in sentencing, allowing a trial court judge to sentence a University of Iowa undergrad low-dollar ecstasy dealer ($30K netted) to 36 months probation, rather than that same length in jail, based on his clean living as a construction subcontractor since his arrest.
Given the constant ratcheting-up of sentences by politicians looking to be “tough on crime,” today’s decisions should help tremendously in allowing judges to be just, humane and merciful.
December 10th, 2007
ABC News reports that the military, presumably in a rush to get soldiers back in the field, is overmedicating them. ABC News claims that this reliance on drugs can teach soldiers to rely on other drugs, including illegal ones, leading to a rising addiction rate.
Instead of providing proper counseling and care for Iraq war veterans suffering from physical and psychological pain, too often the U.S. military is trying to medicate the problem away, according to drug counselors and therapists.
Andrew Pogany, who works with service members nationwide as an investigator with the veterans advocacy group Veterans for America, said overmedicating veterans is a common problem.
“Pretty much every person in my caseload is medicated, heavily medicated,” said Pogany. “There’s potential for them to become addicted.”
According to Pogany, a reliance on prescription drugs often leads veterans to reach for other coping mechanisms — illegal drugs such as marijuana, cocaine and crystal meth.
The report attributes the overmedication to a lack of counseling resources.
But Andrew Pogany said the reason why vets suffering from PTSD are not afforded better psychiatric care is clear — a lack of resources on the part of the military.
“Do they have enough trained providers to provide individual care? The answer is no,” he told ABC News.
And the military apparently agrees. Results from the DOD (Department of Defense) Task Force on Mental Health released in June 2007 find that “the military system does not have enough resources, funding or personnel to adequately support the psychological health of service members.”
“Handing somebody a bag of medication and then seeing them once a month for a half-hour appointment, that’s not adequate,” said Pogany.
Another factor that may contribute I’ve heard about from some vets, and from reporters investigating the issue is that military commanders simply cannot accept that military experience could lead to trauma, as in PTSD. These sources feel that the pervasive denial contributes to some of the abuses os soldiers and vets that have recently been reported in several media sources.
December 2nd, 2007
A psychologist reader responds to this morning post of Jeff Stein’s article Padilla Case Opens Old Questions on CIA ‘Truth Serums’.
But you know what always surprises when I hear this story, being someone in the drug and addictions field myself, is the sort of naivete of Padilla’s attorneys to say they think he was injected with PCP or LSD.
It would sort of be like a NUCLEAR WEAPON hitting a city and saying, we know it must be an enormous amount of DYNAMITE that they used.”
But we can’t figure out why they would even try using dynamite because it never produces an explosion that big.
The attorneys and everyone else in this case seem to have no scientific sense or even creative thinking about how drugs have evolved, how much they develop each decade, particularly with military funding. No one in the military is using LSD or PCP–unless it is just some soldier who snuck it on the ship–I guess that’s possible. Even ecstasy and methamphetamine are child’s play with what the government is likely to have at its disposal. The assumption is also that the government is giving detainees one drug at a time rather than combinations and sequences of far more advanced drugs.
Oxytocin that’s involved in natural infant attachment to the mother is a hormone that has been found to increase trust in adult research participants and could be used in conjunction with sensation producing euphorics like ecstasy to produce a situation far more conducive to interrogations than LSD or PCP. It is far more targeted but any subjective description from someone who was given this combination of these things a month before would make it sound like a typical hallucinogen. But the right combinations and the right sequences and how they interact with the procedures in the army field manual are probably what’s key and exactly what the military wants to test, and may be testing.
So I think we should not accept this argument that oh the government would never try to use truth serums because our research from 4 decades ago says they’re not effective. It comes back to our efficacy question. It may not be effective yet, but that’s not going to stop them from trying.
I guess in this whole thing I am guilty of underestimating the government’s savvy and dedication to science to increase their arsenal to win their “war”.
February 27th, 2007