Providentia

How Safe is Methadone?

 Yes, I'm still in Nashville and CSICon is an awesome experience that I'll be writing about eventually.   In the meantime, here is another post to tide you over.

While methadone clinics are a familiar sight in most cities these days,the synthetic opioid's reputation as a safe treatment for heroin and morphine addiction has been shaken by the rising number of overdose deaths linked to its use.  

Since it was first developed in Germany during the 1930s, the analgesic that eventually became known as methadone has been praised as a safe and effective pain medication with fewer dependency issues than more powerful opiates such as heroin.   While going under a range of different names (including Dolophine, Symoron and Amydone), the drug was rechristened as "methadone" in 1947 when it became generic.  Although methadone treatment was eventually phased out during the 1950s as better analgesics came along, everything changed in 1964 when Doctors Marie Nyswander and Vincent Dole began using methadone to treat heroin addicts.   Since methadone has cross-tolerance with other opioids with a long effect duration and very similar effects,  addicts were successful in weaning themselves off more dangerous opioids such as morphine and heroin and methadone maintenance programs became widely used in many countries.  Higher doses of methadone can even block the euphoric "highs" that addicts experience with heroin and other addictive opiates. 

Physicians typically require specialized licensing and training to prescribe methadone safely and precautions are usually needed to prevent potential abuse.   Given the potential for methadone to be diverted for use as a street drug, methadone clinics often require added security and safety procedures for proper dispensing.   Some clinics provide methadone in concentrated form to reduce the number of daily doses needed although safeguards need to be in place to avoid the possibility of overdose.   With careful management, methadone maintenance treatment (MMT) can be maintained for months or years depending on the policies of the clinic administering the medication.   MMT use is still controversial though and many countries ban its use  (Russia for example).   In the United States and Canada, conservative politicians have advocated against MMT and argue in favour of total abstinence programs instead.  

In recent years, methadone has also become more popular as an analgesic as well as a way of weaning chronic pain patients off other pain medications to which they have become addicted.   That includes Oxycontin and codeine which have become major street drugs in their own right.   Along with methadone's (largely exaggerated) reputation for being non-addictive, or at least less addictive than other alternatives, methadone is also low-cost due to being generic.  It is also more effective against neuropathic pain since methadone acts directly on the NMDA receptor.   Unfortunately, methadone has a longer half-life than other analgesics (remains in the system longer) which causes it to build up in the system over time.   This leads to an increased risk of breathing and cardiac problems.    Due to cautions over methadone use and the continuing need for special licensing to prescribe it, methadone is still not as common as other analgesics.  In 2009 alone, only two percent of all pain prescriptions were for methadone in the United States. 

While not as popular as other pain medications, recent statistics issued by the Center for Disease Control's Vital Signs report show that methadone has been implicated in nearly a third of all overdose deaths linked to prescription pain relievers.   National data covering the years from 1999 to 2010 shows that four out of every overdose deaths from a single pain medication implicated methadone in some way.   With the rise in methadone use as an analgesic unfortunately, there has also been a corresponding rise in its popularity as a street drug.    According to CDC director, Dr. Thomas R. Frieden:

Deaths from opioid overdose have increased four-fold in the past decade, and methadone now accounts for nearly a third of opioid-associated deaths ... Methadone used for heroin substitution treatment does not appear to be a major part of this problem. However, the amount of methadone prescribed to people in pain has increased dramatically. There are many safer alternatives to methadone for chronic non-cancer pain.

To curb the rising trend of methadone-related deaths, the CDC recommends the following:

• screening potential methadone patients for substance abuse and other mental health problems
• prescribing only the amount needed based on the expected duration of pain
• using patient-provider agreements in conjunction with regular urine testing to monitor people taking methadone for  long-term treatment
• using prescription drug monitoring programs to flag patients abusing methadone or other pain relievers
• educating patients on the proper dosage, safe use and storage of prescription pain

While methadone is available in tablet or ampoule form, the U.S. Department of Health has strongly warned against prescribing them to patients due to the added risk of illicit sales and/or vein damage if they are injected directly in veins.  The U.S. Drug Enforcement Agency has been particularly militant in shutting down "pill mills" in Florida and other states producing methadone pills for illegal use.   

Along with a Federal bill signed into law by President Barack Obama in 2010 making it easier for local authorities to dispose of unneeded or expired pharmaceuticals, most U.S. states have also passed laws against "doctor shopping".   Since many prescription drug abusers often see multiple doctors with the pain symptoms, they are able to accumulate large hoards of prescription drugs through repeated prescriptions.  Patient registries allow physicians to check drug histories of prospiective pain patients to identify the abusers.

Although these measures are promising, the grim toll of methadone-related deaths is unlikely to change in the forseeable future.   While the current safeguards in methadone drug treatment programs appear to be working (few methadone deaths have been linked to formal clinic practices), patients receiving methadone for pain should only take it as prescribed by their doctors.   Those patients wishing to go off methadone should follow medical instructions carefully since "cold turkey" withdrawal can have devastating consequences as well.

Patients should also store methadone safely to ensure that no one else in their household can take it, either accidentally or on purpose.   Consult your pharmacist for advice on safe disposal (not in the nearest trashcan!).

For more information.

 

 

 

 

 

 

When Children Testify About Abuse

In every case of child sexual abuse that goes to trial, it is often the child’s testimony that is the most crucial part of the prosecution’s case.    Since the child is typically the only real witness against the suspected abuser, successful prosecution depends on how credible the child will be.   This is especially true when there is no forensic evidence available and the case rests on the child’s word against the suspect’s.

According to the Story Model of juror decision-making, people sitting on a jury are swayed by the side telling the most believable “story” about what actually happened.   After hearing conflicting accounts from the plaintiff and the defendant, the side with the most coherent account tends to be the one that is believed.   Defence attorneys are often required to interrogate child witnesses to shake their confidence or otherwise suggest that the child was coached into making false or inaccurate statements about the client.   Given the serious nature of the charge and the likelihood of the defendant being classified as a sex offender for life, the attorney is strongly motivated to cast as much doubt as possible on the child’s testimony.

What kind of questions need to be asked during forensic interviews to persuade children to tell about what happened to them?   And why do many juries have trouble accepting this testimony?

To read more, check out the latest post on my Psychology Today blog.

The Indiana Jones of Tennessee

While I'm away at CSICon in Nashville, I'd thought I'd entertain you with this Tennessee-themed post I wrote that just went up at the James Randi Educational Foundation's Swift Blog:

After some hemming-and-hawing, I have finally decided to attend this year’s CSICON in Nashville, Tennessee (I hear the world is coming to an end in December of this year so I might not get another chance).   Since this will be my first visit to the Volunteer State, giving this post a Tennessee theme seemed a natural enough idea. The only problem was picking out what to write about considering that state has more than its fair share of, er, eccentrics.   In the end, I decided to write this post about the amazing Ronald Eldon Wyatt, archaeologist/explorer/fundamentalist extraordinaire.

Click here to read more...

 

Age at injury and long-term behavior problems after traumatic brain injury in young children.

A study published recently in Rehabilitation Psychology examined the effects of age at injury on the persistence of behavior problems and social skill deficits in young children with complicated mild to severe traumatic brain injury (TBI).  A concurrent cohort/prospective research design was used with repeated assessments of children with TBI (n = 82) or Orthopedic Injury (OI) (n = 114). Parents completed the Child Behavior Checklist, the Behavior Rating Inventory of Executive Functions, and the Preschool and Kindergarten Behavior Scales or the Home and Community Social and Behavior Scales shortly after injury to assess preinjury functioning, and at an extended follow-up an average of 38 months postinjury. Generalized linear modeling was used to examine the relationship of age at injury to the maintenance of behavior problems, and logistic regression was used to examine the persistence of clinically significant behavior problems. Results: At the extended follow-up, severe TBI was associated with significantly greater anxiety problems relative to the Group OI. With increasing time since injury, children who sustained a severe TBI at an earlier age had significantly higher levels of parent-reported symptoms of ADHD and anxiety than children who were older at injury. Conclusions: Findings suggest that longer-term treatment for behavior problems may be needed after severe TBI, particularly for those injured at an earlier age.

For the abstract.

Off To Nashville and CSICon 2012

I will be off most of next week as I am attending this year's CSICon in Nashville, Tennessee.   I am looking forward to meeting some  of my skeptical idols including Elizabeth Loftus, Richard Wiseman, Scott Lilienfeld, P.Z. Myers, Joe Nickell, Ray Hyman and assorted Novellas (Novellae?).   If all goes well, I will have a lot to report and I may even try some live-Tweeting at the conference.   I may even finally discover what exactly a Honky-tonk is and whether that's a verb or a noun. 

Talk to you later.   In the meantime, enjoy my first ever Youtube video featuring the latest Toronto Zombie Walk.

 

When a Loved One Commits Suicide

Every year there are an estimated one million suicides worldwide and those numbers have been rising in many countries.   In the United States alone, that means 37,000 deaths due to suicide making it the tenth leading cause of death overall.   What impact does that have on people dealing with the suicide of a loved one?  And do they always get they need afterward?  

In recent years, self-help resources are becoming more common, whether online or through the various self-help books and booklets available at bookstores or in libraries.    How effective these resources can be is still open to question since actual research investigating their benefit is still limited. 

As a response to the 5500 suicide deaths that happen each year in the United Kingdom, the National Suicide Prevention Strategy for England was launched in 2002.  As part of the comprehensive anti-suicide initiative, a self-help booklet titled Help Is At Hand was released in 2006.   Available in hardcopy and online, the booklet was developed by an advisory group made up of bereavement organizations, mental health professionals, law enforcement agencies and academics specializing in suicide research. 

To read more, check out my new Psychology Today blog post. 

After Mesmer (Part 2 of 2)

Continued from Part 1

As a "common-sense" alternative to "Mesmerism", James Braid coined his own term:  "hypnotism".   Also known as "nervous sleep", Braid defined the state of suggestibility that he induced in his patients as: 

a peculiar condition of the nervous system, into which it may be thrown by artificial contrivance, and which differs, in several respects, from common sleep or the waking condition. I do not allege that this condition is induced through the transmission of a magnetic or occult influence from my body into that of my patients; nor do I profess, by my processes, to produce the higher [i.e., supernatural] phenomena of the Mesmerists. My pretensions are of a much more humble character, and are all consistent with generally admitted principles in physiological and psychological science.

Braid also discovered that the classic Mesmerist approach to inducing a hypnotic state was actually not necessary.   Through work with his own patients, he learned that he could induce hypnosis simply using voice instructions and having subjects focus on a shiny object that he moved in front of their eyes (Braid used a scalpel case).     He also developed several different techniques for hypnotic induction (which are still largely used today by hypnotists) and even discovered that he could implant suggestions in patients while they were under hypnosis  (Braid downplayed this considering the sinister reputation that Mesmerists already had).   An Attempt to read his 1842 paper, "Practical Essay on the Curative Agency of Neuro-Hypnotism" to a British science group was rejected at the last minute and Braid faced an uphill battle to separate his own work from what the Mesmerists were claiming.   As he pointed out in a letter to the Lancet in 1845,

"I adopted the term "hypnotism" to prevent my being confounded with those who entertain those extreme notions [that a mesmeriser's will has an "irresistible power… over his subjects" and that clairvoyance and other "higher phenomena" are routinely manifested by those in the mesmeric state], as well as to get rid of the erroneous theory about a magnetic fluid, or exoteric influence of any description being the cause of the sleep. I distinctly avowed that hypnotism laid no claim to produce any phenomena which were not "quite reconcilable with well-established physiological and psychological principles"; pointed out the various sources of fallacy which might have misled the mesmerists; [and] was the first to give a public explanation of the trick [by which a fraudulent subject had been able to deceive his mesmerizer]

Although Braid was never fond of the term "hypnosis" (which he felt made it seem too much like a form of sleep), he could never find a term that worked better.   His own suggestion of "monoideism" never caught on and critics simply called his new technique "Braidism".   By the time of his death in 1860,  James Braid had managed to inspire a new generation of medical doctors and researchers to continue his work.  

In France, the movement that Braid started actually split into two main schools:  the Nancy school (a.k.a. the "Suggestion school") founded by Ambroise-August Liebeault and the Paris school founded by Jean-Martin Charcot.   Liebeault started his own work with hypnosis in the same year that Braid died.  He was a close friend of Braid's chief French disciple, Etienne Eugene Azam, and learned about Braid's ideas on hypnosis and suggestion.   Being a general practitioner with a practice in the country, Liebeault had to promise patients free medical care so long as they agree to let him use hypnosis in their treatment.   He soon found himself with more patients than he could handle but his use of hypnosis upset his medical colleagues (who equated hypnosis with Mesmerism).    Although Liebeault managed to publish his book, "Le sommeil et les états analogues, considérés surtout du point de vue de l'action du moral sur le physique" (Sleep and its analogous states considered from the perspective of the action of the mind upon the body) in 1866, there was not a lot of interest (according to legend, it sold only a single copy in ten years).   While he became more famous later in life,  Liebeault's only real source of income was his medical practice (and that income was limited considering that most of his patients could not afford to pay him).  

Jean-Martin Charcot had an easier time of it overall.   Not only was he a giant in the field of neurology but he also worked and taught at the famous Salpetrerie Hospital in Paris.   While best known for his work in hypnosis and hysteria, Charcot also has a lengthy list of diseases named after him.  Along with his prize pupil, George Gilles de la Tourette, Charcot treated patients from all over the world and managed to given hypnosis the respect that it badly neede.   It was Charcot who formed many of the modern ideas about hypnosis, including the link between hypnosis and suggestability (although he mistakenly assumed that it was an element of hysteria and that hysterics were the only ones who could be hypnotized).   He and Tourette conducted numerous public demonstrations of hypnosis at Salpretrerie Hospital and repeatedly hypnotized patients to show that hypnosis was harmless and effective.   At least, that was what he intended.   Gilles de la Tourette was later shot and nearly killed in 1893 by a patient who believed that he and Charcot had "ruined her life" by causing her mental illness using hypnosis.  If Charcot and Tourette managed to give hypnosis a new respectability, the sinister Svengali-like reputation never really went away either.

While the new fame that hypnosis enjoyed was enough to attract serious attention from rising stars in neurology such as Sigmund Freud, the failure of hypnosis to live up to its early promise seemed obvious as well.   Despite studying with Charcot and Liebeault, Freud eventually abandoned hypnotherapy completely in favour of his own "talking cure" which he felt was more effective.   Well into the 20th century, scientific reformers including  Emile Coue, Clark Hull,  Dave Elman and Milton Erickson attempted to make hypnotherapy more acceptable as a mainstream tool.   Despite the popularization of hypnosis by entertainers and therapists, hypnosis still suffers from a serious identity problem as scientists and skeptics still wrestle with the problem of exactly what hypnosis is.  Not only has it failed to live up to the reputation laid down by the vast array of hypnosis-themed books, movies, and other entertainment avenues making hypnosis a cultural icon, but its value as a tool for medical and mental health professionals has been limited as well.   That includes forensic applications with hypnotic recall being found to be no better than simple relaxation for retrieving information from memory (and being much worse given the vulnerability of suggestible subjects to false memories implanted by improperly used hypnotic techniques).

The fundamental question of whether or not a hypnotic "state" actually exists has never been answered to anyone's satisfaction.   Although James Braid initially argued that hypnosis was a special state, even he backed away from that position later in life.   Pierre Janet and Ernest Hilgard both argued that hypnosis was a form of dissociation in which subjects voluntarily divided their consciousness.  Whatever the explanation given, the physiological evidence for the existence of a hypnotic state or trance remains minimal.  Neurological imaging studies have shown some brain changes in highly suggestible subjects during hypnosis but the changes are hardly unique and have also been observed in conscious subjects as well.  While some studies have suggested that neurological changes can occur under limited circumstances, these results remain controversial.

Nearly two enturies after Franz Mesmer's death, the question of what he had actually discovered seems as relevant as ever.   If hypnosis remains an international phenomenon with hypnotherapists practicing in nearly every country in the world,  skepticism about the very nature of hypnosis still remains strong.   Famous stage magician-hypnotists such as the Amazing Kreskin and Peter Reveen have openly denied that hypnosis is real.  Kreskin has even gone so far as to offer a $100,000 reward to any hypnotist or psychologist who can prove the existence of a hypnotic trance under controlled scientific conditions.   No one has ever collected on that challenge.

So, the next time anyone suggests that you try hypnosis to lose weight, recall past lives, or eliminate pain, spare a thought for Franz Mesmer and the controversy that remains his greatest legacy.  

Just a suggestion...

 

 

Could This Computer Game Save Your Kids From Fire?

How safe are your children if a fire breaks out?

While statistics from the United States Fire Administration show that fire is the third leading cause of unintentional injury in children under the age of 14, at least 40 per cent of all fire-related injuries involve children under the age of five. In 2007 alone, 52 per cent of all fire deaths were children under the age of four who are often too young to understand proper safety procedures when a residential fire happens.

Though fire prevention strategies for older children and adults have been relatively effective in reducing death or injury, programs to teach younger children about fire safety (such as "stop, drop, and roll" when clothes catch fire) have had mixed success. Educational programs designed to teach children about fire safety are already available. Unfortunately, they are often too expensive to use on a national scale and tend to focus on school age children instead of younger children who are more vulnerable.

Could an interactive computer game teach younger children about how to stay safe in a fire? An interactive computer game titled "The Great Escape" was developed by Winnipeg firefighter Shane Ferguson as part of the Staying Alive program. Ferguson had created the Staying Alive program and The Great Escape as a tribute to five-year old Laura Johnson. He had been one of first responders of the scene to discover her body after she died of smoke inhalation in a 1998 house fire.

Spurred by Laura's death to take action, Ferguson developed The Great Escape game with the financial support of the Winnipeg Fire Fighters Burn Fund and Cooperators Insurance Inc. Released on CD in both French and English, Staying Alive and The Great Escape have been widely praised and Shane Ferguson has received numerous awards for his fire safety efforts.

To read more, check out my new contribution at the Huffington Post.

Staying Hopeful Can Lead to Better Recovery

A study published recently in Rehabilitation Psychology examined the association between differnt helping factors and functional rehabilitation outcomes following acute medical rehabilitation. Using a longitudinal design and correlational and regression analyses, the authors studied 174 adults who were participating in inpatient rehabilitation for acute spinal cord dysfunction, stroke, amputation, or orthopedic surgery recovery. All participants completed the Hope Scale, Positive and Negative Affect Schedule, and Functional Independence Measure (FIM) during the first days of their inpatient stay, and then were contacted 3 months after discharge to complete the Craig Hospital Assessment and Reporting Technique (CHART) and FIM. Results showed that hope accounted for a statistically significant amount of the variance in the prediction of functional role participation at 3 months postdischarge (as measured by the CHART) above and beyond the variance accounted for by demographic and severity variables. In contrast, positive affect was not found to contribute to the prediction of functional role participation, and neither hope nor positive affect contributed to the prediction of functional skill level (FIM). The results indicate that positive psychological variables present during the rehabilitation stay, such as hopefulness, may contribute to the prediction of functional outcomes after discharge in rehabilitation populations. These findings suggest that incorporating interventions that enhance hope and build on the individual's psychological strengths may be useful to improve participation outcomes following acute medical rehabilitation

For the abstract.

Stories I've Been Following

More stories I've been following recently:

Alzheimer’s Disease International has recently published the World Alzheimer’s Report 2012.    In this latest report, the number of people living with dementia is estimated to rise from 36 million worldwide in 2010 to more than 116 million by 2050.  Nearly two-thirds of these new dementia cases will come from low and middle-income countries.   The cost for caring for dementia cases already topped $604 billion in 2010 alone and will likely skyrocket in coming years.   Will we be ready?  (h/t to The Amazing World of Psychiatry for the link)

Vaughan Bell of Mind Hacks discusses a recent New York Times article on New York's "suicide cops" who are tasked with talking down potential "jumpers".    A harrowing and often thankless task. 

Mind Hacks also recommended a fascinating post on the Chirugeon's Apprentice blog describing the strange history of hysteria and the bizarre theories of female anatomy that went with it. 

What makes self-directed learning effective?  A new post by Science Daily reviews recent research examining self-direct learning from a cognitive and a computational perspective.  Some of the most effective learning does not take place inside classrooms.

Also from Science Daily,  a new research study from Sweden examined tooth loss and chewing ability in the elderly and found that chewing ability appears linked to dementia risk.

After sitting on Texas' death row for 32 years, Max Soffar seems set for execution despite clear inconsistencies in the confession that he gave for a 1980 triple-murder.   Although the American Civil Liberties Union has been championing his case with legal arguments that Soffar's confession "smells fishy" and that the low-IQ inmate may not have committed the crime for which he faces execution, his latest appeal has been denied.   The ACLU blog has the details.

Can video games be used to diagnose PTSD and mild brain injury in military personnel?  Danger Room looks at a new Pentagon project that awarded contracts  to several private companies to develop video games to help with the diagnosis of PTSD and cognitive impairments.  While no one is expecting a "magic bullet" to the problem of undiagnosed PTSD, changes in video game performance may provide an important clinical clue to help identify soldiers in need of help.

During an emergency, rumours can fly like wildfire with potentially tragic results.    Can social media help provide information to the public more effectively than press releases?   The Canadian Red Cross's blog describes how the mayor of Iqualuit, Nunavut uses her platform on Facebook and Twitter  to get the word out in crisis situations and allow for the two-way communication that regular news channels do not provide.

Steven Novella of Science Based-Medicine weighs in with disheartening news from Africa about the distribution of anti-retroviral medicines being bogged down by governments placing more faith in traditional healers than in modern medicine.   Although I have already described the devastating consequences of Thako Mbeki's sabotaging of anti-HIV health campaigns in South Africa,  Gambia's president Yahya Jammeh appears to be doing the same with his own "secret" herbal remedy for curing HIV which calls for patients discontinuing antiretroviral treatment.   How many lives this will end up costing is anybody's guess.

Was Joseph Jastrow America's first pop psychologist?   Jack El-Hai of Wonders and Marvels describes Jastrow's illustrious career explaining and interpreting psychology for the public.   Being the first American to earn a doctorate in psychology, Jastrow earned a permanent place in psychology's history.

The proper treatment for PTSD in solders will likely always be controversial, but how valid is the use of potentially addictive psychoactive drugs like Seroquel and Risperidone?   The NextGov blog talks discusses a recent Army Surgeon General memo backtracking on the longstanding policy of prescribing medication for traumatized soldiers.   That memo also warns against prescribing tranquilizers such as Xanax and Valium because of dependency issues.   Considering a 2010 report found that one-third of all active duty military suicides involved prescription drugs, the new changes are way overdue.

Finally, we have an article from Times Healthland that suggests that the field of psychiatry is "committing professional suicide" due to its dangerously close relationship with the pharmaceutical industry.  While few experts view that relationship as healthy, will real change happen in the forseeable future?    And will the $58 billion being spent on advertising by pharmaceutical companies override medical concerns about patient health? 

That's all for now.   Please check out these stories for yourself and let me know of others that you think I should be following. 

Until next time.