Can Medications Turn Problem Drinkers Back Into Moderate Drinkers?

The organization that integrates scientific information for the UK National Health Service has recommended that the drug nalmefene can be prescribed to alcohol dependent patients for the purpose of reducing their drinking but not necessarily stopping it. Nalmefene, like the better known medication naltrexone, is an opiate antagonist that is intended to make the experience of drinking less rewarding. This reduction in subjective reward could make it more likely than a drinker will stop at 2, 3 or 4 drinks rather than going on to 5, 6, 7 or many more drinks.

Many people will find this concept strange, as they think that the purpose of opiate antagonists (indeed all alcohol-related medications) is to help problem drinkers continue pre-existent abstinence (e.g., Keep dry after leaving a detox center). Sometimes they do just that. However, from the point of view of behavioral extinction, one could argue that its actually a good thing when a person on an opiate antagonist decides to drink. They will then experience drinking behavior as less rewarding, which should over time reduce the behavior and also the craving to drink.

My colleagues and I, led by Dr. Natalya Maisel, conducted a meta-analysis of this question focused on the medication naltrexone, which we contrasted with a different medication prescribed to problem drinkers that is not an opiate antagonist (acamprosate). The entire research synthesis is available for free here, but the key finding for present purposes is that while acamprosate was more strongly associated with maintaining abstinence, naltrexone was better at limiting the number of drinks on drinking days.

Does this mean that every problem drinker can return to problem drinking if they just take naltrexone or nalmefene? No. Problem drinkers who have more physical dependence symptoms (e.g., needing a drink in the morning, tremors, cravings), less social capital and worse mental health are generally unlikely to return to moderate drinking no matter what treatment they get. However, if dependence isn’t too advanced and the problem drinker has significant social and psychological resources available to support their efforts, they may indeed be able to go back to non-problem drinking, and medication can help with that. Even then, it’s a decision to make in consultation with a health professional, and the taking of the medication should be accompanied by additional counselling.

Please Share Your Modestly Useful Advice With the RBC Community

Good advice makes life easier, and therefore it should be shared. This post is intended to encourage the sharing of “modestly useful” advice among RBCers, i.e., keep it practical but not too heavy, not when to divorce a violent spouse or how to disarm a live nuke.

To kick us off, here are three suggestions from me.

1. If you work in an office, keep a Swiss Army knife in your desk. You might think you wouldn’t ever need it, but then one day you will be trying to screw in a computer cable with your key, or biting a piece of loose string from the hem of your jacket, and you will be glad to have it handy.

2. If you are playing hearts with three people, throwing in a random card as the widow card introduces so much chance as to make the game a crapshoot. A better variant is to explicitly make the two of clubs the widow in every hand (or just set it aside) and have the first trick be led by the three of clubs instead.

3. When drinking port at a dinner party, recall that the port side of a ship is the left side, so you always pass in that direction after pouring a glass for the person on your right. If someone forgets to pass, ask him/her if knows the Bishop of Norwich. An experienced port drinker will recognize this cue and just pass the port. If the person says “no”, politely give the required hint by responding with something like “Excellent fellow, but he always forgets to pass the port”.

Weekend Film Recommendation: Lola Rennt [Run Lola Run]

In this week’s movie recommendation, Tom Tykwer’s independent German film Lola Rennt [Run Lola Run], you’re corralled through one of the most frenetic and high-octane interpretations of the butterfly effect conceit ever put to the screen.

The story begins with Lola, a fiery red-headed woman played by Franka Potente, receiving a phone call from her distraught lover Manni (played by Moritz Bleibtreu). Manni has botched an assignment that he hoped would initiate him into Berlin’s organized crime gang headed by Ronnie (played by Heino Ferch). In particular, Manni has misplaced a bag that was filled with 100,000 of Ronnie’s Deutsch Marks, and he has to produce the delivery in twenty minutes else he’s a dead man. Can Lola save the day? Continue Reading…

Pot stings in school: But what about the children?

Sam Hampsher asks an excellent question: Do we want to send police into schools to set students up for marijuana stings? It’s not easy to imagine what could justify that practice, other than the relentless pressure to “make cases.”

Graduated re-entry and the rhetoric of reaction

This country has about five times as many people in prison and jail (per capita) as it ever had before 1975, and about seven times as many as other economically and socially advanced countries. Unfortunately, and contrary to current myth, most of those people aren’t innocent, and aren’t harmless “NonNonNons.” More than half are currently serving time for a violent offense, and many of the rest have prior convictions involving violence. So we can’t escape the mass incarceration trap by releasing “low-risk” offenders; to get back to a civilized rate of imprisonment, we need to get some seriously guilty people out of cellblocks. The current system of taking someone who is locked up (and fed, clothed, and housed at public expense) one day and turning him loose the next day under sporadic supervision, with $40 and our very best wishes for success in his future endeavors, is obviously idiotic, and the results are predictably rotten.

Angela Hawken, Ross Halperin, and I have proposed an alternative system of early release under tight supervision and with supported transitional work and housing, plus strong incentives – in the form of gradually increasing liberty – to find and hold non-supported employment.  Since nothing precisely like this has been tried before – that’s true of any genuinely original idea – there’s no way to predict precisely what the results would be, but there’s enough data on specific elements of the plan, including the swift-certain-fair approach to sanctioning misconduct and rewarding compliance and achievement, to give us reasonable confidence that some version of “graduated re-entry” would outperform the current system.

Leon Neyfakh at Slate runs the idea past a distinguished criminologist and a leading advocate of decarceration. Their responses illustrate  that the use of  Albert Hirschman’s  “rhetoric of reaction” is not restricted to one side of the political spectrum. Every new idea, Hirschman says, is attacked on three bases: futility, perversity, , and jeopardy. That is, the idea can’t possibly work, will actually have the opposite of its intended effect, and will create appalling risks.

Of course, all of those things might be true about any given proposal – there are a lot more bad new ideas than there are good ones – but they can also serve as mere reflex reactions, designed to cut off debate rather than foster it.

The standard “perversity” argument against more effective community corrections systems is that they will “widen the net”: instead of substituting for incarceration, they will be added on top of incarceration. They are said to be futile on the grounds that punishment has been demonstrated not to work. And the jeopardy is that, since attempts at control are doomed to fail, closer monitoring and more consistent sanctioning will only further entrap offenders in the web of the carceral state.

In fact, properly implemented swift-certain-fair approaches demonstrably succeed in changing behavior, and demonstrably reduce recidivism and days-behind-bars. But the rhetoric of reaction is designed to be fact-proof.

Otherwise it would be hard to figure out how anyone could imagine that a program that starts with people currently in prison and not scheduled to get out would possibly “widen the net.” Obviously, a graduated re-entry program is more restrictive than unconditional release: that’s the whole point. And insofar as we can identify current prisoner who would be good candidates for unconditional release, using graduated re-entry on that population instead of letting them out unconditionally would involve unnecessary expense, unnecessary intrusion, and, yes, the risk that people who would have made it on their own will instead get tripped up in a cycle of technical violation and re-incarceration. But surely there must be some population not safe to simply turn loose but safe enough to turn loose under the right sort of close monitoring. Maybe that population is small, in which case the benefits of graduated re-entry will be limited, though it still might turn out to be true that a phased re-entry will work better than a sudden re-entry.

Here’s my challenge to those who oppose graduated re-entry on the grounds that it’s too tough on offenders: Imagine that you were in prison, or that your son or brother was in prison.  Would you prefer having the next year of that sentence be served in the new “super-min” program, or on a cellblock?  Once you ask the question that way, the answer should be fairly obvious.








The most important book of 2015

I have wrung my hands in the past, in this space and elsewhere, about the collapse of a workable market for digital goods.  I find it hard to get people as excited about this as I am–if I still had enough hair for anyone to notice it would be on fire–but I have some help from Scott Timberg now  so I am going to try again.  Short version: buy this book, Culture Crash, and read it. Now. I believe it is the Piketty of 2015, and the first book I’ve stayed up to read straight through at one sitting–sometimes literally in tears, both of pain and of rage– in years.  It is not just about culture, but about whatever really big issue you lie awake worrying about.

Long post (no, not a substitute for the book; read it), get a cup of coffee  .

Continue Reading…

Housing policy success

As is well-known, housing prices in the Bay Area of California have become unsustainable; the median home price is $ 3/4 million in San Francisco/Oakland, more in the South Bay.  You need a household income of almost $150K to buy that house (which is no kind of mansion), and we are experiencing yuppification/gentrification conflicts and an exodus of the middle class (don’t even ask about blue-collar and service workers) to hour-long commutes away.

One thing that would help a lot is relaxing the traditional hostility of our local planning bodies to owner-occupied rental housing. Last night, the Berkeley City Council started to put our zoning law on a new course, approving (not enacting, yet, but the train is on the tracks) new rules that greatly ease the parking, minimum and maximum unit size, and lot size requirements for these accessory dwelling units (details to be posted at Annotated Agenda for the March 24 meeting here).

Why is this such a good idea? I discuss these “in-law” units in an op-ed in the San Francisco Chronicle (below the jump, if you have trouble with the paywall).  It may have been useful, but my wife, Debra Sanderson, who used to be Berkeley’s land use planning manager, was the heroine of this success, doing the real politicking. As we met in MIT’s city planning department, it was especially fun to partner on a project like this again.

Continue Reading…

The bottom of the pit

Will Rogers said it first:

When you find yourself in a hole, quit digging.

From an IEA press release on Friday 13 March (sic), my emphasis:

Global emissions of carbon dioxide stood at 32.3 billion tonnes in 2014, unchanged from the preceding year. [...]
In the 40 years in which the IEA has been collecting data on carbon dioxide emissions, there have only been three times in which emissions have stood still or fallen compared to the previous year, and all were associated with global economic weakness: the early 1980′s; 1992 and 2009. In 2014, however, the global economy expanded by 3%.

This statistic is highly reliable. The IEA was set up in 1974 with the initial task

to help countries co-ordinate a collective response to major disruptions in oil supply through the release of emergency oil stocks.

Keeping tabs on the oil market and giving advance warning of another price spike means counting barrels of oil, and later wagons of coal and millions of cubic feet of gas. It’s what they do for a living. If you want to challenge their methods, outlined here, feel free, but I reckon it’s a waste of time. Continue Reading…

Public Service Announcement: Don’t Judge Mass Media Writing by the Title

A short note from all of us who write for magazines and newspapers to all of you who write essays and emails denouncing us based on the title of our latest contribution.

(1) Authors don’t generally pick their titles. Editors do. Even if your screaming is justified, you are screaming at the wrong person. The author may not like the title either.

(2) It’s excusable not to know that authors usually don’t pick the titles of their articles because it’s the inside baseball of journalism. However, when you write your long ranting emails and essays based on a title that doesn’t match the content of the article (because a different person penned each) you are effectively announcing to the world that you feel comfortable making lengthy pronouncements about material you have not in fact read. This is particularly acute when you make points that are in the author’s own piece and which you would have agreed with if only you’d troubled to read the piece you are criticizing.

End of PSA. You may now resume your regularly scheduled blathering, but those of us who write hope you won’t.

Not logic but experience: why I was wrong about the ACA then, and will be right in the future

The Affordable Care Act turned five years old yesterday. As any honest parent knows, that’s a common occasion for saying, “thank goodness: we survived.” And it’s as good an occasion as any for me to write a post I’ve been considering for some time but never got around to because I lacked the time for proper research on public opinion. Rather than delay longer, I’m writing it now as a thought piece. My confidence that I’m right is, for the moment, strong but fragile. It relies on the evidence of things not cited.

The basic point is this: the ACA is set up to mimic private insurance coverage for those who previously lacked it. I claimed that would and should make it, over time, acceptable and routine. That claim tacitly assumed, though, that everyone had experience with private insurance coverage and thought it worked OK. The uninsured in fact lacked that experience, and that more-or-less automatic judgment. Continue Reading…