Cannabis Addiction Is a Drug to Treat Cannabis Addiction Finally Within Reach? BORDEAUX, France — Could AEF0117, a drug that has a novel mechanism of action in the brain, be the drug to fight cannabis addiction? Results from a phase 2a clinical trial that examined the efficacy of AEF0117 in patients with cannabis use disorder have created quite a stir. The study was published in Nature Medicine. Not only did AEF0117 weaken the effects of cannabis, but it also decreased a person's desire to use it, all without causing withdrawal symptoms. These findings have generated a significant buzz in the scientific and medical community. "In the past, 8% of cannabis users would develop an addiction — today, this figure is 15%. Addiction to cannabis has become the main reason for seeking treatment at specialist drug clinics," said Pier Vincenzo Piazza, MD, PhD, psychiatrist, neurobiologist, and general director of Aelis Farma, the biopharmaceutical company that developed AEF0117. This rise in cases can be explained by the increase in THC content in cannabis over the years. THC content increased from 5% in the 1970s to 30% today. Although cannabis is still less addictive than tobacco (33% of users become addicted), cocaine, heroin, or alcohol (25% of users become addicted), the number of cannabis users is increasing. Currently, 14.2 million in the United States and more than half a million in France use cannabis. CB1 Receptor Inhibition Neutral CB1 Receptor Antagonists as Pharmacotherapies for Substance Use Disorders: Rationale, Evidence, and Challenge AEF0117 is the first signaling-specific inhibitor of the CB1 receptor. THC acts in the brain via CB1 cannabinoid receptors located on neurons. The total inhibition of CB1 receptors has long been an avenue of research, but the adverse effects caused by CB1 receptor antagonists are incompatible with a therapeutic approach. "We thought that it would be impossible to modulate part of a receptor by a molecule. But in 2014, we discovered this unexpected natural mechanism precisely at the level of the CB1 cannabinoid receptors," Piazza told Medscape French Edition. At the time, he was the director of the Magendie Neurology Center (Inserm ― the French National Institute of Health and Medical Research) in Bordeaux, France. Along with his colleagues, he demonstrated that in response to high doses of THC, a hormone, pregnenolone, is synthesized and becomes bound to CB1 receptors, which reduces some of the effects of THC. The discovery of this new mechanism was published in Science in 2014. "It then took 2 years to create a synthetic molecule that could mimic the effects of pregnenolone on the CB1 receptors," Piazza continued. Unlike pregnenolone, the new molecule needed to to be fully absorbable, stable, and not transformable into other steroids. Triple Action AEF0117 was assessed as part of a placebo-controlled, double-blind, phase 2a study. The participants were volunteers who had a cannabis addiction. In the treated group, the volunteers received either 0.06 mg (n = 14) or 1 mg (n = 15) of the investigational drug. Use of AEF0117 was associated with a significant reduction in the positive subjective effects of cannabis (19% for the 0.06-mg dose and 38% for the 1-mg dose; P < .04). The investigators showed an association with reduced cannabis use, as measured by self-administration (P < .05). No adverse events were linked to the treatment in comparison with placebo. Furthermore, there were no withdrawal symptoms, even among healthy volunteers who would smoke several grams of cannabis a day. "I call this triple action: reduced positive effects of cannabis, reduced desire to use it, and a lack of withdrawal symptoms linked to the partial receptor inhibition," said Piazza. Commenting on the study for Medscape, Guillaume Davido, MD, a psychiatrist who specializes in addiction studies at Bichat Hospital in Paris, said, "Patients really miss the psychoactive anxiolytic effect of cannabis when they stop using it. This is what makes stopping so difficult. Getting rid of this 'honeymoon' effect with the product is a considerable step forward." Davido is sure AEF0117 will be approved for prescription use. It should be used in conjunction with appropriate psychotherapeutic care, as is the case with the treatment of alcohol addiction, which combines medication with cognitive-behavioral therapy (CBT). Currently, CBT is the only recommended treatment for cannabis use disorder. Currently, no treatments are approved for cannabis use disorder, said Davido. "At the moment, we can only provide medicinal products to treat cannabis withdrawal symptoms, such as irritability, sleep disorders, and anxiety." New Trial Recruiting A phase 2b trial has been launched in the United States. It is in the process of recruiting 330 participants with cannabis addiction at 11 sites. Recruitment is scheduled to be completed by October. The three doses to be assessed in this new trial, which is being conducted in collaboration with Columbia University Irving Medical Center in New York, will be around 1 mg. "We tested two very different doses (0.06 mg and 1 mg) of AEF0117, because in animals, very low doses block some of the effects of cannabis," said Piazza. "But it became apparent that we would need a much higher dose to stop the desire for cannabis use completely." The results should be available by mid-2024. "And if its therapeutic efficacy is confirmed, a whole new pharmacology of receptors is opened up to us," said Piazza. Piazza is the general director of Aelis Farma, the biopharmaceutical company developing AEF0117.

Amid Shortages Federal Agencies Ask Drugmakers to Boost Output of ADHD Meds | Community Healthcare SystemVisit Agencies are also asking prescribers to carefully monitor their prescribing practices. HealthDay News — While demand for prescription stimulants is surging, a shortage of the drugs persists, so federal officials have stepped in and asked drug companies to ramp up production of the medications. Officials from both the US Food and Drug Administration and the US Drug Enforcement Administration made the joint request. “The FDA and DEA do not manufacture drugs and cannot require a pharmaceutical company to make a drug, make more of a drug, or change the distribution of a drug,” FDA Commissioner Robert Califf, M.D., and Drug Enforcement Administration leader Anne Milgram wrote in a letter issued. “That said, we are working closely with numerous manufacturers, agencies, and others in the supply chain to understand, prevent, and reduce the impact of these shortages.” The agencies are also asking prescribers to carefully monitor their prescribing practices. “The lack of availability of certain medications in recent months has been understandably frustrating for patients and their families,” Califf and Milgram wrote in their letter. Reasons for the shortage include manufacturing delays by 1 drugmaker last fall. Meanwhile, demand for prescription stimulants for adults surged during the pandemic, according to a US Centers for Disease Control and Prevention report. The FDA first announced a shortage of Adderall last October. The DEA limits the amount of stimulants that can be produced, but manufacturers have not been reaching that upper limit, the joint letter noted. A 2022 analysis showed they were 30% short of the quota. The agency is asking manufacturers to relinquish any quota they cannot meet so the DEA can redistribute it, while it is “committed to reviewing and improving” the quota process.

Interpreting the latest suicide data. KEY POINTS The number of suicides in the U.S. climbed 2.6 percent in 2022, to just under 50,000. The suicide rate has been climbing steadily since 2000. Study Shows Impact of Adults on Reducing Student Suicide Men are four times more likely than women to die by suicide. Men die by suicide 3.5x more often than women. Suicide Prevention Men in non-urban areas are particularly at risk of suicide due to social and economic factors. Suicide and suicide attempts in the Pacific Islands: A Systematic Literature Review We’re past the point of using metaphors like alarms and wake-up calls. They have been going off for years, and the provisional figures from the Centers for Disease Control and Prevention (CDC) on suicide in 2022 once again convey a grim increase in deaths that has been the general trend since 2000. Though the overall number of suicides declined in 2019 and 2020, the figure has once again risen in 2021 and 2022—by 5 percent and 2.6 percent, respectively. There is no positive spin that one can put on the fact that just under 50,000 Americans chose to end their lives last year. And while there may not be a silver lining in this story, we at least have the epidemiological tools to better understand where more suicides are happening and who is more likely to die by suicide, which may eventually help us understand why the number of suicides is climbing. Though it is a category error to treat suicide as no different than a disease, there are most certainly social factors that are contributing to the rise in suicides, and they are affecting some communities more than others. Three preliminary things are worth noting. First, while the number of suicides has trended upward since 2000 and may seem unprecedented, the annual suicide rate is similar to what it was for much of the 1960s and 1970s (see Figure 1). Figure 1. OECD (2023), Suicide rates (indicator). The second is that the rise in suicides since 2000 has been accompanied by an increase in the number of overdose deaths, which has accelerated more recently due to the rising presence of fentanyl in the illicit drug trade and the COVID-19 pandemic (see Figure 2). Moreover, many of the antecedent social factors propelling the rise in drug use and overdose deaths are almost certainly driving the surge in suicides. Third, 90 percent of completed suicides occur in patients with a mental illness. However, the percentage of people who have a mental illness and take their own lives is only 5 percent. Moreover, an estimated 50 percent of suicide victims are people with no known psychiatric illness, even at their time of death. Figure 2. Overdose deaths and suicide deaths in the U.S. All that said, here’s what the epidemiological data says. Where? Within the U.S., density appears to be inversely associated with suicide rates, with large metropolitan areas like New York seeing suicide rates half that of rural areas. As of 2021, the states with the highest suicide rates per 100,000 were Wyoming (32.3), Montana (32.0), and Alaska (30.8). The states with the lowest suicide rates were New Jersey (7.1 percent), New York (7.9 percent), and Massachusetts (8 percent). Alaska has the lowest population density, followed by Wyoming and then Montana. Conversely, New Jersey is the most densely populated state, New York ranks seventh, and Massachusetts ranks third. Who? As Figure 3 shows, men have been about four times more likely to die by suicide than women for the last 20 years. There are also clear racial and ethnic disparities in suicide rates; non-Hispanic Whites and Non-Hispanic American Indian or Alaska Natives have significantly higher rates than average, while Hispanic, Non-Hispanic Black, and Non-Hispanic Asian or Pacific Islander individuals all have lower than average rates. Figure 3. Suicide rates for men and women. Source: Garnett MF, Curtin SC, Stone DM. Suicide mortality in the United States, 2000–2020. NCHS Data Brief, no 433. Hyattsville, MD: National Center for Health Statistics. 2022. What is truly astonishing is what happens when you split ethnic groups along the rural or non-rural divide for men (see Figure 4). The graph on the right appears to be a continuation of the graph on the left, but it’s actually a visualization of this divide. When? While the non-rural or rural divide and patterns among ethnicities are fairly straightforward, age is not. Moreover, the age groups with the highest suicide rates skew a bit older than one might expect. Among women, it’s the 45 to 64 age group. For men, it’s those who are over 75. Additionally, every age group for females is lower than for males, except for those aged 10-14. Figure 4. Suicide rates by race/ethnicity. How? Guns have become the most common method of suicide among both men and women within the U.S. In 2021, 54 percent (26,328) of all firearm deaths were suicides compared to 43 percent of deaths which were murders (20,958). The remaining 3 percent included accidents (549), shootings by police officers (537), or deaths with undetermined circumstances (458). Raw Numbers While rates fluctuate from year to year for varying groups, I want to stress that the largest number of suicides each year continues to be middle-aged White males who die by firearm in non-rural areas. Similarly, suicide rates within rural areas may be elevated, but the raw number of deaths is still far higher in non-rural areas because more people live there. Takeaways There is no doubt that there is a mental health crisis in America, and non-Hispanic American Indian/Alaskan Native and non-Hispanic White men in non-urban areas are perhaps struggling as much, if not more, than anyone else, as the data shows. For decades, unique cultural hurdles have prevented men in these communities from asking for help, such as stigmas against seeking assistance or limited access to mental health care. However, we have not seen the high suicide rates described above. Something else has to be fueling the problem. It seems clear that the widely reported macroeconomic trends that have resulted in disproportionate levels of poverty, drug use, and despair are the issues driving the epidemic of non-urban suicide more than social stigmas. While this should not stop us from providing resources for short-term crisis intervention, long-term suicide prevention will require meaningful economic changes and a resurgence of hope. If you or someone you love is contemplating suicide, seek help immediately.

The series explores the origins of the first opioid crisis in the United States. The recent Netflix TV series Painkiller (2023) depicts the first opioid crisis in the United States. The plot merges an article by Patrick Keefe—“The Family That Built an Empire of Pain”—and a book by Barry Meier—Pain Killer: An Empire of Deceit and the Origin of America’s Opioid Epidemic. The series explores the dynamics originating the first opioid epidemic in the 1990s and holds the Sackler family, owners of Purdue Pharma, responsible for it while denouncing the deceitful marketing strategies they used to sell the addictive drug oxycontin. The story is told in a mixed resemblance to Hollywood’s academy winner The Big Short (2015) and Scorsese’s mafia films. Most of the characters are fictional and contrast with real testimonies of victims from the epidemic at the beginning of each episode. The result nonetheless seems a little in-cohesive. Throughout the series, we can see how 1 family is destroyed after the father is prescribed oxycontin following a back surgery intertwined with the story of Richard Sackler and the steps he took to build his “empire of deceit.” The series does a good job of making the viewer frustrated at seeing how a group of psychopathic businessmen become filthy rich by causing major damage in society. Furthermore, it destroys the idea of human integrity: Everyone has a price, and everyone is corruptible by money. The spectator is left in an existential crisis, only to be rescued by the protagonist, Edie Flowers—a lawyer whose family was affected by the crack epidemic and brings the case against Purdue Pharma. Painkiller has a villain, Richard Sackler, and a heroine, Edie Flowers. Richard is the son of Raymond Sackler and nephew of Arthur and Mortimer Sackler, the patriarchs who bought Purdue Pharma, starting the Sackler dynasty. Arthur Sackler is inaccurately portrayed as a frivolous psychiatrist who practiced lobotomy before coming up with the idea of marketing thorazine. After dying of a heart attack, his nephew took over the company; however, his hostile ghost will appear to Richard Sackler throughout the series to remind him of the legacy of the family. Richard seems to have an unresolved Oedipus complex when dealing with the introjection of his uncle and his family’s legacy as a bad object and an inferiority complex. Psychiatrically, that relates to his narcissism, his obsession with greed and power, and his lack of remorse for the impact and consequences of his practices, deeming him incapacitated to feel empathy for anyone. However, the repression is not always effective and the neurosis here is manifested in the spirit of his uncle, who torments him reminding him of his failure to keep the family legacy. In contrast, Edie Flowers is a victim of the prior crack epidemic. As a result of it, her mother died, and her brother went to jail. Edie and her brother became estranged. She blamed him for selling crack to her mom. Now, as an adult and as a lawyer, she will have an opportunity to redeem and heal with an act of altruism. By bringing a case against the Sackler family, she can restore justice and undo the guilt of not having saved her family. The TV series is effective at expanding solidarity for the victims of the first opioid epidemic and the subsequent epidemics. However, it is told in a sensationalized manner, leaving the viewer with the biased idea that 1 individual could be responsible for the whole current opioid problem in North America. As we know, in the real world, the factors related to the current opioid crisis in society are much more complex and the individuals are neither all good nor all bad. However, as physicians, we can learn a few lessons from Painkiller. Marketing aims to sell, and often at the cost of offering biased science, advice, and practice. It is our responsibility to read and critique what we are taught and what we read, to stay humble, and to constantly search truth. At an individual level, we must evaluate and foresee the impact that prescription patterns of opioids, benzodiazepines, stimulants, and antipsychotics will have on our patients and our society in both the short and the long term. As clinicians, we are an important and essential element in the chain, and thus we are responsible.

Pregnancy-Specific Alcohol Policies May Not Work Most of these pregnancy specific alcohol policies have no impact on infant injuries and morbidities. Alcohol and Pregnancy HealthDay News — Most pregnancy-specific alcohol policies are not associated with decreased odds of infant injuries or morbidities, according to a study published online Aug. 3 in JAMA Network Open. Sarah C.M. Roberts, Dr.P.H., from the University of California in San Francisco, and colleagues examined the association between state-level pregnancy-specific alcohol policies and infant morbidities and maltreatment. The analysis included data from 1.4 million U.S. birthing person (aged 25 to 50 years) and infant pairs (singleton birth between 2006 and 2019). Researchers found that the policies of Reporting Requirements for Assessment/Treatment and Mandatory Warning Signs were associated with increased odds of infant injuries but not morbidities. The only policy to lower the risk for infant injuries was Priority Treatment for Pregnant Women Only. There was an association seen between Civil Commitment and increased odds of infant injuries but decreased odds of infant morbidities. For Priority Treatment for Pregnant Women and Women With Children, increased odds were observed of both infant injuries and infant morbidities. The investigators found no association between Reporting Requirements for Child Protective Services, Reporting Requirements for Data, Child Abuse/Neglect, and Limits on Criminal Prosecution with infant injuries or morbidities. “Policy makers should not assume that pregnancy-specific alcohol policies improve infant health,” the authors write. Full Article

An Engineered Human-Antibody Fragment with Fentanyl Pan-Specificity That Reverses Carfentanil-Induced Respiratory Depression Anti Fentanyl “We expect this antibody to be a valuable new weapon for fighting the opioid crisis.” Human Anti-body that targets carfentanil, Fentanyl and related opioids reverses overdose effects in preclinical study A study found that an anti-fentanyl antibody reversed the signs of carfentanil overdose. In the study, the investigators developed an antibody in single-chain fragment variable format that binds with very high affinity to several variants of fentanyl, including carfentanil—the most dangerous variant. They designed the antibody to enter the bloodstream quickly via intramuscular injection and to persist in the body in order to offer long-term protection.1 Upon administering the antibody to rodents in the study, the investigators found that administration shortly following an overdose of carfentanil reverses the signs of the potentially deadly respiratory depression caused by carfentanil overdose.1 The investigators concluded that these results show that the antibody has the potential to be a more powerful and longer-lasting treatment for synthetic opioid overdose. “We expect this antibody to be a valuable new weapon for fighting the opioid crisis,” said study senior author Kim D. Janda, PhD, the Ely R. Callaway, Jr. professor of chemistry at Scripps Research, in a press release.1

Investigation by BMJ Questions Antipsychotic's Approval for Agitation in AD How the FDA approved an antipsychotic that failed to show a meaningful benefit but raised the risk of death The US Food and Drug Administration (FDA) approved the antipsychotic drug brexpiprazole (Rexulti) for agitation due to Alzheimer’s disease despite questionable efficacy data and a known higher risk of death, alleges a new investigation in the BMJ. Journalist Robert Whitaker took a deep dive into the safety and efficacy data soon after the FDA approved the new indication for the drug in May of this year. After sifting through the data and watching the agency's April 14 advisory panel meeting, he concluded that brexpiprazole presented no advance, despite winning the backing of both the advisory committee and the FDA. The advisory panel meeting "just seemed like a rubber-stamp exercise rather than a probing of really what are the risks and benefits of this drug," Whitaker told Medscape Medical News. Whitaker wrote that "no benefit was seen at the US sites in the one study that provided the primary evidence for approval." And yet, the lack of efficacy in the US was never discussed by any of the advisers, he told Medscape. Brexpiprazole, along with other antipsychotics such as aripiprazole, risperidone, and olanzapine have long been used off label to treat dementia-related agitation. But in 2005, the FDA warned against this use, noting that older patients were at higher risk for death, primarily due to strokes and other cardiovascular events. Indeed, all the antipsychotics — including the new label for brexpiprazole — carry boxed warnings on the increased risk of death. Whitaker reported that the mortality risk with brexpiprazole was four times higher than with placebo. Meanwhile, the US Centers for Medicare and Medicaid Services (CMS) has campaigned against the inappropriate use of antipsychotics in nursing homes at least since the start of an initiative in 2012. Not 'Statistically Persuasive' Still, Otsuka and Lundbeck, the manufacturers of brexpiprazole, decided to pursue FDA approval for agitation. Such an approval would allow the companies to essentially rebrand the medication and specifically market it for agitation — at an estimated monthly cost of $1400, noted Whitaker in his article. Whitaker reported that the FDA was skeptical of the manufacturers' first two pivotal controlled studies, telling them in a 2017 meeting that the agency did not consider a 3.8-point reduction in symptoms on the Cohen-Mansfield Agitation Inventory (CMAI) scale with the 2-milligram dose when compared with placebo to be "statistically persuasive." An international group determined in 2021 that a "minimal clinically important difference" on the CMAI scale was 17 points, Whitaker reported. The FDA ordered Otsuka and Lundbeck to conduct a third trial. In that study, there was a maximum 5.3-point improvement over placebo on the 174-point CMAI, far short of the 17 points considered to be clinically important, Whitaker noted. And yet, in its approval, the FDA wrote that "patients who received 2 mg or 3 mg of Rexulti showed statistically significant and clinically meaningful improvements in total CMAI scores compared to patients in the placebo group at week 12." Whitaker told Medscape that he asked FDA why the results were considered "clinically meaningful." First, the agency said it could not respond in time for his deadline. It later told him that he would have to file a Freedom of Information Act request to get answers. The reporter also said he received no response to multiple requests for comment from Rajesh Narendran, MD, a professor of psychiatry at the University of Pittsburgh, Pittsburgh, Pennsylvania, and the chair of the FDA advisory committee that weighed the approval. Lon Schneider, MD, a professor of psychiatry, neurology, and gerontology at the University of Southern California's Keck School of Medicine, Los Angeles, told Whitaker that brexpiprazole was no different than other antipsychotics. It offers the "same small points of difference on the CMAI scale," and "the same level of side effects, the same black box warning," he said. The FDA has a "lower standard of approval" than it did two decades ago, Schneider told the BMJ reporter. FDA: Drug Fills Unmet Need But in a response to Medscape Medical News, the FDA defended the approval process. The agency granted brexpiprazole a fast-track approval — signaling that it was an advance over existing therapies and that it fills an unmet medical need. The agency also gave it a priority review. "Both fast track and priority review are programs intended to help ensure that therapies for serious conditions are approved and available to patients as soon as it can be concluded that the therapies' benefits justify their risks," an FDA spokesperson told Medscape. "The clinical benefits of Rexulti are stated in the prescribing information," he added. "This submission was discussed at an advisory committee meeting on April 14; the overwhelming majority of the advisory committee members agreed with FDA's conclusion that the drug is effective and that the benefit risk assessment was favorable for the use of Rexulti in the treatment of agitation in patients with dementia due to Alzheimer's disease," said the spokesperson. Whitaker said the approval "is going to open the floodgates for the use of this antipsychotic," adding that "the FDA is saying this drug is different from the drugs that are being prescribed off label right now. That's the message to the prescribing population and that's exactly the message that Otsuka and Lundbeck are going to market their drug with." The BMJ reporter also noted that a number of patient advocacy groups — including the Alzheimer's Association, the Alliance for Aging Research, Leaders Engaged on Alzheimer's Disease, and Us Against Alzheimer's — have backed brexpiprazole. Many of these organizations also receive funding from Otsuka and other drug makers, Whitaker reported. Medscape sought comment from Otsuka but received no response. Medicare Coverage a Given A CMS spokesperson told Whitaker that the agency still posits that, "Antipsychotic medications are especially dangerous among the nursing home population because of their potentially devastating side effects, including death," and that the agency would "continue its efforts to reduce the prescribing of unnecessary antipsychotics in nursing homes." However, the spokesperson also told Whitaker that Medicare already covers brexpiprazole. Part D drug plan formularies must include brexpiprazole since it was previously FDA-approved for schizophrenia, the spokesperson said. The drug plans can, however, "add limits to this medication to prevent inappropriate use," the spokesperson told Whitaker. A CMS spokesperson confirmed to Medscape Medical News the quotes given to Whitaker.

Marijuana and hallucinogen use, binge drinking reached record highs in middle-aged adults, survey finds The latest results of the Monitoring the Future (MTF) longitudinal survey show that American adults are consuming marijuana and hallucinogens, vaping, and binge drinking at historic levels. "In 2022, we are seeing that marijuana and hallucinogen use, and vaping of nicotine and marijuana, are higher than ever among young adults ages 19 to 30," said Megan Patrick, research professor and principal investigator of the MTF study. "In addition, midlife adults ages 35 to 50 have the highest level of binge drinking we have ever seen in that age group," she said in a statement. The survey, conducted annually since 1975 by the University of Michigan's Institute for Social Research in Ann Arbor, queries nationally representative samples of eighth, 10th, and 12th graders and then follows a subset through adulthood to come up with longitudinal data. It is funded by the National Institute on Drug Abuse (NIDA). The adult data for 2022 were gathered by online and paper surveys from April to October 2022 and included responses from some 10,000 individuals. Particpants were divided into two cohorts: those aged 19–30 years and those aged 35–50 years. About a third of the older age group reported using marijuana in the past year, an all-time high, up from 25% in 2021 and more than double the users in 2012 (13%). Of this group, 4% reported past-year hallucinogen use, also a record high and double the reported use in 2021. Alcohol use among adults aged 35–50 has gradually increased over the past decade. Of this group, 85% reported past-year drinking in 2022, up from 83% in 2012. Binge drinking — defined as having five or more drinks in a row in the past 2 weeks — has also been on the rise in the past decade. One third of older adults reported binge drinking in 2022. Binge drinking was highest among White (31.4%) and Hispanic (30.6%) midlife adults and was lower among Black (17.1%) midlife adults. Vaping among the older age cohort has remained at similar levels since first measured in 2019; 9% vaped marijuana in the past year, while 7% vaped nicotine. Marijuana Popular Among Younger Americans Marijuana use on the rise among young Americans: study "In 2022, marijuana use among young adults reached the highest levels ever recorded since the indices were first available in 1988," the study authors write. Both past-year and daily use hit record levels for the cohort of those aged 19–30. Forty-four percent reported past-year marijuana use, up from 28% in 2012. The highest levels of use were in those aged 27 to 28. One in five reported daily use, up from 6% a decade ago; almost 14% of 23- to 24-year-olds reported daily use. Past-year use of hallucinogens — including LSD, MDMA, mescaline, peyote, mushrooms or psilocybin, and PCP — was reported by 8% of this age group. Most of the increase was driven by use of hallucinogens other than LSD, which accounted for 7% of the reported use. Young adults also reported record levels of vaping marijuana, with 21% reporting past-year use and 14% reporting past-month use. Vaping of nicotine has doubled in prevalence since the survey started asking about it, from 14% for past-year use in 2017 to 24% in 2022. NIDA Director Nora Volkow, MD, noted in a statement that the survey results show that "substance use is not limited to teens and young adults," adding that "these data help us understand how people use drugs across the lifespan."

Gene Therapy Offers New Way to Fight Alcohol Use Disorder A type of gene therapy that reboots the brain's reward system could curb drinking in those with severe alcohol use disorder. Researchers from Oregon Health & Science University implanted the therapy directly into the brains of rhesus monkeys that had been conditioned to drink eight to 10 alcoholic drinks a day. A harmless virus that carried a specific gene was placed in the region of the brain that regulates dopamine, which provides feelings of reward and pleasure. "We wanted to see if we could normalize the dopamine in these motivational areas – if, indeed, motivation to overdrink or drink heavily would be mitigated," said study author Kathleen Grant, PhD, a professor and chief of the Division of Neuroscience at the university's Oregon National Primate Research Center. Alcoholism research at OHSU advances with new $2.4 million federal grant The need for new alcohol use disorder treatments may be more dire than ever. Alcohol-related deaths in the United States increased dramatically between 2007 and 2020, especially in women, according to research published in the journal JAMA Network Open. The next year, they spiked again, to 108,791 alcohol-related deaths in 2021 alone, according to the National Institutes of Health. That's slightly more than the number of drug overdoses recorded in 2021. For the 29.5 million Americans with alcohol use disorder, also known as alcohol abuse or dependence, the road to recovery can be challenging. One reason is that the reward systems in their brains are working against them. At the first taste of alcohol, your body releases the feel-good brain chemical dopamine. But if you drink too much for too long, your brain reduces dopamine production, and you want even more alcohol to feel good again. The gene researchers placed in the monkeys' brains is called glial derived neurotrophic factor. It is a "growth factor," meaning it stimulates cells to multiply. It may help improve function of brain cells that synthesize dopamine, effectively resetting the whole system and reducing the urge to drink. The study was surprisingly successful. Compared to primates that received a placebo IV, those that received the growth factor gene decreased their drinking by about 90%. They basically quit drinking, while the primates that got the placebo resumed their habit. A similar procedure is already used in patients with Parkinson's disease. But more animal studies, and human clinical trials, would be needed before this therapy could be used in humans with alcohol use disorder. This invasive treatment involves brain surgery, which has risks, so it would likely be reserved for those with the most severe, dangerous drinking habits. "I think it'd be appropriate for individuals where other treatment modalities just weren't effective, and they're worried for their lives," Grant said. Alcohol Use Disorder Treatments Today, treatment for alcohol use disorder ranges from a brief conversation with a health care provider, in mild cases, to psychiatric treatment or medication in moderate or severe cases. FDA-Approved Medications for Alcohol Use Disorder There are four FDA-approved treatments for alcohol use disorder and a few more medications that health care providers can prescribe off-label. "They're not widely used," said Henry Kranzler, MD, a professor of psychiatry and director of the Center for Studies of Addiction at the University of Pennsylvania Perelman School of Medicine. "They're shockingly underutilized." One reason: Just 4.6% of people with alcohol use disorder seek treatment each year, according to NIH data. "Some of the issues include the ubiquity of alcohol, and its acceptance in American culture – and the fact that that makes it difficult for people to acknowledge that they have a problem with alcohol," said Kranzler. But another problem is that many health care professionals don't recognize and treat alcohol use disorder in patients who do seek care. Those seeking treatment for alcohol use disorder can find a qualified provider at the American Academy of Addiction Psychiatry or American Society of Addiction Medicine directories. The Future of Treatment Advances in the science and treatment of alcohol use disorder Ongoing research could lead to more treatments, and make them more available and more appealing. Unlike many other drugs that work on a single receptor in the body – like opioids that target opioid receptors, or nicotine, which targets choline receptors – alcohol affects many different receptors, said Robert Swift, MD, PhD, a professor of psychiatry and human behavior at Brown University Alpert Medical School. It also penetrates cells at high doses. "There are so many different effects of alcohol, which makes it very hard to treat," he said. "But on the other hand, it gives us an advantage, and there are probably different points that we can attack." Other exciting developments are underway, although more research, including clinical trials in humans, is needed before they arrive. Some of the most promising: Hallucinogens. In the 1950s, before they became illegal, these trippy drugs helped people drink less. Even Bill Wilson, co-founder of Alcoholics Anonymous, used hallucinogenic treatment in his recovery; it helped him envision overcoming a challenge. Today, there is renewed interest in hallucinogens for alcohol use disorder. In a study published in JAMA Psychiatry , people with alcohol use disorder who were given the hallucinogen psilocybin along with therapy spent fewer days drinking heavily over the following 32 weeks than people who received a different medication. Don't try to do this yourself, though. "It's not just taking a hallucinogen and having a trip," Swift said. "It's a therapy-guided session, so it's a combination of using the hallucinogenic substance with a skilled therapist, and sometimes two skilled therapists, helping to guide the experience." What Are Hallucinogens? Common Types of Hallucinogens CRISPR technologies for precise epigenome editing Epigenetic editing. Alcohol exposure can affect the activity of a gene in your amygdala, a brain region involved in emotional processing. Researchers at the University of Illinois at Chicago found that by editing that gene in rats through an IV of genetic material, they reduced the rodents' drinking and anxiety. Tell Me All I Need to Know About Oxytocin Oxytocin. The so-called love hormone, produced by your brain when you hug your partner, could help reset the dopamine system to make alcohol less appealing. "There are oxytocin receptors on dopamine neurons, and oxytocin makes your dopamine system more effective," Swift said. In a recent study from the Medical University of South Carolina, mice injected with oxytocin didn't drink during a stressful situation that could have otherwise led to relapse. Nutrients | Free Full - Text | Molecular Mechanisms and Health Benefits of Ghrelin: A Narrative Review Ghrelin. This stomach hormone that helps you stay full could help curb drinking. In a study published in Neuropharmacology , mice that received drugs that increased ghrelin reduced their alcohol intake.

Amy Palmer discusses the strength of fentanyl compared to other opiates during a naloxone training event on July 8 at The Dandy Lion Cafe in Ashland, Missouri. The next training event is scheduled for Sept. 12, but Palmer said the goal is to host events monthly fentanyl epidemic Fentanyl 101: What You Need to Know The fentanyl epidemic is getting worse in Missouri, with record numbers of overdoses in the last four years and 2023 on course to be another record year. Data points to a nearly 75% increase in overdoses in Missouri since 2019, and last year was the second consecutive year that fentanyl accounted for over two-thirds of overdoses in Missouri. Trends in Missouri match what the U.S. Drug Enforcement Administration describes as a “nationwide overdose epidemic” fueled by the spread of fentanyl. The drug has a place in reducing suffering when its use is deliberate and controlled. Diluted to thousandths of a milligram and administered by medical professionals, fentanyl can relieve pain in half the time it takes morphine and without its unpleasant side effects. However, it takes merely one grain of salt’s worth of fentanyl to cross into a fatal dose. The drug is up to 50 times more powerful than heroin and far cheaper to produce. It can also be spliced into various drugs to make counterfeit pills that can be fatal. Counterfeit pills are often disguised as legitimate prescription drugs such as Oxycontin, Xanax, Vicodin, Adderall and Percocet and are increasingly culprits in fentanyl overdoses. Overdoses can occur when victims believe they are using cocaine or pill-based drugs that don’t usually prove fatal, according to the DEA. For every 10 fentanyl-laced counterfeit pills created, six contain a dose that can kill, the agency said in a public notice. Earlier in June, nearly 1,000 counterfeit Percocet pills laced with fentanyl were recovered in one traffic stop in Miller County. Nationwide, DEA seizures of counterfeit pills containing fentanyl have risen by 430% since 2019. The DEA released a letter in 2021 warning federal, state and local law enforcement about so-called “mass-overdose” events — three or more overdoses at the same time and place. “Fentanyl is killing Americans at an unprecedented rate,” according to DEA Administrator Anne Milgram. “Drug traffickers are driving addiction, and increasing their profits, by mixing fentanyl with other illicit drugs. Tragically, many overdose victims have no idea they are ingesting deadly fentanyl until it’s too late.” Amy Palmer discusses the strength of fentanyl compared to other opiates during a naloxone training event on July 8 at The Dandy Lion Cafe in Ashland, Missouri. The next training event is scheduled for Sept. 12, but Palmer said the goal is to host events monthly. Citizens make a difference Amy Palmer, an emergency responder who works at Columbia/Boone County Public Health and Human Services, said she’s seen overdoses across all ages, races and socioeconomic classes. Emergency services will typically know a “bad batch” has hit town because of a sudden burst of overdose calls, she said. Palmer also works as an educator with the University of Missouri-St. Louis Addiction Science team and recently led a 45-minute class to teach participants how to administer naloxone, a synthetic drug that inhibits opiate receptors in the nervous system while reversing adverse effects. Throughout the course of this Save-a-Life class, attendees receive step-by-step instructions about naloxone to keep a person alive while waiting for first responders. Students are given 4mg doses, typically enough to save a life. If a first dose isn’t effective, emergency responders can administer additional doses until the patient is revived. Eighty-five percent of revivals recorded by UMSL are achieved within two doses. In the last two years, records from Palmer’s EMS station show that her team has administered naloxone 189 times. The procedure has reversed a number of potential deaths in Boone County. Missouri Institute of Mental Health data shows that no more than four people given naloxone in Columbia perished each year from 2018 to 2022. Save-a-Life training is often attended by people with no background in emergency medical aid, or “good Samaritans,” said Heather Harlan, who has also been an instructor. She said family members and friends of those with substance use disorder seek out the class. “We don’t ask questions — they get training and they get naloxone,” she said. Good Samaritans Brian Adermann, who works in grounds and maintenance at Rock Bridge Memorial State Park, attended a recent class. Three weeks before the training, Aldermann said he noticed a half-conscious stranger with a needle in their arm in a parked car. Adermann’s first thought was fentanyl overdose. He knocked on the window, and the stranger slowly sobered up and drove away. If it had been an overdose, Adermann said he wouldn’t have known what to do. So, he decided to attend the training. A recent UMSL report suggests that fire police, EMS and clinicians account for only slightly more naloxone administration than friends, significant others, parents and strangers like Aldermann. As of April 2023, citizens made up 47% of reported naloxone administrations, with emergency personnel taking responsibility for nearly 50%, approaching an even split, according to UMSL data. The UMSL Addiction Science Team responsible for the data set qualifies its findings, saying that results are “limited to those who (have) been trained and (feel) comfortable completing it,” and that its figures are likely a “large underestimate” of non-fatal overdoses in Missouri. Harlan said residents can no longer expect to avoid witnessing an overdose event — a person slumped in a public space and unresponsive — and as the first person on scene they’re best equipped to give the victim the best shot of survival. Camaron Nielsen, a volunteer for Heart of Missouri CASA, court-appointed special advocates for children in foster care, came to the training as part of her continuing education. As an advocate for children in foster care, Nielsen said she knows fentanyl might reach those communities too, so she wants to be prepared. “It (drug use) is something that is an unfortunate reality so we try to be knowledgeable about it,” she said. Since October 2021, Boone County has received 908 boxes of naloxone, and nearly all have been distributed. For those who haven’t seen an overdose in their circle of friends or acquaintances, it’s difficult to understand fentanyl overdoses, Harlan said. But stories she’s heard make the impact on the community clear. “We too casually say that ‘this is a choice,’” and dismiss the problem as a moral failing, Harlan said. “When people ask me, ‘well why do people use drugs?’ Pain is why.”

Tobacco dependence was significantly lower among polyusers of cigarettes, e-cigarettes, cigars, as well as dominant smokeless product users. HealthDay News — Cigarette-dominant tobacco users have a higher level of tobacco dependence (TD), according to a study published online July 26 in Nicotine and Tobacco Research. Lihua Li, Ph.D., from the Icahn School of Medicine at Mount Sinai in New York City, and colleagues examined tobacco use (TU) profiles and their associations with TD over time among 3,463 adult recent tobacco users. TU profiles were identified by applying a latent class analysis based on participants’ usage of 8 common tobacco product groups at each of waves 1 to 4 of the Population Assessment of Tobacco and Health study. Researchers identified 3 distinct TU profiles that remained consistent across the 4 survey waves: dominant cigarette users; polyusers with a high propensity of using traditional cigarettes, electronic cigarettes, and cigars; and dominant smokeless product users (62 to 68%; 24 to 31%; and 7 to 9%, respectively). Compared with dominant cigarette users, TD was significantly lower among polyusers and dominant smokeless users. “As individuals may change their habits over time, future studies should examine patterns of tobacco use changes, including whether people’s changing habits differ by sociodemographic factors, and we should investigate how these changes impact tobacco dependency over time in the context of other smoking behaviors, including attempting to quit, relapse, and smoking cessation,” Li said in a statement. Full Article

How many children in your community are on ADHD medications? Do you know how important it is to find out? It may be time for a new nightly public service announcement. Throughout the 1970s, American TVs warned “It’s 10 o’clock. Do you know where your children are?” Today a more fitting message might be, “Young kids abuse mental health meds. Do you know how many of your child’s schoolmates have an ADHD prescription?” A national study published earlier this year showed that ADHD drug abuse among U.S. high and middle school students has been rising for the past 20 years. The problem is more than 30 times greater in some schools than others. The main factor affecting the magnitude of the problem is the percent of ADHD-diagnosed students in a school. More children diagnosed equates to more drug abuse. While ADHD drug abuse may be a problem in school communities around the country, significant risk factors for abuse were schools located in suburban neighborhoods and schools with highly educated and primarily white populations. Like the opioid epidemic, ADHD drug abuse may be most evident outside inner cities but that doesn’t mean it’s not a problem in urban communities too. ADHD prescribing rates are important because ADHD often represents a gateway diagnosis not only into the mental health system but also into the world of youthful drug experimentation. Once diagnosed, many children experience a cascade of psychotropic prescriptions—drugs used to treat mental health problems. Stimulants like Adderall and Vyvanse are often prescribed first, but tolerance to the drug effects can develop quickly or induce adverse effects. This often leads doctors to switch up and add on various drugs. In the U.S., 40% of ADHD-diagnosed 2- to 24-year-olds are on multiple types of psychotropics concurrently. Even the use of powerful antipsychotics—the drugs once reserved for treating adults with schizophrenia—has become a common part of ADHD treatment. A diagnosis of ADHD has been implicated in 25 percent of antipsychotic adverse drug reactions. In the past, access to local ADHD prescribing rates would have required academic professionals to secure grant money to support labor-intensive research. That’s no longer the case. Thanks to the proliferation of electronic health record systems (EHRs), information about a community’s rate of prescribing ADHD drugs and other mental health meds is sitting in databases begging for air. Without violating patient privacy or confidentiality, it would be relatively easy for a hospital or health system to generate “de-identified” rates of drugs prescribed to children for ADHD or any other mental health conditions. De-identified information does not include names or other personally identifying information. It is limited to 3-level zip codes (except when fewer than 20,000 individuals reside in the specified geographic region). It includes only aggregate information such as the percent of individuals under 18 who have been diagnosed with ADHD. As individuals who spent much of our careers conducting scientific investigations on the prevalence and impact of mental health diagnoses and drug treatment trends, we value the ease with which communities could now learn about their mental health trends. In the early to mid-2000s, our research documented that ADHD treatment rates were many times higher than nationally recognized ADHD experts insisted were possible. One of the most prominent ADHD authority figures of the time came to southeastern Virginia (SEVA), which includes Virginia Beach, Norfolk, Portsmouth, and several surrounding cities. He told community members to ignore reports of ADHD overdiagnosis. But when SEVA citizens saw how high its rate of ADHD prescribing was, they took decisive action. Through the help of a community coalition of key stakeholders and community movers and shakers, SEVA systematically decreased ADHD treatment by 32 percent while also developing non-drug interventions that improved educational outcomes. Unfortunately, individuals with financial ties to the pharmaceutical industry attacked and derailed the community-based work beyond repair, as first mentioned in Anatomy of an Epidemic by Robert Whitaker and more recently in Deconstructing ADHD, a volume edited by Eric Maisel. As detailed in Shooting the Messenger: The Case of ADHD, effort was taken to convey to the medical community and the public that the SEVA epidemiologic and intervention research was based on fabricated data to suit an anti-medication agenda and that the research was being conducted without proper informed consent. One of us (Gretchen LeFever Watson) was the lead researcher at the time. Here’s what happened: The attacks on my credibility culminated in an anonymous false allegation of scientific misconduct. The allegation was leaked to the press and Eastern Virginia Medical School (EVMS) confirmed that one of its faculty members was under investigation for scientific misconduct. A local newspaper reporter began pestering the researcher’s staff and community collaborators and local K-12 school officials about the research and their role in it. Local pediatricians affiliated with the medical school became increasingly hostile toward me. Pediatric neurologist Dr. Donald Lewis repeatedly threatened me and rebuked me in an email: “repeated news media reports, fueled by your reports, which depict our clinicians as quick-triggered, pill-pushers undermines the credibility of the Children’s Hospital [Children’s Hospital of The King’s Daughters, CHKD, in SEVA] as well as our community partners.” Lewis was one of the principal investigators for an EVMS-affiliated clinical research organization that had contracts with over 40 pharmaceutical companies, including numerous ADHD clinical drug trials. At some point during the investigation, a K-12 school administrator reportedly marched into the medical school dean’s office complaining that they had been misled about consent procedures. This allegation was false, and wholly unsupported by the record. Fear on the part of medical and school officials of legal action and press scrutiny apparently created an atmosphere in which the self-preservation instinct overcame solid factual analysis. The looming threat of a scandalous newspaper expose about local ADHD research had the potential to become a public relations nightmare. The unsubstantiated claim by a local school administrator was the straw that broke the camel’s back. The medical school placed me on leave without pay, permanently terminated my federally funded research, and promised school officials that my data—which were collected at taxpayer expense and with the expectation of full public dissemination—would never be used for any reason. Contact with my staff was severed and I was forced to communicate with the medical school through an attorney, which racked up expenses while on leave without pay. Because EVMS terminated my research, the U.S. Centers for Disease Control and Prevention (CDC) asserted that it was forced to severe their cooperative agreement and withdraw grant funding for my portion of a multisite investigation of the prevalence and impact of ADHD—the portion of the study that was also investigating the prevalence and impact of depression, bipolar disorder, obesity, parenting strategies, sleep hygiene, and related health issues. EVMS eventually cleared me of all wrongdoing. However, as an institution that does not offer tenure, it simply failed to renew my contract the following year. Despite having a copy of official documentation clearing me of scientific misconduct, a local newspaper story was published which implied my ADHD research may have misled the public and “missed the mark.” The ordeal led to the total dismantling of a public health approach to improve ADHD care which had the potential to serve as a national model for reducing overuse of psychotropic drugs while also improving educational and behavioral outcomes among school-aged children. This included cancellation of programs designed to systematically manage behaviorally challenging children, improve school-provider communication, teacher training and education, and parent education and support. It also led to the termination of the nation’s first public health psychology internship—a clinical psychology internship program approved by the American Psychological Association. That, in a nutshell, is how an originally anonymous, unsubstantiated complaint led to the termination of a very promising line of research. Imagine if instead of relying on a single faculty member writing and securing grant funding to collect information from research subjects, the work had been overseen by a community task force that monitored data trends captured by EHRs. It would have been much more difficult for people to cancel the work because it conflicted with their financial interests. Today, the latter approach is possible, but first people must be alerted to the fact that there is reason to be concerned about psychotropic overprescription and that EHR data can help to clarify the extent of the problem. This is especially true in places like SEVA, where the healthcare is dominated by one large, integrated healthcare system and a single pediatric hospital and its affiliated practices. The benefit of hindsight indicates that SEVA was an epicenter, if not the epicenter, for psychotropic overprescription in children. By 2000, data demonstrated that about 19 percent of the region’s elementary school students were medicated for ADHD, with 28 percent of those students on two or more types of psychotropics concurrently. Early on, this unprecedented level of psychotropic prescribing was associated with surprisingly poor educational outcomes. Since then, the most definitive national study of ADHD treatment modalities documented that ADHD drug treatment led to worse outcomes than other options. In that federally-funded longitudinal study, known as the MTA study, researchers monitored ADHD treatment outcomes among children who were randomly assigned to various treatment modalities. During the initial assessment, stimulant drugs appeared to reduce ADHD symptoms. However, by the 3-year follow-up, children who were taking stimulants had worse outcomes than those who were not. Stimulants use “was a significant marker […] not of beneficial outcome, but of deterioration. That is, participants using medication in the 24- to 36-month period actually showed increased symptomatology during that interval relative to those not taking medication,” the researchers wrote. One of the MTA researchers, Dr. William Pelham, has repeatedly sought to convey to the public that, over the long haul, stimulant drugs are not as effective as commonly believed. “We had thought that children medicated longer would have better outcomes. That didn’t happen to be the case. The children had a substantial decrease in their rate of growth, so they weren’t growing as much as other kids in terms of both their height and their weight. And the second was that there were no beneficial effects—none,” he said in a 2007 Daily Telegraph interview. These results were reinforced by a 2022 study conducted by Pelham and others showing that, while ADHD children taking stimulant medication sat in their seats longer and got more work done in the short run, they did not learn any more academic material than when they were not taking stimulants. Other research has confirmed the association between stimulant drugs and a deterioration in functioning on both educational and social-emotional measures. Analyzing a massive and longitudinal set of data from children across Canada, a Princeton University professor documented the downside of long-term use of stimulant drugs. Expanding the use of ADHD drug treatment “had little positive benefit and may have had harmful effects given the average way these drugs are used.” Though not precisely understood, the “mechanism of action of prescription stimulants is not drastically different from that of cocaine and MA [methamphetamine, known also as meth].” Moreover, 70 to 80 percent of all individuals (whether or not they are diagnosed with ADHD) experience an initially favorable response to stimulant medication, according to Dr. Larry Diller, pediatrician, and author of Running on Ritalin. In a PBS interview, Diller explained that people can get a dopamine “rush” from taking a prescription stimulant, cocaine, or methamphetamine. He also noted that few people realized that methamphetamine, which is generally considered dangerously addictive, is listed in Physician’s Desk Reference as a treatment for ADHD, much like stimulants more commonly prescribed (Ritalin, Adderall, Vyvanse, etc.). “Rates of overdose deaths from psychostimulants [ADHD pills] have been increasing since 2010,” according to the CDC. The U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA) is now warning of a new wave of addiction stemming from stimulants like Ritalin and Adderall, as well as cocaine and methamphetamine. It is increasingly common for people in drug rehabilitation programs to report that their drug experimentation began with ADHD pills. In 2018, John Eadie, a project coordinator for the National High Intensity Drug Trafficking Areas, told WebMD, “No one is paying attention to this. Everyone, correctly, is focused on opioids and should be because of the known problem there. But this other problem is catching up with us very rapidly.” According to Eadie, law enforcement agents are seizing fifteen times more kilograms of stimulants than opioids. ADHD prescriptions surged during the COVID-19 pandemic, again raising questions about the appropriateness of ADHD care. Is it possible that things would have turned out differently for millions of people suffering with substance abuse problems if efforts to publicly report on trends first observed in SEVA had not been quashed by pharmaceutical industry interests? We’ll never know, but the data sitting in EHRs in every U.S. community might offer insights that could make a difference in the future of countless children, families, schools, and communities. Several organizations have sponsored a petition to raise awareness about the problem of psychotropic overprescription among U.S. children and calls for the potential to use de-identified EHR information to monitor and publicly report psychotropic prescribing rates at the community level. The authors and sponsors of the petition believe community-level reporting could help reverse our society’s tendency to “medicate normal.” An award-winning documentary film with the same title exposes the underappreciated problem of widespread use of psychotropics, especially when used long-term. How many children in your community are on ADHD drugs or other psychotropics? For those who might be interested, the petition can be found here. *** Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own. *** Mad in America has made some changes to the commenting process. You no longer need to login or create an account on our site to comment. The only information needed is your name, email and comment text. Comments made with an account prior to this change will remain visible on the site. Gretchen LeFever Watson Dr. Watson is a clinical psychologist, academic affiliate of the University of South Carolina College of Pharmacology, and Vice President of the Institute for the Study of Integrated Healthcare Advisory Council at Utica University. She is the author of Your Patient Safety Survival Guide: How to Protect Yourself and Others From Medical Errors. Contact her at gwatsonphd@gmail.com. David O. Antonuccio is a Professor Emeritus in the Dept. of Psychiatry and Behavioral Sciences at the University of Nevada School of Medicine, where he taught for 32 years. Concurrently, he worked for 24 years at the V.A. Medical Center in Reno. He has also had a private practice for more than 35 years. He served on the Nevada State Board of Psychological Examiners from 1990 to 1998. His clinical and research interests include the behavioral treatment of depression, anxiety, and smoking.