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The decades-long global war on drugs has failed and it’s time to shift the focus from mass incarceration to public health and human rights, according to a new report endorsed by five Nobel Prize-winning economists.

The report, titled “Ending the Drug Wars” and put together by the London School of Economics’ IDEAS center, looks at the high costs and unintended consequences of drug prohibitions on public health and safety, national security and law enforcement.

“The pursuit of a militarized and enforcement-led global ‘war on drugs’ strategy has produced enormous negative outcomes and collateral damage,” says the 82-page report. “These include mass incarceration in the US, highly repressive policies in Asia, vast corruption and political destabilization in Afghanistan and West Africa, immense violence in Latin America, an HIV epidemic in Russia, an acute global shortage of pain medication and the propagation of systematic human rights abuses around the world.”

The report urges the world’s governments to reframe their drug policies around treatment and harm reduction rather than prosecution and prison.

It is also aimed at the United Nations General Assembly, which is preparing to convene a special session on drug policy in 2016. The hope is to push the U.N. to encourage countries to develop their own policies, because the report declares the current one-size-fits-all approach has not proved to be effective.

“The UN must recognize its role is to assist states as they pursue best-practice policies based on scientific evidence, not undermine or counteract them,” said Danny Quah, a professor of economics at LSE and a contributor to the report. “If this alignment occurs, a new and effective international regime can emerge that effectively tackles the global drug problem.”

In addition to contributions from Quah and a dozen other foreign and drug policy experts, the report has been endorsed by five past winners of the Nobel Prize in Economics: Kenneth Arrow (1972), Sir Christopher Pissarides (2010), Thomas Schelling (2005), Vernon Smith (2002) and Oliver Williamson (2009). Also signing on to the report’s foreword are a number of current and former international leaders, including George Shultz, secretary of state under President Ronald Reagan; Nick Clegg, British deputy prime minister; and Javier Solana, the former EU high representative for common foreign and security policy.

Guatemalan President Otto Perez Molina, who has announced that his government may present a plan to legalize production of marijuana and opium poppies by the end of 2014, has also publicly backed the report. Molina plans to discuss the report at the U.N.

A recent Pew survey suggests that Americans may be ready to refocus the U.S. end of the drug war, with 67 percent favoring policies that would provide drug treatment.

“The drug war’s failure has been recognized by public health professionals, security experts, human rights authorities and now some of the world’s most respected economists,” said John Collins, the International Drug Policy Project coordinator at LSE IDEAS. “Leaders need to recognize that toeing the line on current drug control strategies comes with extraordinary human and financial costs to their citizens and economies.”

http://www.huffingtonpost.com/2014/05/06/end-drug-war_n_5275078.html?utm_hp_ref=politics

Thanks to Dr. Lutter for bringing this to the attention of the It’s Interesting community.

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drugs

dr nutt
Nutt says politicians often have a “primitive, childish” way of thinking about drugs.

David Nutt is trying to develop a new recreational drug that he hopes will be taken up by millions of people around the world. No, the 62-year-old scientist isn’t “breaking bad.” In fact, he hopes to do good. His drug would be a substitute for alcohol, to create drinks that are just as intoxicating as beer or whiskey but less toxic. And it would come with an antidote to reverse its effects, allowing people to sober up instantly and drive home safely.

Nutt, a neuropsychopharmacologist at Imperial College London and a former top adviser to the British government on drug policy, says he has already identified a couple of candidates, which he is eager to develop further. “We know people like alcohol, they like the relaxation, they like the sense of inebriation,” Nutt says. “Why don’t we just allow them to do it with a drug that isn’t going to rot their liver or their heart?”

But when he presented the idea on a BBC radio program late last year and made an appeal for funding, many were appalled. A charity working on alcohol issues criticized him for “swapping potentially one addictive substance for another”; a commentator called the broadcast “outrageous.” News-papers likened his synthetic drug to soma, the intoxicating compound in Aldous Huxley’s dystopian novel Brave New World. Some of his colleagues dismissed the idea as scientifically unfeasible.

Nutt wasn’t surprised. As a fierce advocate of what he says are more enlightened, rational drug policies, he has been a lightning rod for a long time. Politicians, in Nutt’s view, make irrational decisions about drugs that help them win votes but cost society dearly. Drug policy is often based on the moral judgment that people should not use drugs, he says. Instead, it should reflect what science knows about the harms of different drugs—notably that many are far less harmful than legal substances such as alcohol, he says. The plan for a synthetic alcohol alternative is his own attempt to reduce the damage that drug use can wreak; he believes it could save millions of lives and billions of dollars.

Such views—and the combative way in which he espouses them—frequently land Nutt in fierce disputes. Newspaper commentators have called him “Professor Nutty” or “the dangerous professor.” In 2009, he was sacked from his position as chair of the United Kingdom’s Advisory Council on the Misuse of Drugs, tasked with giving scientific advice to the home secretary, after he criticized a government decision on cannabis.

But in November 2013, he received the John Maddox Prize for standing up for science. “In circumstances that would have humiliated and silenced most people,” wrote neurobiologist Colin Blakemore, one of the judges, “David Nutt continued to affirm the importance of evidence in understanding the harms of drugs and in developing drug policy.”

Controversial comparisons
David Nutt does not look like a dangerous professor. Short and heavyset, he has a jovial, round face and an old-fashioned mustache; one could mistake him for a London taxi driver. He limps slightly, has a down-to-earth way of speaking, and laughs a lot when he talks. “He is a real personality,” says psychopharmacologist Rainer Spanagel of Heidelberg University in Germany. “You can be in a meeting and almost have a result, then he will come in an hour late, stir everything up, and in the end convince everyone of his position.”

Nutt says he realized at an early age that “understanding how the brain works is the most interesting and challenging question in the universe.” When he was a teenager, his father told him a story of how Albert Hofmann, the discoverer of LSD, took a dose of that drug and felt that the bike ride home took hours instead of minutes. “Isn’t that incredible, that a drug can change time?” he asks. On his first night as an undergraduate in Cambridge, he witnessed the powers of drugs again when he went drinking with fellow students. Two of them couldn’t stop. “I just watched them transform themselves. One of them started wailing and crying and the other became incredibly hostile.”

During his clinical training, Nutt says he treated many alcoholics but failed “to get anyone interested in how to reduce their addiction to the drug that was harming them.” He set out to answer that question, first in the United Kingdom, later as the chief of the Section of Clinical Science at the U.S. National Institute on Alcohol Abuse and Alcoholism, a job he held for 2 years. Today, he runs the department of neuropsychopharmacology at Imperial College, using modern imaging techniques to see what happens in the brain when people take drugs or develop an addiction.

But his biggest contribution to science, he says, was a discovery he made quite early in his career: that some molecules don’t just block receptors in the brain, but actually have the opposite effect of the molecules that normally stimulate them—and in doing so shut down a brain pathway. Nutt called these molecules contragonists, and he has made a second career out of being a bit of a contragonist himself, trying to calm society’s overexcited responses to the steady stream of alarming news about drugs.

Fictional affliction
In 2009, Nutt published an article in the Journal of Psychopharmacology comparing the harms from ecstasy with those caused by horse riding. Every 10,000th ecstasy pill is likely to hurt someone, he calculated, while an average horse enthusiast can expect a serious accident every 350 hours of riding. The sport, he concluded, was more dangerous than the notorious party drug. That “raises the critical question of why society tolerates—indeed encourages—certain forms of potentially harmful behaviour but not others such as drug use,” he added.

Politicians were not amused, and Nutt’s whimsical reference to a fictional affliction he called equine addiction syndrome, or “equasy,” did not help. In his book Drugs – Without the Hot Air, Nutt provided his account of a phone conversation he had with U.K. Home Secretary Jacqui Smith after the paper was published. (Smith calls it an “embroidered version” of their talk.)

Smith: “You can’t compare harms from a legal activity with an illegal one.”

Nutt: “Why not?”

“Because one’s illegal.”

“Why is it illegal?”

“Because it’s harmful.”

“Don’t we need to compare harms to determine if it should be illegal?”

“You can’t compare harms from a legal activity with an illegal one.”

Nutt says this kind of circular logic crops up again and again when he discusses recreational drugs with politicians. “It’s what we would call ‘splitting’ in psychiatric terms: this primitive, childish way of thinking things are either good or bad,” he says.

He’s often that outspoken. He likens the way drug laws are hampering legitimate scientific research, for instance into medical applications for psychedelic compounds, to the church’s actions against Galileo and Copernicus. When the United Kingdom recently banned khat, a plant containing a stimulant that’s popular among people from the Horn of Africa and the Arabian Peninsula, he compared the decision with banning cats. And he accuses the Russian government of deliberately using alcohol to weaken the opposition. “However miserable they are, however much they hate their government and their country, they will just drink until they kill themselves, so they won’t protest,” he says.

But it’s his stance on cannabis that got him sacked. In early 2009, ignoring advice from Nutt’s advisory council, Smith upgraded cannabis from class C to class B, increasing the maximum penalty for possession from 2 to 5 years in prison. A few months later, Nutt criticized the decision in a public lecture, arguing that “overall, cannabis use does not lead to major health problems” and that tobacco and alcohol were more harmful. When media reported the remarks, Alan Johnson, who succeeded Smith as home secretary in mid-2009, asked him to resign. “He was asked to go because he cannot be both a government adviser and a campaigner against government policy,” Johnson wrote in a letter in The Guardian.

Nutt did not go quietly. With financial help from a young hedge fund manager, Toby Jackson, he set up a rival body, the Independent Scientific Committee on Drugs, “to ensure that the public can access clear, evidence based information on drugs without interference from political or commercial interest.” Politics have skewed not just drug laws but research itself, he argues. “If you want to get money from the U.S. government to work on a drug, you have to prove it damages the brain,” he says.

One of his favorite examples is a paper that Science published in September 2002. The study, led by George Ricaurte at Johns Hopkins University, seemed to show that monkeys given just two or three doses of ecstasy, chemically known as MDMA, developed severe brain damage. The finding suggested that “even individuals who use MDMA on one occasion may be at risk for substantial brain injury,” the authors wrote. The paper received massive media attention, but it was retracted a year later after the authors discovered that they had accidentally injected the animals not with MDMA but with methamphetamine, also known as crystal meth, which was already known to have the effects seen in the monkeys. Nutt says the mistake should have been obvious from the start because the data were “clearly wrong” and “scientifically implausible.” “If that result was true, then kids would have been dropping dead from Parkinson’s,” he says.

Some resent this combative style. “He is a polarizing figure and the drug policy area is polarized enough,” says Jonathan Caulkins, a professor of public policy at Carnegie Mellon University in Pittsburgh, Pennsylvania. But Jürgen Rehm, an epidemiologist at the Centre for Addiction and Mental Health in Toronto, Canada, says Nutt has helped stimulate debates that were long overdue. “You don’t get to be on the front page of The Lancet and The New York Times unless you sharpen your arguments a little bit,” Rehm says. “I can live with that.”

Ranking the drugs
In 2010, Nutt sparked a new firestorm when he published another comparison: a Lancet paper ranking drugs according to the harm they cause. Nutt and other experts scored a long list of drugs on 16 criteria, nine related to the user, such as death from an overdose or wrecked relationships, and seven related to society, such as drug-fueled violence and economic costs. In the end, every drug was given a score between 0 and 100 to indicate its overall harm. Alcohol came out on top, ahead of heroin; mushrooms and ecstasy were at the low end.

Critics said the study’s methodology was flawed because it didn’t address drug interactions and the social context of drug use. “For instance, the number of fatalities caused by excessive alcohol use is going to depend in part on gun control laws,” says Caulkins, who calls the whole idea of expressing drug harm as a single number “embarrassing.”

Caulkins adds that even if a perfect ranking of drug harms were possible, it wouldn’t mean that politicians should put the tightest control measures on the most harmful drugs. Suppose drug A is more harmful to the individual and society than drug B, he says, but impurities in drug A, when illegally produced, can lead to potentially fatal organ failure while they just taste bad in drug B. If you were going to prohibit only one of the two drugs, it should be drug B, he says, even though it causes less harm per se, because criminalizing drug A would lead to a more dangerous product and more deaths. Nutt’s ranking of drugs, he says, is “a pseudoscientific exercise which is trying to take control of the policy process from a technocratic perspective in a way that isn’t even sound.”

Other scientists defended the paper. Using Nutt’s harm scales, “flawed and limited as they may be, would constitute a quantum leap of progress towards evidence-based and more rational drug policy in Canada and elsewhere,” two Canadian drug scientists wrote in Addiction. Regardless of its quality, the paper has been hugely influential, Rehm says. “Everyone in the E.U. knows that paper, whether they like it or not. There is a time before that paper and a time after it appeared.”

Nutt says his comparisons are an essential first step on the way to more evidence-based drug policies that seek to reduce harm rather than to moralize. The best option would be a regulated market for alcohol and all substances less harmful to the user than alcohol, he argues.

That scenario, under which only heroin, crack cocaine, and methamphetamine would remain illegal, seems unlikely to become a reality. But Nutt says he can already see more rational policies taking hold. Recently, Uruguay and the U.S. states of Colorado and Washington legalized the sale of recreational cannabis, going a step further than the Netherlands, which stopped enforcing laws on the sale and possession of small amounts of soft drugs decades ago. Nutt was also happy to read President Barack Obama’s recent comment that cannabis is less harmful than alcohol. “At last, a politician telling the truth,” he says. “I’ll warn him though—I was sacked for saying that.”

New Zealand, meanwhile, passed a law in 2013 that paves the way for newly invented recreational drugs to be sold legally if they have a “low risk” of harming the user. Nutt, who has advised the New Zealand government, is delighted by what he calls a “rational revolution in dealing with recreational drugs.” The main problem now, he says, is establishing new drugs’ risks—which is difficult because New Zealand does not allow them to be tested on animals—and deciding what “low risk” actually means. “I told them the threshold should be if it is safer than alcohol,” he says. “They said: ‘Oh my god, that is going to be far too dangerous.'”

Safer substitute
Nutt agrees that alcohol is now one of the most dangerous drugs on the market—which is why he’s trying to invent a safer substitute. The World Health Organization estimates that alcohol—whose harms range from liver cirrhosis, cancer, and fetal alcohol syndrome to drunk driving and domestic violence—kills about 2.5 million people annually. “When I scan the brains of people with chronic alcohol dependence, many have brains which are more damaged than those of people with Alzheimer’s,” Nutt says.

In a paper published this month in the Journal of Psychopharmacology, Nutt and Rehm summarize the top six interventions that governments should consider to reduce the harms of alcohol, such as minimum prices and restrictions on the places that can sell hard liquor. They also argue that governments should support the development of alternatives. Nutt points to e-cigarettes—devices that heat and vaporize a nicotine solution—as a model. “In theory, electronic cigarettes could save 5 million lives a year. That is more than [the death toll from] AIDS, malaria, tuberculosis, and meningitis put together,” he says. “I would argue that the e-cigarette is going to be the greatest health invention since vaccination.”

Can an alcohol alternative do the same? “I think that idea is utopian,” says Spanagel, the German psychopharmacologist. One reason is that researchers have recently developed a much more complex picture of what ethanol, as chemists call it, actually does. Twenty years ago, they thought that once it reached the brain, alcohol elicited its many effects by infiltrating the membranes of neurons there and changing their properties. “Now we know that’s nonsense. You would have to drink 5 liters of schnapps for that to happen,” Spanagel says.

In fact, scientists have learned that alcohol, like other drugs, interacts with the receptors for certain neurotransmitters. But unlike other drugs, it acts on a wide range of them, including receptors for GABA, NMDA, serotonin, and acetylcholine. That will make it hard to find a substance to emulate most of alcohol’s wanted effects while avoiding the unwanted ones, Spanagel predicts.

Nutt is concentrating on the GABA system—the most important inhibitory system in mammalian brains. Alcohol activates GABA receptors, effectively quieting the brain and leading to the state of relaxation many people seek. Nutt has sampled some compounds that target GABA receptors and was pleasantly surprised. “After exploring one possible compound I was quite relaxed and sleepily inebriated for an hour or so, then within minutes of taking the antidote I was up giving a lecture with no impairment whatsoever,” he wrote in a recent article.

But he wants to go one step further. “We know that different subtypes of GABA mimic different effects of alcohol,” he says. Nutt combed the scientific literature and patents for compounds targeting specific GABA receptors, and, in an as-yet unpublished report that he shared with Science, he identifies several molecules that he says fit the bill. Compounds targeting subtypes of the GABAA receptor called alpha2 and alpha3 are particularly promising, he says. Some of these molecules were dropped as therapeutic drug candidates precisely because they had side effects similar to alcohol intoxication.

Gregg Homanics, an alcohol researcher at the University of Pittsburgh, is skeptical that another substance could mimic all the positive effects of alcohol. “You could come up with a drug that might make you feel good. But is it going to be the same good feeling as alcohol? I doubt that.” Such a drug might have downsides of its own, warns Andreas Heinz, an addiction researcher at Charité University Medicine Berlin. It could still turn out to be addictive or to harm a small proportion of the population. “There is an advantage when you have known drugs for hundreds of years and you know exactly what they do,” he says.

Still, Nutt’s appearance on the BBC radio program attracted new investors, ranging “from Ukrainian brewers to American hedge funds,” he says, and Imperial Innovations, a company that provides technology transfer services, is working with him “to consider a range of options for taking the research forward,” a spokesperson says. “We think we have enough funding now to take a substance all the way to the market,” Nutt says—in fact, he hopes to be able to offer the first cocktails for sale in as little as a year from now.

Even a very good alcohol substitute would face obstacles. Many people won’t forsake drinks they have long known and loved—such as beer, wine, and whiskey—for a new chemical, Spanagel says. The idea will also trigger all kinds of political and regulatory debates, Rehm says. “How will such a new drug be seen? Will you be able to buy it in the supermarket? In the pharmacy? Will society accept it?”

Whatever the outcome, Nutt’s quest for a safer drink has already made people think about alcohol in a new way, Rehm adds. “It’s provocative in the best sense of the word.” Much the same could be said of the scientist who thought it up.

http://www.sciencemag.org/content/343/6170/478.full

silk road

From an Internet café in San Francisco, a 29-year-old free-market evangelist who called himself “Dread Pirate Roberts” used untraceable web services, an international network of servers and anonymous digital currency to run a global online exchange of cocaine and heroin beyond the reach of the law.

For two years, cybercrime experts from the FBI pored over the secretive online drug bazaar known as Silk Road — an underground operation that had become, by the time the FBI shut it down this week, the venue for $1 billion worth of illegal transactions, according to prosecutors. Seeking the mastermind behind it, investigators began picking up clues: an anonymous posting to a website devoted to hallucinogenic mushrooms, recurring references to an Austrian school of economics, and early clues left on public sites including Google and LinkedIn.

A big break came in July, when a routine inspection of inbound mail from Canada turned up a parcel containing nine counterfeit IDs — each with a different name, but all featuring the photograph of the same man.

According to a 33-page criminal complaint unsealed yesterday in Manhattan federal court, the man in the ID photos was Ross Ulbricht, Silk Road’s alleged overseer. FBI agents arrested Ulbricht in San Francisco the same day at the Glen Park library in San Francisco, where he had gone to log onto a computer, according to a person briefed on the matter.

The criminal complaint against Ulbricht depicts the dark side of Internet commerce. In it, special agent Christopher Tarbell of the FBI’s New York office described Silk Road as “the most sophisticated and extensive criminal marketplace on the Internet today” — a virtual bazaar where buyers could find everything from heroin and hacking software to contact information for hit men in more than 10 different countries.

Meanwhile, on July 10 of this year, customs officials intercepted the package from Canada as part of what the complaint characterized as a routine inspection. The package, addressed to an apartment on 15th Street in San Francisco, contained nine counterfeit IDs, each in a different name, but all featuring a photo of the same person.

Agents from Homeland Security Investigations arrived on July 26 at the 15th Street address. There, according to the complaint, they encountered Ross Ulbricht, whose photo matched those on all nine fake IDs.

Confronted with a fake California driver’s license bearing his photo and birthdate but a different name, Ulbricht avoided answering questions about the purchase of false IDs, according to the complaint. Instead, he volunteered that “hypothetically” anyone could go onto a website named Silk Road and purchase any drugs or counterfeit IDs they wanted. Ulbricht then produced his real ID, a Texas driver’s license, according to the complaint, and explained that he was subletting a room in the apartment for $1,000 a month. According to the complaint, he also said the roommates knew him as “Josh.”

Ulbricht stands accused of narcotics trafficking, money laundering, computer-hacking conspiracy and, in an indictment unsealed yesterday in Maryland, of attempted murder.

Bitcoin Bets Feed Twitter Dreams as Regulators CircleCyber Drug Bazaar’s Alleged Boss Paired EBay Style, Crime
The genius of Silk Road’s design and the reason it eluded the FBI’s grasp for so long, according to the complaint, was its impenetrability. The site was accessible only on a so-called tor network, which is designed to conceal the true Internet addresses of computers using it. Its exclusive reliance on Bitcoin, an anonymous digital currency, added another layer of protection for its buyers and sellers.

Since November 2011, Tarbell’s team made more than 100 purchases of drugs from Silk Road vendors, accepting shipments of ecstasy, cocaine, heroin, LSD and other drugs posted from 10 different countries, including the U.S., according to the complaint.

In the FBI’s bid to identify the individual behind Silk Road, an agent on Tarbell’s team combed through Internet postings and discovered the earliest mention of the site on shroomery.org, an informational website for consumers of “magic mushrooms,” in January 2011.

The posting, from someone with the username altoid, alerted the site’s visitors to Silk Road and asked if anyone had tried it. Two days later, someone using the same username posted a similar message on “bitcointalk.org,” a discussion forum for the virtual currency.

“The two postings created by ’altoid’ on Shroomery and Bitcoin Talk appear to be attempts to generate interest in the site,” Tarbell wrote. “The fact that ’altoid’ posted similar messages about the site on two very different discussion forums, two days apart, indicates that ’altoid’ was visiting various discussion forums…and seeking to publicize the site among the forum users — which, based on my training and experience, is a common online marketing tactic for new websites.”

In October 2011, altoid surfaced again on the Bitcoin forum, seeking an “IT pro” to help build a Bitcoin startup company and directing potential job candidates to the Gmail account of someone named Ross Ulbricht. From a Google profile associated with the account, the FBI learned that Ulbricht had an interest in the Austrian school of economics and the Auburn, Alabama-based Ludwig von Mises Institute. According to the group’s website, it functions as a center of Libertarian political and social theory.

Similar sentiments are voiced on a page of professional networking site LinkedIn that is also attributed to Ulbricht, according to the complaint. In a LinkedIn profile accessed yesterday, a user identified as Ross Ulbricht describes himself as an “investment adviser and entrepreneur” and lists his interests as “trading, economics, physics, virtual worlds, liberty.”

Agents made a connection between Ulbricht and Silk Road: The site’s webmaster, who identified himself as Dread Pirate Roberts, made regular references to Austrian economic theory and the teachings of Mises to justify Silk Road’s existence.

The New York FBI agents weren’t the only lawmen gunning for Silk Road. In April 2012, a federal agent in Maryland began communicating with Dread Pirate Roberts in an undercover capacity, posing as a drug dealer.

In January, the undercover agent completed the sale of a small quantity of cocaine to a Silk Road employee and was paid the equivalent of $27,000 in Bitcoin currency. According to the Maryland indictment, Dread Pirate Roberts subsequently asked the undercover agent to murder an employee the site overseer believed to have stolen money from Silk Road.

During this time, Tarbell’s team in New York tracked the Silk Road webmaster’s online logins to an Internet café on Laguna Street in San Francisco, near an apartment where Ulbricht had moved.

Following the confrontation, Tarbell and his team learned that in the weeks leading up to the discovery of the counterfeit identity papers, Dread Pirate Roberts had sent a series of private e-mails suggesting that he “needed a fake ID,” according to the complaint.

All the while, word of Silk Road and its bazaar of illicit goods and services spread around the Internet. In August, Forbes.com posted an interview with Dread Pirate Roberts that it said was conducted via messages sent through the site. “The highest levels of government are hunting me,” the cyber entrepreneur said, adding: “I can’t take any chances.”

Yesterday afternoon, Ulbricht surfaced at San Francisco’s Glen Park library, a small branch facility where public computers are located in front of the check-out desk. There, according to the person familiar with the matter, he was arrested by the FBI.

The criminal case is U.S. v. Ulbricht, 13-mg-023287; the civil forfeiture case is U.S. v. Ulbricht, 13-cv-06919, U.S. District Court, Southern District of New York (Manhattan).

To contact the reporters on this story: Greg Farrell in New York at gregfarrell@bloomberg.net

To contact the editor responsible for this story: Michael Hytha at mhytha@bloomberg.net

http://www.businessweek.com/news/2013-10-03/fbi-captures-alleged-silk-road-pirate-boss-using-his-own-methods#p2

Thanks to Kebmodee for bringing this to the attention of the It’s Interesting community.

 

How far should doctors go in attempting to cure addiction? In China, some physicians are taking the most extreme measures. By destroying parts of the brain’s “pleasure centers” in heroin addicts and alcoholics, these neurosurgeons hope to stop drug cravings. But damaging the brain region involved in addictive desires risks permanently ending the entire spectrum of natural longings and emotions, including the ability to feel joy.

In 2004, the Ministry of Health in China banned this procedure due to lack of data on long term outcomes and growing outrage in Western media over ethical issues about whether the patients were fully aware of the risks.

However, some doctors were allowed to continue to perform it for research purposes—and recently, a Western medical journal even published a new study of the results. In 2007, The Wall Street Journal detailed the practice of a physician who claimed he performed 1000 such procedures to treat mental illnesses such as depression, schizophrenia and epilepsy, after the ban in 2004; the surgery for addiction has also since been done on at least that many people.

The November publication has generated a passionate debate in the scientific community over whether such research should be published or kept outside the pages of reputable scientific journals, where it may find undeserved legitimacy and only encourage further questionable science to flourish.

The latest study is the third published since 2003 in Stereotactic and Functional Neurosurgery, which isn’t the only journal chronicling results from the procedure, which is known as ablation of the nucleus accumbens. In October, the journal World Neurosurgery also published results from the same researchers, who are based at Tangdu Hospital in Xi’an.

The authors, led by Guodong Gao, claim that the surgery is “a feasible method for alleviating psychological dependence on opiate drugs.” At the same time, they report that more than half of the 60 patients had lasting side effects, including memory problems and loss of motivation. Within five years, 53% had relapsed and were addicted again to opiates, leaving 47% drug free.

(MORE: Addicted: Why We Get Hooked)

Conventional treatment only results in significant recovery in about 30-40% of cases, so the procedure apparently improves on that, but experts do not believe that such a small increase in benefit is worth the tremendous risk the surgery poses.  Even the most successful brain surgeries carry risk of infection, disability and death since opening the skull and cutting brain tissue for any reason is both dangerous and unpredictable. And the Chinese researchers report that 21% of the patients they studied experienced memory deficits after the surgery and 18% had “weakened motivation,” including at least one report of lack of sexual desire. The authors claim, however, that “all of these patients reported that their [adverse results] were tolerable.” In addition, 53% of patients had a change in personality, but the authors describe the majority of these changes as “mildness oriented,” presumably meaning that they became more compliant. Around 7%, however, became more impulsive.

The surgery is actually performed while patients are awake in order to minimize the chances of destroying regions necessary for sensation, consciousness or movement.  Surgeons use heat to kill cells in small sections of both sides of the brain’s nucleus accumbens.  That region is saturated with neurons containing dopamine and endogenous opioids, which are involved in pleasure and desire related both to drugs and to ordinary experiences like eating, love and sex.

(MORE: A Drug to End Drug Addiction)

In the U.S. and the U.K., reports the Wall Street Journal, around two dozen stereotactic ablations are performed each year, but only in the most intractable cases of depression and obsessive-compulsive disorder and after extensive review by institutional review boards and intensive discussions with the patient, who must acknowledge the risks. Often, a different brain region is targeted, not the nucleus accumbens. Given the unpredictable and potentially harmful consequences of the procedure, experts are united in their condemnation of using the technique to treat addictions. “To lesion this region that is thought to be involved in all types of motivation and pleasure risks crippling a human being,” says Dr. Charles O’Brien, head of the Center for Studies of Addiction at the University of Pennsylvania.

David Linden, professor of neuroscience at Johns Hopkins and author of a recent book about the brain’s pleasure systems calls the surgery “horribly misguided.”  He says “This treatment will almost certainly render the subjects unable to feel pleasure from a wide range of experiences, not just drugs of abuse.”

But some neurosurgeons see it differently. Dr. John Adler, professor emeritus of neurosurgery at Stanford University, collaborated with the Chinese researchers on the publication and is listed as a co-author.  While he does not advocate the surgery and did not perform it, he believes it can provide valuable information about how the nucleus accumbens works, and how best to attempt to manipulate it. “I do think it’s worth learning from,” he says. ” As far as I’m concerned, ablation of the nucleus accumbens makes no sense for anyone.  There’s a very high complication rate. [But] reporting it doesn’t mean endorsing it. While we should have legitimate ethical concerns about anything like this, it is a bigger travesty to put our heads in the sand and not be willing to publish it,” he says.

(MORE: Anesthesia Study Opens Window Into Consciousness)

Dr. Casey Halpern, a neurosurgery resident at the University of Pennsylvania makes a similar case. He notes that German surgeons have performed experimental surgery involving placing electrodes in the same region to treat the extreme lack of pleasure and motivation associated with otherwise intractable depression.  “That had a 60% success rate, much better than [drugs like Prozac],” he says. Along with colleagues from the University of Magdeburg in Germany, Halpern has just published a paper in the Proceedings of the New York Academy of Sciences calling for careful experimental use of DBS in the nucleus accumbens to treat addictions, which have failed repeatedly to respond to other approaches. The paper cites the Chinese surgery data and notes that addiction itself carries a high mortality risk.

DBS, however, is quite different from ablation.  Although it involves the risk of any brain surgery, the stimulation itself can be turned off if there are negative side effects, while surgical destruction of brain tissue is irreversible. That permanence—along with several other major concerns — has ethicists and addiction researchers calling for a stop to the ablation surgeries, and for journals to refuse to publish related studies.

Harriet Washington, author of Medical Apartheid:  The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present, argues that by publishing the results of unethical studies, scientists are condoning the questionable conditions under which the trials are conducted. “When medical journals publish research that violates the profession’sethical guidelines, this serves not only to sanction such abuses, but to encourage them,” she says. “In doing so, this practice encourages a relaxing of moral standards that threatens all patients and subjects, but especially  the medically vulnerable.”

(MORE: Real-Time Video: First Look at a Brain Losing Consciousness Under Anesthesia)

Shi-Min Fang, a Chinese biochemist who became a freelance journalist and recently won the journal Nature‘s Maddox prize for his exposes of widespread fraud in Chinese research, has revealed some of the subpar scientific practices behind research conducted in China, facing death threats and, as the New York Times reported, a beating with a hammer. He agrees that publishing such research only perpetuates the unethical practices. Asked by TIME to comment on the addiction surgery studies, Fang writes that publishing the research, particularly in western journals, “would encourage further unethical research, particularly in China where rewards for publication in international journals are high.”

While he doesn’t have the expertise to comment specifically on the ablation data, he says “the results of clinical research in China are very often fabricated. I suspect that the approvals by Ethics Committee mentioned in these papers were made up to meet publication requirement. I also doubt if the patients were really informed in detail about the nature of the study.” Fang also notes that two of the co-authors of the paper are advertising on the internet in Chinese, offering the surgery at a cost of 35,000 renminbi, about $5,600.  That’s more than the average annual income in China, which is about $5,000.

Given the available evidence, in fact, it’s hard to find a scientific justification for even studying the technique in people at all. Carl Hart, associate professor of psychology at Columbia University and author of the leading college textbook on psychoactive drugs, says animal studies suggest the approach may ultimately fail as an effective treatment for addiction; a 1984 experiment, for example, showed that destroying the nucleus accumbens in rats does not permanently stop them from taking opioids like heroin and later research found that it similarly doesn’t work for curbing cocaine cravings. Those results alone should discourage further work in humans. “These data are clear,” he says, “If you are going to take this drastic step, you damn well better know all of the animal literature.” [Disclosure:  Hart and I have worked on a book project together].

(MORE: Top 10 Medical Breakthroughs of 2012)

Moreover, in China, where addiction is so demonized that execution has been seen as an appropriate punishment and where the most effective known treatment for heroin addiction— methadone or buprenorphine maintenance— is illegal, it’s highly unlikely that addicted people could give genuinely informed consent for any brain surgery, let alone one that risks losing the ability to feel pleasure. And even if all of the relevant research suggested that ablating the nucleus accumbens prevented animals from seeking drugs, it would be hard to tell from rats or even primates whether the change was due to an overall reduction in motivation and pleasure or to a beneficial reduction in desiring just the drug itself.

There is no question that addiction can be difficult to treat, and in the most severe cases, where patients have suffered decades of relapses and failed all available treatments multiple times, it may make sense to consider treatments that carry significant risks, just as such dangers are accepted in fighting suicidal depression or cancer.  But in the ablation surgery studies, some of the participants were reportedly as young as 19 years old and had only been addicted for three years.  Addiction research strongly suggests that such patients are likely to recover even without treatment, making the risk-benefit ratio clearly unacceptable.

The controversy highlights the tension between the push for innovation and the reality of risk. Rules on informed consent didn’t arise from fears about theoretical abuses:  they were a response to the real scientific horrors of the Holocaust. And ethical considerations become especially important when treating a condition like addiction, which is still seen by many not as an illness but as a moral problem to be solved by punishment.  Scientific innovation is the goal, but at what price?
Read more: http://healthland.time.com/2012/12/13/controversial-surgery-for-addiction-burns-away-brains-pleasure-center/#ixzz2ExzobWQq

Thanks to Dr. Lutter for bringing this to the attention of the It’s Interesting community.

 

Oxycodone

Posted: June 26, 2011 in Health, Oxycodone

Abuse of oxycodone, a prescription opioid painkiller, is an epidemic responsible for millions of overdoses and at least 11,000 deaths annually.

 A pharmaceutical form of heroin, the drug is now a top seller, with 100 million prescriptions written over the past 15 years – the equivalent of 1 bottle of pills for every 3 Americans.

Read about it here:  http://www.alaskadispatch.com/article/why-its-so-hard-win-war-against-us-oxycodone-epidemic