Drugs and Society: Harm Reduction

CJ Trowbridge

2020-06-30

Drugs and Society

Section 10 Reading Response: Harm Reduction

Swapping Politics for Science
- When the drug czar calls for an end to the war on drugs, it’s clearly the start of a new era.
- Obama lifted the federal ban on needle exchanges in 2010
- all of the top brass in the Obama administration were on record in favor of lifting the ban
- The house went back and forth for a long time on the wording of what would essentially still be a ban.
- research suggests that funded needle exchanges will cut down on deaths due to drug-related infectious disease
  - Inject Narcan–i.e., naloxone–into the muscle of someone who is dying of a heroin or OxyContin overdose, and within seconds he is awake and very much alive. Narcan has been used for decades in ambulances and emergency rooms to reverse opiate overdose
- the majority of states lack legislation on the issue, so a person administering naloxone to someone else may be vulnerable to prosecution should something go wrong.
- At least a half-dozen countries, including the Netherlands, Switzerland, and the UK, allow prescription of pharmaceutical heroin, known as diamorphine, to users who have failed to improve using all other available treatment options. Diamorphine is prescribed to “people who have been through methadone, been through jail, been through drug free [treatment facilities], been through the whole gamut of things, and for whom nothing was working,” says Ethan Nadelmann, the executive director of the Drug Policy Alliance (DPA), which worked in partnership with a group in Canada to set up that country’s first clinical trial of heroin maintenance.
  - (The trial enrolled 250 users in two cities; early results show a significant reduction in participants’ criminal involvement and an increase in their health.) As recently as this year, both the German and Danish parliaments voted to allow prescription of heroin to those who have not responded to other treatments.
  - Nadelmann is hopeful that a clinical trial similar to Canada’s can be set up in the US in the coming years. but Columbia University associate professor of clinical neuroscience Carl Hart is not so sanguine. “People have been brainwashed [into thinking], ‘These awful drugs that are causing so many problems–you’re going to give it as a medication?’ ” he says, citing deepseated public fears.
- That precisely describes methadone. Methadone and heroin operate in identical ways on opiate receptors in the brain. They are both “full agonists,” meaning they fill up opiate receptors in such a way as to make the user high.
  - The main difference between heroin and methadone is not their chemical composition but their legality. The daily hustle for heroin often forces users into other illegal activity, like petty drug dealing, prostitution and burglary, to support their habit, and creates an expensive, unproductive revolving door between prison and the street. Methadone, covered by insurance, frees people from this cycle.
  - Because methadone is administered by physicians, it can be dispensed in amounts precisely calibrated to someone’s addiction to make that person feel “normal,” rather than high, and eliminates the craving and withdrawal symptoms that drive people to use. Heroin, sold on the black market, is “cut” with adulterants; at best, the cut (like baby powder or quinine) is itself harmless but causes wide variation in the strength of the heroin–which makes it impossible for a user to know exactly how much he is using.
- Over the years, a cottage industry of ancillary services has grown up around methadone clinics. Everything from talk therapy to medical care to Narcotics Anonymous meetings to group picnics and bowling excursions has come to be understood as a necessary component of the treatment of such a psychosocially complicated problem as addiction.
- Scientists have been looking for years for a gene or a pill that can treat the disease without all the messy and unpredictable psychological baggage that the meetings and talk therapy are designed to address.
  - What will happen when users can sidestep the counseling and the clinics, and just take the “anti-addiction pill” that their local primary care doc prescribes along with their blood pressure medication?
  - I find this idea laughable because it fails so completely to learn the lessons of what causes addiction.
- yes to scs California
  - Safer drug consumption services (SCS) are designated sites where people can use drugs under the the safety and supervision of trained personnel.
  - Over 100 sites exist in 67 cities in eleven countries around the world. After 30 years of operations, SCS have demonstrated to prevent overdose, HIV and hepatitis C transmission, injection-related infection, and public disposal of syringes.
  - the California State Assembly became the first legislative body in the U.S. to pass a bill to permit safe consumption services that would allow people who use drugs to use controlled substances under the supervision of staff trained to treat and prevent drug overdose and link people to drug treatment, housing and other services.
    - passed the CA state assembly with bipartisan support
    - The bill would allow local jurisdictions to choose to permit SCS and provide legal protections for the programs and participants. It creates a pilot program, allowing a limited number of jurisdictions to operate the services, and requires a report on the efficacy of the services
    - In September of 2018, the bill was amended to only apply to San Francisco County and was brought back up for a vote. The amended bill passed both the Assembly and the Senate, but was then veteod by exiting California State Governor, Jerry Brown
  - In May 2017, Board of Supervisors President London Breed appointed a 15-member task force to assess if and how SCS could become a reality in the city
  - There is a page of links to lots of other documents
  - Most of the information on the site is years out of date. They say to follow them on twitter for more current information
- Clean needles save lives
  - Congress voted to lift the ban on needle exchanges
  - The idea started as a way to reduce the spread of hiv by exchanging old dirty needles for new clean needles
  - In New York, about half of injection drug users in the 80s had AIDS. Over a dozen syringe exchanges were started as a way of reducing the spread of AIDS. Now, just 10% of injection drug users have HIV, so it was very effective at slowing the spread of HIV among injection drug users in New York
  - 5-10% of injection drug users nationwide are using needle exchanges.
  - A single HIV case costs over a quarter of a million dollars over a person’s lifetime.
    - Syringes cost about ten cents.
  - Syringe exchanges also offer drug users access to healthcare, mental healthcare, STI testing, and treatment for other problems associated with drug use.
    - This includes providing them the option of getting into drug treatment.
  - Syringe exchanges also teach people to use naloxone and supply it to them so they can save one another from overdoses.
- I love my job: fighting addiction and overdose in the streets of San Francisco
  - “I would do this job for free if I won the lottery tomorrow”
  - A team stands in sf’s civic center handing out harm reduction supplies like condoms, needles, Narcan, etc.
  - Over the next couple of hours, they distribute 2,840 needles, 33 safe disposal bins, and 3 naloxone refills
  - These brief exchanges are meant to get users on the path to treatment: The idea is that after hearing Buehlman’s spiel over and over, users might actually take him up on the offer of help. “Sometimes it might be 50 to 100 times we’ll see somebody” before they make their way to Glide for supplies or treatment, he says. “Sometimes, I’ll see someone once on outreach, they come in, they do a HIV and Hep C test, we link them with our navigators, a month after that, they’re like, ‘I got into residential! I’m clean, bro!’”
  - The program is as classic example of harm reduction, a public health philosophy that encourages making illicit drug use safer so that users survive and eventually seek treatment.
  - a wealth of academic research has found that these kinds of interventions stop the spread of disease and save lives
  - Last year, users and other laypeople with no medical training used naloxone to reverse 877 overdoses—about as many as the San Francisco Fire Department, the city’s largest emergency medical provider. In 2015, San Francisco had just two documented cases of new HIV infections transmitted through dirty needles.
  - Over the past couple years, using heroin has become far more dangerous due to the arrival of fentanyl, an illicitly produced synthetic opioid that’s up to 100 times more powerful than morphine. It’s often mixed in with heroin and other drugs so that, as Todd puts it, “you don’t know what you’re doing anymore.”
- a radical reversal
  - Early on the morning of Feb. 22, several hours before sunrise, a security guard at the Urban School on Page Street found three men sheltered in the arched doorways of the elite private academy. He couldn’t wake them, and when paramedics arrived, they pronounced the trio dead at the scene. Several hours later, the three were identified as David Clark, 31, Adam Wilson, 36, and Michael Campbell, 32 — the latter of whom was known by his friends as Pan. The friends, who all lived in the Haight, had allegedly found a baggie of drugs on the ground as they left a liquor store. Assuming it was ketamine, they smoked it, not knowing it contained fatal levels of fentanyl.
  - At the center of San Francisco’s battle against these fatal overdoses is one drug: Narcan. Packaged under the generic name naloxone, Narcan was developed to reverse opioid overdoses while they’re in process. When someone has taken too much of an opiate, their breathing slows, and may eventually cease, resulting in death. When Narcan is administered — either in a nasal spray or an intramuscular injection — the opioids are knocked out of the brain’s receptors. If applied early on in the overdose, Narcan immediately stops the effects, bringing the person to consciousness.
  - Today, more than 120 Narcan teachers have completed the training program. They have subsequently taught 10,414 others in San Francisco how to recognize an overdose and administer the overdose medication. In addition, Narcan can be found at more than 15 locations throughout the city, from pop-up needle-exchanges to food banks.
    - San Francisco’s overdose mortality rate is one of the lowest in the nation
  - “We have achieved an extremely high level of people carrying naloxone, partly because of our program structure which allows people to access it in all areas,”
  - Fentanyl test strips hit the streets in S.F. in August 2017, and the DOPE Project has closely monitored the results. Between August and January, nearly 250 surveys from people who’d used them have been turned in at syringe-access sites, presenting useful data for harm reduction researchers. Of the drugs tested, 78 percent of the speed or methamphetamine samples tested came back positive for fentanyl, as did 67 percent of the crack cocaine samples. Of those who had positive results, 92 percent of them shared the information with their community.
    - “This means 62 percent of drugs testing positive for Fentanyl,” she writes.
  - President Donald Trump has compared opioid use to his late brother’s alcoholism, saying he plans to launch an ad campaign targeted at youth that will disclose “the devastation and ruination [drugs cause] people and people’s lives.” He’s also proposed an additional $400 million for the Drug Enforcement Administration, to criminalize those dealing and using drugs.
  - There are innumerable issues with all of this: Trump launching a campaign to shame drug users, his commitment to filling prisons with dealers, and the click-bait headlines that easily skirt by the human intricacies behind the “opioid crisis.” But what is most frustrating to those who’ve worked in harm reduction for years is that this “epidemic” is only now getting attention.
    - “There is nothing new about what is happening right now,” Marshall said. “People have been dying from drug use and the War on Drugs for years. The only reason we’re calling for compassionate treatment is because the visibility right now is that white folks and affluent folks are dying from drug use.
  - worth saving
    - Back story with several anecdotes leading to the DOPE project as discussed in the previous article.
    - The threat of incarceration prevents people from acting to save the lives of others who are suffering from overdoses
    - “The idea that we engage with people where they are and help them to develop techniques to reduce harm to themselves and others is a basic tenet of practicing medicine.”
    - The central argument of the video is that while there is a pervasive fascist belief in American culture that drug users should simply be allowed to die if they overdose, educating people about saving lives during overdoses includes first showing them that people who are overdosing are worth saving. This prejudice can often be internalized by drug users. At one point in the video it is explained that when one drug user saves another drug user, they may say to themselves, “hey I’m worth saving too.”
  - Chicago Recovery Alliance: Substance Use Management
    - Disease has increased our motivation to reconsider how our help system deals with drug related problems. A more concrete focus on disease prevention as an additional goal has, for many, lead to a re-evaluation of the goals of drug help work. Such a critical examination shows how much there is to improve with the system even in the absence of blood borne disease.
    - Substance Use Management (SUM) is the practice of setting a new perspective on what constitutes help with drug problems and respectfully and collaboratively assisting the positive changes selected by the person seeking help
      - recognizes that no matter how far into drug abuse a person is their basic humanity is never completely lost
      - Our history of attempting to assist others in lessening negative consequences of drug use is relatively brief compared to other disciplines
      - More effective than abstinence models
    - SUM replaces the indoctrination of the disease model of addiction ideology so common in the treatment system today with an ideology of actual improvement and a process of respectful and collaborative engagement. Four steps to guide the counselor in the practice of SUM are described below:
      - Making a transition to SUM’s multi-goal approach requires a good degree of reframing of what it means to give or receive help for drug problems. It is so entrenched in popular belief that abstinence is the only successful outcome of the drug help system that “cleaning/drying/sobering up” are part and parcel of any common understanding of treatment. In reality, people could benefit from the treatment system by simply moderating their drug use or otherwise relieving drug related problems. These non-abstinent alternatives are real outcomes today, even though they are not assisted directly and, at some level, the individual’s continuing use is judged a failure by the program.
      - Continuing the buffet table metaphor, Step Two would involve the counselor giving the person seeking help a clean plate and silverware, introducing her to each dish if not familiar with it, and allowing her to select dishes and portion sizes . Assisting someone to make these choices freely without guiding her to the dish (approach/method/goal) you or your agency most prefer requires great skill and respect for the person. Limiting any ‘help’ in this step to explaining all options with equal balance and having the readiness to support the client’s choice(s) as they freely make them is critical. As well, accepting the client’s level of intensity and prioritizations they give each choice is a critical aspect to SUM. Such client directed selections are essential steps to initiating SUM’s work.
      - By working entirely with the choices of the person you are helping you are saying two things loud and clear that are critical to SUM’s practice: 1) The person is not only in charge but self-responsible; and 2) The counselor accepts and respects this fact at all times. I have found such an approach releases the counselor of undue responsibility for the person they are assisting and thus allows a healthier, more realistic relationship. Many counselors will rejoice in the release of this burden associated Page 9 with forcing a goal of abstinence-only. Others may struggle to accept this as truly ‘caring’ and ‘helpful’. Clearly, today’s counselor will be challenged to clarify her own desires from those of the people she is helping and to deal with the emotional turmoil that can arise from accepting and respecting the inclinations of someone not only seeking help but also who is ‘sick’. In SUM, no one is ‘too sick’ to make their own decisions regarding their drug use no matter the shame or devastation in their lives. SUM accepts the reality that people will always make their own decisions regarding their drug use. Openly addressing the issues involved in this choice allows a person to make a better decision for themselves.
      - By offering respect and working with your client’s direction and intensity you are laying the ground work for an honest evaluation of progress — beyond shame and fear of condemnation. The clarity that comes from acceptance and respect of an individual works its miracles here. Unburdened by punitive measures and failure to achieve program given goals, people can be more honest in evaluating the effectiveness of what they have chosen to work on. Such examinations should be a regular part of SUM in order to reassess any and all aspects of the chosen SUM plan. What some consider a overly permissive system in SUM is purposefully so due to the benefits from such an approach in the evaluation phase. By laying a bridge of connection through respect and collaboration the person seeking help will very likely have developed an alliance with the counselor and be likely to use this relationship to re-examine their actual experiences and plan other directions for their next effort at improvement.
    - According to Webster, enabling simply means “provision of the means or opportunity for doing”. Clearly, whether enabling is constructive or destructive depends upon what is enabled. Traditionally, talking with significant others of problematic drug users about enabling often helps them recognize their own role in the user’s drug consumption and how to ‘get tough’ in helping the drug user to get better. While self-examinations are never out of place for anyone and much can be gained from such insights to relieve drug problems, enabling must not be used to generate punishment and condemnation for lack of abstinence. Such tag-team oppression towards a person with drug problems increases her risk of harm. Still, lines sometimes need to be drawn in relations with another Page 11 person. SUM re-frames enabling as both helpful and hurtful according to both its impact and the values of the person acting it out.
      - If the enabler’s action in question is not consistent with her own values, and also directly causes harm to the other person, then this action is harmfully enabling
      - If the enabler’s action in question is consistent with her own values, and does not directly cause harm to the other person, then this action is not harmfully enabling.
    - san francisco drug user union
      - It is the tenants who set 149 Turk apart: a ragtag group of current and former drug users who make no apologies about their fondness for illegal narcotics, intravenous experiences and the undeniable rush of getting high.
      - “If you pass a drug test,” joked Gary West, a member, “you’re outta here.”
      - The union is one of several groups in the United States and Canada that advocate for the rights of drug users, following the lead of older European drug user organizations.
      - The group says they are not promoting illegal drug use, just confronting the reality that many people use.
      - “People think it’s a joke,” he said. “They think of union as a kind of trade union. They don’t understand that we’re using ‘union’ in the sense of a consumer union. And we’re consumers of drug policies, we’re consumers of rehab, we’re consumers of drugs.”
      - In San Francisco, the drug union received its first grant in 2009, Mr. Jackson said, and got more help in December 2010 from the city’s Hepatitis C Task Force, which advocated for a pilot “supervised injection facility” for intravenous drug users because they often contract hepatitis by using dirty needles. No such facility exists in the United States — a so-called safe injection site in Vancouver, British Columbia, has been considered a success there — and it has become a central goal of the San Francisco union.
      - There are lots of anecdotes about how the various members got into this work.
    - Risk Environment
      - The new public health movement of the 1980s coincided with the emergence of HIV infection and AIDS in many countries. The movement was heralded as a shift beyond bio-medical understandings towards a new understanding which encompassed the social and environmental influences on health
      - The new public health advocates the need to balance individual and collective action as a means of facilitating changes in individual and population health
      - The World Health Organization endorsed principles of the new public health movement are contained within the Ottawa Charter for Health Promotion (WHO, 1986). The five principles are:
        
        developing individual personal and social skills;
        
        re-orientating health services toward improving access, availability, and use;
        
        facilitating and strengthening community participation and collective action;
        
        creating local environments that are conducive to individual and community health;
        
        and, lastly, creating public policies supportive of health.
        
        Taken together, risk reduction is an inter-sectoral and multi-level activity encouraging individual, community, policy, and environmental change.
      - The principles of the new public health are one and the same as the principles of effective harm reduction. The new public health and harm reduction are parallel social movements. Not only do they coincide historically, they coincide conceptually. More than this, harm reduction has been held up as a model of the new public health movement. The international evidence for this is that the cities or countries with most success in controlling, averting or reversing HIV epidemics among injecting drug users have adopted interventions in keeping with the principles of effective public health
      - Evidence in Kathmandu shows the importance of HIV prevention coverage, with approximately 50 000 needles and syringes distributed annually to IDUs in the context of an estimated 1.6 million sets required in order to eliminate needle sharing, assuming that the estimated number of IDUs use the same needle and syringe five times
      - Neo-liberal western societies are arguably the worst for victim-blaming, despite claims to the contrary and having developed elaborate forms of citizenship rights and responsibilities. The individuation of risk reduction persists even in those settings reportedly most progressive in their pursuance of ‘new’ public health oriented drug policies. A risk environment and enabling approach seeks to work against victim-blaming.
      - A harm reduction praxis founded on a risk environment framework illuminates the parallels in how social contexts influence health and vulnerability in general as well as drug-related harms in particular. This inevitably leads to a consideration of non-drug and non-health specific factors in harm reduction, and in turn, points to the importance of what might be described as ‘non health oriented interventions’ in harm reduction. Shifts in housing policy, for example, may have harm reduction impact, as have a variety of microeconomic, employment and other community development initiatives
        
        This is politically important for two reasons. First, it mainstreams drugs and harm reduction as part of wider social movements in public health. This raises the possibilities for broadening the scope for political alliances lobbying for social and environmental change. And second, it shifts the locus and politics of change from issues of drug use to wider issues of health vulnerability and human rights.
      - Micro and macro levels of influence intersect across different types of environment in inextricable ways. The distinctions between ‘macro’ and ‘micro’, and between ‘physical’, ‘economic’, ‘social’ and ‘policy’ forms of environment are to a large extent phony divides, serving an heuristic or analytical purpose and necessarily clouding the depiction of situated social realities of risk
      - In addition to types of environment and levels of environmental influence, we can consider two types of environmental factors which assist in understanding the mechanisms of how environments structure risk. The first are susceptibility factors, defined as factors which ‘determine the rate at which an epidemic is propagated’. The second are vulnerability factors, which are the ‘features of a social or economic entity that make it more or less likely that excess morbidity and mortality associated with disease will have deleterious impacts upon that unit’
        
        In the context of HIV prevention, whereas susceptibility is the chance of becoming infected, vulnerability is the degree to which the epidemic has an adverse effect on the capacity to respond. Taken together, ‘a society, community or group might be described as susceptible to infection by a disease but vulnerable to its effects’.
      - A risk environment approach to harm reduction seeks to connect with wider calls for a paradigm shift in public health from behavioural to ecological approaches
        
        an environmental approach highlights the parallels and connections in how context influences health and ulnerability in general as well as drug-related harm specifically
      - demand reduction and harm reduction
        
        Harm reduction, that is attempting to reduce harms directly without necessarily reducing consumption, is a very valuable part of the response to all psychoactive drugs including illegal drugs.
        
        Needle syringe programmes and methadone treatment are the best known examples. Both are effective, not accompanied by significant unintended negative consequences and bth are cost-effective. Harm reduction has helped to reduce the spread of HIV among people who inject drugs and from them to the general population.
        
        Drug education is provided in school-based and mass education programmes. These provide only modest reduction of illicit drug use. However, prevention approaches usually chosen for implementation are relatively ineffective while prevention methods known to be more effective are rarely implemented.
        
        If a substantial proportion of drug users can be attracted and retained in an effective form of drug treatment for long enough for the treatment to work, demand for drugs in that community decreases. This is why drug treatment is considered a form of demand reduction
        
        The majority of people struggling with severe problems with alcohol, tobacco, prescription or illicit drugs manage to overcome their difficulties without the benefit of treatment from a clinician.
        
        Evidence of the effectiveness and safety of residential rehabilitation is weak. Residential rehabilitation is considerably more expensive than methadone treatment. Often residential rehabilitation interrupts family life and employment
        
        Methadone treatment attracts, retains and benefits more heroin users than any other treatment option. It has also been more extensively studied than all other treatments for heroin dependence.
        
        Heroin assisted treatment involves daily, carefully supervised, high dose, self-administered, intra-venous heroin in association with intensive psychosocial assistance. The rigorous studies have been published in prestigious, peerreviewed journals. Most trials involved severely dependent heroin users who had not benefited from multiple previous episodes of a diverse range of treatments. In each of these studies, heroin assisted treatment was compared to high quality methadone treatment. Improvements of about 60% were reported in each study in physical and mental health and social functioning in the heroin assisted treatment subjects compared to those receiving methadone only. Crime fell considerably and illicit drug use also declined in the heroin assisted treatment group
        
        The International Harm Reduction Association defines ‘harm Reduction’ as ‘policies, programmes and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption
        
        Harm reduction refers to approaches to psychoactive drug use that aim to reduce the harms associated with drug use for people who are unable or unwilling to abstain.
        
        The dominant global approach to illicit drugs for many decades strongly emphasized drug law enforcement rhetorically and financially. Consequently, scant emphasis and minimal funding was allocated to demand reduction.
        
        A more realistic approach began to emerge after the magnitude of the threat of HIV began to be appreciated in the 1980s. Increasing emphasis was given to harm reduction though harm reduction was often (willfully) misunderstood and virtually always grossly under-funded
      - Is harm reduction a viable choice for kids enchanted with drugs
        
        While the dominant approach to substance abuse treatment has been a disease model, this article describes a strengths-based alternative. Many contemporary youth are experiencing problems with alcohol or other drugs but reject the message of total abstinence and disease models of treatment.
        
        Research has demonstrated that the age when adolescents first start using alcohol, tobacco, and other illicit drugs is a predictor of later alcohol and drug problems.
        
        More than 40% of youth who start drinking at age 14 or younger develop alcohol dependence, compared with 10% of youth who begin drinking at age 20 or older.
        
        the disease model was designed to assist substance-abusing adults, adolescent substance problems differ from those of adults with chronic alcohol dependence. Thus, very few adolescents and young adults meet the DSM-IV criteria for alcohol dependence Most young adults reduce heavy drinking as they learn their limits and begin to assume other responsibilities, such as work and parenting.
        
        Over the last 20 years, the federal government has engaged in a war on drugs – the cigarette industry has been limited in its advertising targeted at adolescents, alcohol advertisements have been restricted, and states have increased the legal drinking and smoking age. Nevertheless, kids continue to smoke, drink, and use other drugs. During this same time, the disease model has shaped most research in the field. This framework has inevitably focused on the negative outcomes of illicit drugs, rather than a preventive, health-promoting perspective that could have explored patterns of adaptation and competence of kids and adults who have learned to manage their lives.
        
        Strengths-based practitioners work from the premise that children and youth have strength and competence and can recover and bounce back from adversities
        
        The focus becomes “finding, enhancing, and encouraging the utilizations of coping skills with which to navigate troubled waters”
        
        Research shows that youthful alcohol problems are often intermittent and may remit without formal treatment, rather than becoming fatal and progressive
        
        The strengths perspective offers a different lens to describe youths’ enchantment with cigarettes, alcohol, and other drugs and allows us to begin to see opportunities, hope, and solutions. Rather than channeling efforts toward correcting deficits of adolescent alcohol and substance use, we aim to achieve the desired outcome, i.e., that kids don’t become lifelong abusers or addicts. True growth only takes Place when individuals’ strengths are channeled toward goals that they themselves set.
        
        A strength-based approach to kids who use drugs and alcohol focuses on reducing the risk in their lives. We promote abstinence and identify possible consequences for continued use of illicit drugs. Additionally we collaborate with youth who are unwilling to accept abstinence as a solution in order to reduce the risks of harm from their use. Success comes as each young person develops inner controls and lives a balanced and healthy life in harmony with self and others.
      - here’s how iceland radically reduced teen substance abuse
        
        “People can get addicted to drink, cars, money, sex, calories, cocaine – whatever,” says Milkman. “The idea of behavioural addiction became our trademark.” This idea spawned another: “Why not orchestrate a social movement around natural highs: around people getting high on their own brain chemistry – because it seems obvious to me that people want to change their consciousness – without the deleterious effects of drugs?”
        
        “We didn’t say to them, you’re coming in for treatment. We said, we’ll teach you anything you want to learn: music, dance, hip hop, art, martial arts.” The idea was that these different classes could provide a variety of alterations in the kids’ brain chemistry, and give them what they needed to cope better with life: some might crave an experience that could help reduce anxiety, others may be after a rush.
        
        Young people aren’t hanging out in the park right now, Gudberg explains, because they’re in after-school classes in these facilities, or in clubs for music, dance or art. Or they might be on outings with their parents.
        
        Today, Iceland tops the European table for the cleanest-living teens. The percentage of 15- and 16-year-olds who had been drunk in the previous month plummeted from 42 per cent in 1998 to 5 per cent in 2016. The percentage who have ever used cannabis is down from 17 per cent to 7 per cent. Those smoking cigarettes every day fell from 23 per cent to just 3 per cent.
        
        It seems obvious that what they’ve actually accomplished is giving these kids the missing interpersonal connections from rat park.
        
        State funding was increased for organised sport, music, art, dance and other clubs, to give kids alternative ways to feel part of a group, and to feel good, rather than through using alcohol and drugs, and kids from low-income families received help to take part. In Reykjavik, for instance, where more than a third of the country’s population lives, a Leisure Card gives families 35,000 krona (£250) per year per child to pay for recreational activities
        
        Between 1997 and 2012, the percentage of kids aged 15 and 16 who reported often or almost always spending time with their parents on weekdays doubled – from 23 per cent to 46 per cent – and the percentage who participated in organised sports at least four times a week increased from 24 per cent to 42 per cent. Meanwhile, cigarette smoking, drinking and cannabis use in this age group plummeted.
        
        Across Europe, rates of teen alcohol and drug use have generally improved over the past 20 years, though nowhere as dramatically as in Iceland, and the reasons for improvements are not necessarily linked to strategies that foster teen wellbeing. In the UK, for example, the fact that teens are now spending more time at home interacting online rather than in person could be one of the major reasons for the drop in alcohol consumption.
        
        Elsewhere, cities that have joined Youth in Europe are reporting other benefits. In Bucharest, for example, the rate of teen suicides is dropping alongside use of drink and drugs. In Kaunas, the number of children committing crimes dropped by a third between 2014 and 2015.
        
        Short-termism also impedes effective prevention strategies in the UK, says Michael O’Toole, CEO of Mentor, a charity that works to reduce alcohol and drug misuse in children and young people. Here, too, there is no national coordinated alcohol and drug prevention programme. It’s generally left to local authorities or to schools, which can often mean kids are simply given information about the dangers of drugs and alcohol – a strategy that, he agrees, evidence shows does not work.
      - can you get over an addiction
        
        There are, speaking broadly, two schools of thought on addiction: The first was that my brain had been chemically “hijacked” by drugs, leaving me no control over a chronic, progressive disease. The second was simply that I was a selfish criminal, with little regard for others, as much of the public still seems to believe.
        
        If, like me, you grew up with a hyper-reactive nervous system that constantly made you feel overwhelmed, alienated and unlovable, finding a substance that eases social stress becomes a blessed escape. For me, heroin provided a sense of comfort, safety and love that I couldn’t get from other people. Once I’d experienced the relief heroin gave me, I felt as though I couldn’t survive without it.
        
        This anecdotal paragraph essentially mirrors the findings of Carl Hart’s work.
        
        If addiction is like misguided love, then compassion is a far better approach than punishment. Indeed, a 2007 meta-analysis of dozens of studies over four decades found that empowering, empathetic treatments like cognitive behavioral therapy and motivational enhancement therapy, which nurture an internal willingness to change, work far better than the more traditional rehab approach of confronting denial and telling patients that they are powerless over their addiction.
        
        Indeed, if the compulsive drive that sustains addiction is directed into healthier channels, this type of wiring can be a benefit, not just a disability. After all, persisting despite rejection didn’t only lead to addiction for me — it has also been indispensable to my survival as a writer. The ability to persevere is an asset: People with addiction just need to learn how to redirect it.
      - fraction of americans receive drug treatment
        
        Millions of Americans suffer from alcoholism or addiction to legal and illegal drugs, but only a fraction are being treated, according to a report released on Thursday by the surgeon general.
        
        One in seven people in the United States is expected to develop a substance use disorder at some point, the report said. But as of now, only one in 10 will receive treatment.
        
        It calls for, among other things, a cultural change in understanding that addiction is a brain disease, not a character flaw.
        
        “It’s time to change how we view addiction,” Dr. Vivek H. Murthy, the surgeon general, said in releasing the report. “Not as a moral failing but as a chronic illness that must be treated with skill, urgency and compassion. The way we address this crisis is a test for America.”
        
        Trump has said that he will “try everything we can” to get Americans “unaddicted” to drugs, but his chief proposal is to build a wall on the border with Mexico. The wall, he said in New Hampshire last month, would keep out drug dealers and keep out “the heroin poisoning our youth.”
        
        Even if a wall kept some heroin out of the United States, it would not necessarily solve the problem. While many Americans are dying of overdoses of heroin, many more are dying from opioid painkillers legally prescribed within the United States. And in some states, deaths from synthetic opioids like fentanyl, which are coming from China, are overtaking deaths from heroin.
        
        Only about 10 percent of people with a substance use disorder receive any type of specialty treatment, the report said. And while more than 40 percent of people with such a disorder also have a mental health condition, fewer than half receive treatment for either.
        
        The three final paragraphs of the article strike me as classist bullshit that hides generationality behind racist claims of inherited weakness rather than generational poverty and other social factors in the generational environment.
        
        From 40 percent to 70 percent of a person’s risk for developing a substance use disorder is genetic, the report said, but many environmental factors — like how old he or she is when first drinking or trying drugs — can influence the risk.
        
        People who first drink alcohol before age 15 are four times more likely to become addicted at some time in their lives than are those who have their first drink at age 20 or older, the report said.
        
        Nearly 70 percent of those who try an illicit drug before the age of 13 develop a substance use disorder within seven years, the report said, compared with 27 percent of those who first try an illicit drug after the age of 17.