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Addiction programs in Manitoba: support is flat in the great flatlands

As a have-less province with a significant fraction of the population that is poorly educated and un- or underemployed, Manitoba has its share of drug-related problems. Manitobans with addictions (many of whom have mental health issues) do not have ready access to treatment. Resources are inadequate and there are long waits. Take the case of methadone intervention programs.

Manitoba has only one-quarter of the methadone spaces per capita as compared to neighbouring Saskatchewan, and it is a sad fact that some programs currently operating in Winnipeg are feeling oxygen-deprived. Two Ten on Maryland, in Winnipeg’s inner city, is a non-profit post-treatment program for recovering addicts run by a former meth addict, Ian Rabb. He has been requesting more support from the provincial government for years, claiming that additional funding is required to provide round-the-clock supervision of clients and improve safety.

Manitoba spends $22 million a year on addiction services. Not surprisingly, belt-tightening is going on throughout government – the province faces a projected $592-million deficit this year – but officials claim this hasn’t prevented the funding of vital programs.

In a recent Winnipeg Free Press article [1] Rabb accuses the government of foot-dragging and insincerity when it claims that money is tight. In his view the programs offered at the facilities save the government money. Clients stay out of hospital and jail, and most of them eventually get off welfare.

By coincidence, in a letter to the editor on the same day a local representative of the Canadian Mental Health Association, Nicole Chammartin, pleads for improved harm-reduction programs for those with addictions, specifically mentioning methadone treatment. “We require a comprehensive and responsive addictions system that serves everyone,” concludes Chammartin.

Existing research provides some evidence for the value of harm-reduction programs for addicts. A Lancet study published last October found that psychosocial interventions used in England are associated with reduced use of heroin and crack cocaine [2]. Outreach programs can lead to high levels of compliance, general improvement, and treatment satisfaction [3]. Feeling that treatment is appropriate, finding staff motivating, and having enough time to sort out problems are important aspects of satisfaction with treatment among users of drug treatment services who achieved positive treatment outcomes. Services should seek to provide more individualized services based on understanding of individual client needs. This may require longer treatment periods and greater client involvement [4].

However, it is difficult to demonstrate conclusively the effectiveness of programs and successful treatment outcomes. A recent Cochrane Review went so far as to say that “there is no good available research to guide the clinician about the outcomes or cost-effectiveness of inpatient or outpatient approaches to opioid detoxification” [5].

Although Manitoba’s left-of-centre NDP government makes the appropriate clucking noises when it comes to addiction problems, its record is not looking good. The Addiction Foundation of Manitoba’s Methadone Intervention & Needle Exchange Program (m.i.n.e.) [6] has shown itself to be effective, but insufficient funds are being directed at this serious problem. People with intractable addictions are waiting for help and inner-city programs are stalled, while money earned from government-run casinos is lavished on developing yet more affluent suburbs and on purchasing law-and-order fetishes like police helicopters to make suburbanites feel safer.

References

1. Owen B. Cuts at addictions centres? Director may trim services without new provincial funding. Winnipeg Free Press. 2010 Jan 23;Sect. A:8 (col. 3).

2. Marsden J, Eastwood B, Bradbury C, Dale-Perera A, Farrell M, Hammond P, Knight J, Randhawa K, Wright C; National Drug Treatment Monitoring System Outcomes Study Group. Effectiveness of community treatments for heroin and crack cocaine addiction in England: a prospective, in-treatment cohort study. Lancet. 2009 Oct 10;374(9697):1262-70. PubMed PMID: 19800681.

3. Henskens R, Garretsen H, Bongers I, Van Dijk A, Sturmans F. Effectiveness of an outreach treatment program for inner city crack abusers: compliance, outcome, and client satisfaction. Subst Use Misuse. 2008;43(10):1464-75. PubMed PMID: 18615321.

4. Morris ZS, Gannon M. Drug misuse treatment services in Scotland: predicting outcomes. Int J Qual Health Care. 2008 Aug;20(4):271-6. PubMed PMID: 18492708.

5. Day E, Ison J, Strang J. Inpatient versus other settings for detoxification for opioid dependence. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD004580. PubMed PMID: 15846721.

6. Bodnarchuk J, Patton D, Broszeit B. Evaluation of the AFM’s Methadone Intervention & Needle Exchange Program (m.i.n.e.) [Internet]. Winnipeg: Addiction Foundation of Manitoba; 2005 July [cited 24 Jan 2010]. Available from: http://www.afm.mb.ca/pdf/MINE_report_final.pdf

Photo credit: cc licensed flickr photo by wysiwtf

Bring on the mind control, please

You don’t expect to find anything funny in a book with a title like this: Breeding Bio Insecurity: How US Biodefense is Exporting Fear, Globalizing Risk and Making Us All Less Secure (Chicago, 2009). In the London Review of Books Thomas Jones writes that “Lynn Klotz and Edward Sylvester make a compelling case for a radical and immediate change in America”s biosecurity policy.”  Foreign Affairs says “the authors make a plausible and disturbing case.” Other reviewers have called it “forceful and provocative,” even “indispensable.”

The book argues that the conditions of research in bioweapons and biosecurity pose a greater risk to the health and security of Americans than do bioterrorist attacks, but that this risk can be countered and defeated with greater efforts against infectious diseases and greater international oversight and transparency. It also raises the question about the moral and legal issues around the billions spent since 9/11 on R&D into bioweapons counter-measures like antibiotics, antivirals, antidotes and vaccines. Testing them clearly requires ready availability of the bioweapons agents themselves, something that contravenes the Biological Weapons Convention, which bans the development, production, and stockpiling of microbial or other biological agents or toxins.

Ever since Hannibal’s forces threw clay pots full of snakes onto the decks of enemy ships in an ancient naval battle against the Pergamenes, nations have turned to biological warfare when it has suited them – especially when it can be claimed that massive reserves of anthrax, smallpox, plague, ricin, botulinum and ebola serve to defend the homeland. Despite the extreme unlikeliness of a large-scale biological terrorist attack, the United States, for example, has 219 labs studying anthrax alone. The number of people working in biodefence has increased twentyfold in the past decade.

A review in Science claims that the authors’ argument deserves serious attention:

Klotz and Sylvester spotlight the huge sums of money invested by the U.S. government in biodefense research. Here, they claim, secrecy is having corrosive effects. They also argue that the money pouring into biodefense research is out of proportion to the level of threat. In addition, they contend, this massive investment has backfired to create more risk because now more scientists are working with dangerous pathogens, thus increasing the chances of accident, theft, and deliberate misuse.

All weighty stuff. But, as Thomas Jones in LRB notes, Klotz and Sylvester also get carried away by what sounds like Cold War paranoia. At one point they bring up the subject of “the scariest weapons of all: mind-control agents.” These are largely the realm of science fiction, but apparently white-ruled South Africa carried out research into the use of MDMA for crowd control. Given the apartheid regime’s usual methods – attack dogs, tear gas, beatings, and shootings – a plan to use Ecstasy to suppress a revolt sounds positively benign.

“Ecstasy or smallpox: I know which I’d rather be attacked with. Bring on the ‘mind-control’, please.”

Photo credit: Flickr creative commons licence, uploaded by ClevelandSGS


A victory for common sense around harm reduction: Vancouver’s injection site wins a court battle

Insite supporters can breathe a sigh of relief. On January 15, 2010, the B.C. appeal court upheld a 2008 ruling by the province’s Supreme Court that allows the supervised injection site in Vancouver’s Downtown Eastside to stay open.

Liz Evans, the executive director of the Portland Hotel Society, which runs Insite, told The Globe and Mail: “Let’s hope [Prime Minister] Stephen Harper doesn’t waste any more taxpayers’ money by taking this to the Supreme Court.”

The debate over the future of Insite has been passionate in the two years since the Canadian government, in the face of convincing research, began questioning the validity of a harm reduction approach to injection drug use.

Thomas Kerr and Evan Wood, research scientists at the British Columbia Centre for Excellence in HIV/AIDS, accused the federal Conservatives of politicizing science in their straight-laced and passive-aggressive approach to Insite’s work with drug users. “This government may already have garnered a reputation for being the most antiscience government in Canadian history,” they wrote in a sharply worded article published online in April 2008.

Doing exactly what it was set up to do

Kerr and Wood charge the government with attempting to “cloud science” and “manufacture uncertainty.” In the Tories’ get-tough, war-on-drugs strategy, they aver, there is no room for sound public health strategies like harm reduction — despite the wealth of scientific evidence to support these interventions, including more than 20 studies by the authors which have appeared in major medical journals such as the New England Journal of Medicine, the Lancet, and the British Medical Journal. This plethora of research shows that Insite is doing exactly what it was set up to do:

  • contributing to reductions in the number of people injecting in public and the number of discarded syringes on city streets,
  • helping to reduce HIV-risk behaviour and saving lives that might otherwise have been lost to fatal overdose,
  • achieving a 30% increase in the use of detoxification programs among Insite users in the year after the site opened,
  • not increasing crime or leading others to take up injection-drug use.

Moreover, Insite appears to be cost-effective and is popular among the general public. Within the strict limits imposed on it, Insite just seems to work. Undeterred by mere facts, however, Prime Minister Stephen Harper, whose strong opposition to “deviant behaviour” is well known, claims to remain unconvinced. Neither the overwhelming scientific evidence nor Insite’s articulate defenders — not even the largely positive conclusions of the government’s own Expert Advisory Committee — seem to have swayed this staunch defender of prudence and propriety and his loyal supporters.

Ideological warfare

Given the significant disagreement on this issue, perhaps the very term “harm reduction” is the problem, as A.I. Leshner of the American Association for the Advancement of Science suggests [1]. The imprecise application of this term and its use as a euphemism for drug legalization have “sufficiently inflamed … drug warriors that they cannot have a rational discussion of even the underlying concept, let alone how harm-reduction strategies might be implemented.” Leshner advocates the avoidance of ideological intensity. “Let’s get on with studying specific strategies to protect the public health and ensure social well-being and give up this term that only gets in the way, even if it does make sense.” This well-meant and seemingly pragmatic dismissal of ideology, so characteristic of certain debates within American elites, is itself highly ideological. Excellent solutions are brought forward in print, and they stay securely in print. There are still no safe injection sites anywhere in the United States.

From a Canadian perspective, Bernadette Pauly of the University of Victoria reminds us that harm reduction, however well implemented, is only a partial solution [2]. Conceived within a broader social justice context, harm reduction strategies should be part of a comprehensive approach to reducing social inequities, providing accessible health care, and improving the health of those who are street-involved. Pauly is proposing to move from print to political project. All well and good, but then we confront the by-one’s-own-bootstraps catechism of the dogged Harperites and their extraordinary ability to mobilize the fear and petty prejudices of Canadians in support of their retrograde policies.

Scientific arguments are insufficient in themselves

In a brilliant commentary on the ideological warfare behind the war on drugs, two Canadian sociologists take on the sententious rhetoric that labels harm reduction advocates as “legalizers” in the guise of scientists and public health professionals [3]. Because the right-wing attack comes from either the intractably convinced or cleverly hypocritical stance that abstinence, prevention, and enforcement are the only acceptable and morally legitimate solutions, harm reduction’s muted stance on morals, rights and values prevents proponents from engaging criticisms of this nature in terms other than the evidence or science. The case of Insite, the authors argue, demonstrates the value of asserting human rights claims that do not rest on evidence per se. Scientific arguments are insufficient in themselves to move beyond the status quo on drugs.

They conclude, “Without commitment to ‘strong rights’ and the sovereignty of users, harm reduction sentiments are easily subverted to a technocratic governance agenda. Against the accusation that we are really ‘legalizers’ harm reduction advocates need not dispute the label but rather the suggestion that opposition to the drug war is somehow irresponsible, dishonest, or immoral. Respect for human rights moves harm reduction past the confines of a scientific project — which has not been well respected outside academic circles — toward a generative programme for replacing prohibition with policies reflecting the costs and benefits of drug use and the costs and benefits of formal intervention.”

Here, surely, is the way to proceed. Palaver and posturing should not get in the way of real progress, which will be measured in terms of real lives and the difference that intelligent and compassionate social programs can make. The decision of the BC Appeal Court in favour of Insite is a victory in what has become a culture war waged on the backs of people who have the least power in this country.

References

1. Leshner AI. By now, “harm reduction” harms both science and the public health. Clin Pharmacol Ther. 2008 Apr;83(4):513-14.

2. Pauly B. Harm reduction through a social justice lens. Int J Drug Policy. 2008 Feb;19(1):4-10.

3. Hathaway AD, Tousaw KI. Harm reduction headway and continuing resistance: insights from safe injection in the city of Vancouver. Int J Drug Policy. 2008 Feb;19(1):11-16.

Photo credit: cc licensed flickr photo by audreyjm529


Will Smitherman clean up Toronto’s soggy bottom? The man with the incontinence product runs for mayor

The Globe and Mail reported today on the official entry of George Smitherman into the race for mayor of Toronto.

A former health minister and deputy premier, Smitherman is renowned for much more than merely having been Ontario’s first openly gay MPP. Over the years the aggressive politician dubbed “Furious George” left a trail of arched eyebrows and stares of incredulity as he blundered into modest notoriety.

Two years ago, in what will surely be remembered as the nadir of his public career, Smitherman demonstrated appalling, cringe-making insensitivity as he made a bad mess worse in responding to criticism of the treatment of the elderly in the province’s largely private nursing homes. He told the media that he was prepared to don an adult diaper — and use it — to justify his government’s policies. Not surprisingly, this deranged outburst did not sit well with an outraged public.

The criticisms Smitherman’s health ministry received were justified. The Ontario Association of Non-Profit Homes and Services for Seniors claimed that seniors in nursing homes should be getting at least three hours of personal care; it said the average in the province is about 2.5 hours a day. The Canadian Union of Public Employees (CUPE), which represents many nursing home workers, called for a standard of 3.5 hours. Many studies have shown that without proper staffing and adequate standards the quality of care plummets. Front-line nursing home staff in Ontario report that residents are sitting in deplorable conditions. Incontinence products are often kept under lock and key, and many homes are directing staff to change residents only when the product is 75% soiled.

On February 27, 2008, two long-term care workers used four bottles of water to fill an adult diaper at a CUPE press conference in Toronto. They wanted to show how much urine had to be in a diaper before care aides were allowed to change it under current legislation. With stunning insensitivity Smitherman said in response that he was ready to test out an adult diaper to show criticism was unfounded. “I’ve got one of these incontinence products — albeit a new one, not the ones that tend to appear at committee — on my desk and I’m really giving this matter very serious contemplation,” Smitherman said. It wasn’t only critics of the Liberal government who were angry. There were loud calls for the minister’s resignation, even within his own caucus.

Wags and cynics sharpened their quills. In March the National Post published an imaginary Smitherman diary entry, with entries like this:

TUESDAY
Major confession, diary. I tried out an incontinence diaper today. It was so … freeing. I had three large coffees … and then I sat through a three-hour meeting with a bunch of bureaucrats. No pee breaks! It was so much more efficient. Made a bit of a stumble at lunch, though, by having the side dish of asparagus. Won’t make that mistake again! I think this will really help in my discussion with the nurses’ union. Five hours seems to be the limit before things get a little soggy. I think I’ll publicly float the idea tomorrow. Right after I shoot up an eight-ball of smack to get a better feel for drug addiction.

Of course, an apology followed immediately. “I wasn’t trivializing the matter,” Smitherman said. “I take it really, really seriously.” The minister could not be reached for comment for a long time after that; but his “diary” entry gives us some insight into why:

FRIDAY
After I came in from my night on the streets yesterday morning, Dalton [Premier Dalton McGuinty] called and ordered me to apologize for the diaper “stunt.” I explained that I only thought it would gain a better understanding of the issue, but he wouldn’t listen. “Also, George,” he said, “please tell me you weren’t wearing one in my office the other day. Because I thought it smelled like asparagus, if you catch my drift.” I told him my cellphone was cutting out and I hung up.

Sam Solomon, writing in his blog Canadian Medicine, addsed that this wasn’t the first time that “Furious George” has run off at the mouth:

Speaking about new building plans suggested by some hospital boards in Ontario, Mr Smitherman dismissively referred to the expensive proposed upgraded facilities as “Taj Ma-hospitals.”Another classic outburst was featured on Stephen Colbert’s American parody politics talk show in 2005. Talking to none other than an assemblage of the Ontario Association of Optometrists, Mr Smitherman called optometrists “a bunch of terrorists, and I don’t negotiate with terrorists.” “Bravo, sir,” Mr Colbert said. “Optometrists are a menace. You have to be careful with a group that gets their kicks blowing air into our eyeballs.”


During the “incontinence product” controversy in 2008 Smitherman’s bizarre antics were dismissed by Sid Ryan, president of CUPE’s Ontario chapter, who said the minister completely missed the point. The problem wasn’t the products, but the cruel reality that residents in long-term care facilities were forced to wear soiled diapers through the night and sometimes up until noon the next day. “If the minister wants to play silly games, well then, let him put on a diaper and sleep in it all night long and come into the legislature and wear it up until 12 o’clock,” Ryan told the Canadian Press.

Could the problems so clumsily dealt with by Ontario’s health minister possibly be related to the fact that in Ontario 60% of all publicly funded long-term care beds are in for-profit institutions, as compared with 15% in Manitoba [1]? There is ample research to show that public investment in not-for-profit, rather than for-profit, delivery of long-term care results in more staffing and improved care outcomes for residents [1,2]. Instead of experimenting with adult diapers, perhaps Mr. Smitherman should have tried absorbing some of those important statistics and the advice of experts. There are a lot of excellent health libraries within throwing distance of the Ontario legislature.

From Eyeweekly.com here is a a taste of what to expect when Smitherman hits the Toronto campaign trail – a few Diaper George gems:

On announcing his candidacy intent: “A native son is coming home to serve.”

On wearing adult diapers to ensure nursing home residents are getting adequate care: “I’ve got one of these incontinence products … on my desk and I’m really giving this matter very serious contemplation.”

On controversial energy audits for homebuyers: “They taught me in some Grade 10 course — which was almost at the end of my stream of education — the notion of caveat emptor, buyer beware.”

On music: “I’ve been working out to the new Whitney Houston. I’m a gay man, so I love Whitney.”

On working with others: “Nobody should associate me with the status quo.”


References:

1. McGrail KM, McGregor MJ, Cohen M, Tate RB, Ronald LA. For-profit versus not-for-profit delivery of long-term care. CMAJ. 2007 Jan 2;176(1):57-8.

2. McGregor MJ, Cohen M, McGrail K, Broemeling AM, Adler RN, Schulzer M, Ronald L, Cvitkovich Y, Beck M. Staffing levels in not-for-profit and for-profit long-term care facilities: does type of ownership matter? CMAJ. 2005 Mar 1;172(5):645-9.


Cancer with no smiley faces. Barbara Ehrenreich frowns at the cost of sugar-coating illness

The Guardian has an interesting piece on Barbara Ehrenreich’s reaction to her own cancer as described in her new book, Smile Or Die: How Positive Thinking Fooled America And The World. She was immediately struck by what she calls “pink ribbon culture” and the insistence on “positive thinking,” an intrusive ideology that has a strong hold on the American imagination. For Ehrenreich cancer was not a rite of passage or a “gift.”

But rather than providing emotional sustenance, the sugar-coating of cancer can exact a dreadful cost. First, it requires the denial of understandable feelings of anger and fear, all of which must be buried under a cosmetic layer of cheer. This is a great convenience for health workers and even friends of the afflicted, who might prefer fake cheer to complaining, but it is not so easy on the afflicted. One 2004 study even found, in complete contradiction to the tenets of positive thinking, that women who perceive more benefits from their cancer “tend to face a poorer quality of life – including worse mental functioning – compared with women who do not perceive benefits from their diagnoses.”

I am reminded of Zizek’s analysis of our society’s generalized injunction “Enjoy!” We are all under the spell of this injunction, what Zizek calls the superego aspect of today’s “non-repressive” hedonism – the constant provocation we are exposed to, enjoining us to explore all modes of jouissance – with the result that our enjoyment is more hampered than ever. Recall the classic yuppie type who combines narcissistic self-fulfillment with the utterly ascetic discipline of rigorous workouts and obsessions around health food. This injunction to smile through thick and thin, through disease and world calamities, can have profound consequences. In a pseudo-permissive society in which the more we are encouraged to care for ourselves the more we lack a fixed identity, ideology directly mobilizes that lack to sustain the endless process of consumerist “self-re-creation.” We no longer have any choice but to pursue happiness forever.

The very injustice of our economic and political system is what allows us to perceive failure (or success) as undeserved or contingent. It is much easier to accept inequalities or misfortunes if one can claim that they result from an impersonal blind force such as the “free market.” This ideology is also at work in the cheerful acceptance of disease that Ehrenreich finds so intolerable.

Breast cancer … did not make me prettier or stronger, more feminine or spiritual. What it gave me, if you want to call this a “gift”, was a very personal, agonizing encounter with an ideological force in American culture that I had not been aware of before – one that encourages us to deny reality, submit cheerfully to misfortune and blame only ourselves for our fate.

Smile or Die will be released in Canada in August 2010. An excellent essay by Ehrenreich on this topic, originally published in Harper’s Magazine, can be found at the Breast Cancer Action website: Welcome to Cancerland: A Mammogram Leads to a Cult of Pink Kitsch.

Here is how it ends:

For me at least, breast cancer will never be a source of identity or pride. As my dying correspondent Geni wrote: “IT IS NOT O.K.!” What it is, along with cancer generally or any slow and painful way of dying, is an abomination, and, to the extent that it’s manmade, also a crime. This is the one great truth that I bring out of the breast-cancer experience, which did not, I can now report, make me prettier or stronger, more feminine or spiritual-only more deeply angry. What sustained me through the “treatments” is a purifying rage, a resolve, framed in the sleepless nights of chemotherapy, to see the last polluter, along with, say, the last smug health insurance operative, strangled with the last pink ribbon. Cancer or no cancer, I will not live that long of course. But I know this much right now for sure: I will not go into that last good night with a teddy bear tucked under my arm.


Addiction and poverty of the spirit

In a consumer society there are inevitably two kinds of slaves: the prisoners of addiction and the prisoners of envy. ~ Ivan Illich, Tools for Conviviality (1973)

I am addicted to the twentieth century. ~ Martin Amis, Money (1984)

Two years ago the Conservative Canadian government launched a multi-million dollar National Anti-Drug Strategy, with its predictably punitive crackdown on illicit drugs, mandatory minimum sentences, hectoring propaganda, abstinence-based “treatment,” and police-heavy approach – in short, a classic drug-prohibition stance.

No one questions that drug addiction is a problem, but the Harper government’s dogmatic handling of this complex issue betrays its inability to get at the true roots of substance use and abuse. The resurgent puritanism in Ottawa angers Bruce Alexander, who has recently published a new book, The Globalisation of Addiction: A Study in Poverty of the Spirit (Oxford University Press).

Alexander, a psychologist and Professor Emeritus at Simon Fraser University, believes that addiction is not about sinners in need of salvation, but about the society they live in. “The conventional wisdom depicts addiction most fundamentally as an individual problem,” he writes. “Some individuals become addicted and others do not. An individual who becomes addicted must somehow be restored to normalcy.”

The government’s dogmatic thinking fails to recognize that a problem as terrifying as addiction has its roots in the kind of fragmentation that is inevitably produced by free-market economics. The solemn press conferences and media images of frowning officials in dark suits or uniforms simply repackage and reinforce the old idea that the reason we have people who aren’t behaving properly is drugs – that drugs have a magical quality of taking over human beings who would otherwise be normal smiling happy people shopping at Wal-Mart.

The Globalisation of Addiction presents a radical reappraisal of the nature of addiction, which science and sermons have failed to manage. There are no reliable methods to cure it, prevent it, or take the pain out of it. There is no durable consensus on what addiction is, what causes it, or what should be done about it. Meanwhile, it continues to increase around the world.

Addicts are people struggling to adapt to and deal with difficult psychological and social circumstances. Viewing addictions of all kinds as adaptive responses to dislocation seems odd at first, for we have been taught to view addiction superstitiously as some kind of malevolent entity taking over the soul. But understanding addiction not as “possession” but as an adaptation makes the phenomenon both more comprehensible and more familiar, and is ultimately a deeply sympathetic and humane perspective. It is also a hopeful one, offering a variety of options that can help addicted individuals find social integration and therefore happier lives.

Alexander argues that the failure to control addiction can be traced back to the conventional wisdom of the 19th and 20th centuries which focused too single-mindedly on the afflicted addict. Although addiction obviously manifests itself in individual cases, its prevalence differs dramatically among societies. For example, it can be quite rare in a society for centuries, and then become common when a traditional culture is destroyed or a highly developed civilization collapses. When addiction becomes commonplace in a society, people become enslaved not only to alcohol and drugs, but to a thousand other destructive pursuits: money, power, dysfunctional relationships, gambling, or computer games.

A social perspective on addiction does not deny individual differences in vulnerability to addiction, but it removes them from the foreground of attention, because social determinants are the more influential factor. This book shows that the social circumstances that spread addiction in a conquered people or a declining civilization are also built into today’s globalizing free-market society. Capitalism is magnificently productive, but it subjects people to irresistible pressures towards individualism and competition, tearing rich and poor alike from the close social and spiritual ties that normally constitute human life. Alexander calls this a “worldwide rendering of the social fabric.” People adapt to their alienation or dislocation by finding the best substitutes for a sustaining social and spiritual life that they can, and addiction serves this function all too well.

The most effective response to a growing addiction problem is a social and political one, rather than an individual one. Because addiction is an individual and social response to “dislocation” – especially severe social, economic, and cultural dislocation – the solution is “psychosocial integration.”

“People can endure dislocation for a time. However, severe, prolonged dislocation eventually leads to unbearable despair, shame, emotional anguish, boredom and bewilderment. It regularly precipitates suicide and less direct forms of self-destruction. This is why forced dislocation, in the form of ostracism, excommunication, exile, and solitary confinement, has been a dreaded punishment from ancient times until the present.”
“Material poverty frequently accompanies dislocation, but they are definitely not the same thing. Although material poverty can crush the spirit of isolated individuals and families, it can be borne with dignity by people who face it together as an integrated society. On the other hand, people who have lost their psychosocial integration are demoralized and degraded even if they are not materially poor. Neither food, nor shelter, nor the attainment of wealth can restore them to well-being. Only psychosocial integration itself can do that. In contrast to material poverty, dislocation could be called ‘poverty of the spirit’.”

Overcoming poverty of the spirit through such integration would not put physicians, psychologists, social workers, policemen, and priests out of work, but it would incorporate their practices in a larger social project to reshape society with enough force and imagination to enable people to find social connectedness and meaning in everyday life. Then great numbers of them would not need to fill their inner void with addictions.

So far, governments have chosen to ignore Alexander’s analysis, which was first introduced in his much-read 2001 paper The roots of addiction in free market society. Not surprising in a nation that is rapidly moving to the right and busy squandering its treasury on unwise stimulus spending and war-making.

References

Alexander BK. The globalisation of addiction: a study in poverty of the spirit. Oxford University Press; 2008. ISBN 978-0-19-923012-9.

Alexander BK. The roots of addiction in free market society. Ottawa: Canadian Centre for Policy Alternatives; 2001. Available from: http://www.cfdp.ca/roots.pdf

Levine HG. Review of “The globalisation of addiction: a study in the poverty of the spirit” by Bruce K. Alexander. Harm Reduct J. 2009; 6: 12. Published online 2009 June 23. doi: 10.1186/1477-7517-6-12. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2717062/


If you had to cancel a health database today? Evidence-based decision-making vs. Hobbesian elbowing

Trying to decide on a database cancellation can be fraught with uncertainty.  Evidence-based criteria are important but often shoved out of the way by other considerations. The culling process is a little more sophisticated than resorting to eeny, meeny, miny, moe. Basing decisions on research is laudable, but in the end it’s dollars and a Hobbesian political deftness that count for more. It’s not a case of evidence-be-damned, but rather the Ellenbogengesellschaft – the sharp-elbowed social reality – of collection development.

Consider the following databases: AMED (Allied and Complementary Medicine Database), CINAHL, EMBASE, and Global Health. If you had to cancel one of them, which would it be? The latter might get the boot from some of us, but I’m guessing most health libraries would probably push AMED overboard first. We would justify this to ourselves with the comforting assumption that the combination of the other databases provides good enough coverage of complementary and alternative medicine. CINAHL, for example, is well known for its lavish attention to allied health; PubMed offers its petal-strewn Complementary Medicine subset to smooth the way for us; and so on. And isn’t it true that in the minds of many faculty and health professionals CAM is to real medicine what holy water is to healing? That, to me, is the key issue. Always present in the background of a library’s cancellation decision is one of the guiding principles of a public service, multa docet fames (hunger teaches us many things). Regardless of what the literature tells us, this question cannot be avoided: to which database’s disappearance would the most influential library patrons object least?

Some justly claim their decisions to be reasoned and evidence-based. Others, if pressed, might have to admit that a decision can be biased, gratuitous, hasty, or obviously political. Journal and database cancellations are determined centrally in my world, and hence are mostly out of my hands. I like to think that the best reasons, and not just sharp elbows, are always brought forward before a subscription is dropped. Be that as it may, with respect to CAM resources, a Canadian study [1] has succeeded in undermining most of my notions about the quality and comprehensiveness of PubMed’s coverage of complementary and alternative medicine. I also see AMED in a new light.

AMED acclaimed
In a recently published article in Evidence-based complementary and alternative medicine, the authors’ objective was to compare a number of databases relevant to CAM. In all, they searched fifteen databases to identify CAM controlled clinical trials not also indexed in MEDLINE.

Their abstract sums things up adequately:

Searches were conducted in May 2006 using the revised Cochrane highly sensitive search strategy (HSSS) and the PubMed CAM Subset. Yield of CAM trials per 100 records was determined, and databases were compared over a standardized period (2005). The Acudoc2 RCT, Acubriefs, Index to Chiropractic Literature (ICL) and Hom-Inform databases had the highest concentrations of non-MEDLINE records, with more than 100 non-MEDLINE records per 500. Other productive databases had ratios between 500 and 1500 records to 100 non-MEDLINE records-these were AMED, MANTIS, PsycINFO, CINAHL, Global Health and Alt HealthWatch. Five databases were found to be unproductive: AGRICOLA, CAIRSS, Datadiwan, Herb Research Foundation and IBIDS. Acudoc2 RCT yielded 100 CAM trials in the most recent 100 records screened. Acubriefs, AMED, Hom-Inform, MANTIS, PsycINFO and CINAHL had more than 25 CAM trials per 100 records screened. Global Health, ICL and Alt HealthWatch were below 25 in yield. There were 255 non-MEDLINE trials from eight databases in 2005, with only 10% indexed in more than one database. Yield varied greatly between databases; the most productive databases from both sampling methods were Acubriefs, Acudoc2 RCT, AMED and CINAHL.

Not unexpectedly, in their conclusion the authors recommend a multi-database approach:

The very low overlap between … non-PubMed sources suggests the need for multiple database searching in addition to MEDLINE in order to comprehensively search for CAM controlled trials. The results indicate that of the six databases analyzed that are not focused on a specific therapy, CINAHL was the most productive, followed by AMED. The Acubriefs and Acudoc2 RCT databases were highly productive for acupuncture trials.

With budget restrictions looming, the University of Manitoba Libraries has just dumped AMED, which this study identifies as second only to CINAHL for controlled clinical trials coverage in complementary and alternative medicine. Who would have guessed that AMED would stand out in this subject area, considering how poorly it is rated in another recent study which has just been published in Physiotherapy [2]?

AMED def-amed
Researchers at the University of Sydney compared the comprehensiveness of indexing the reports of randomized controlled trials of physiotherapy interventions by eight bibliographic databases (AMED, CENTRAL [Cochrane], CINAHL, EMBASE, Hooked on Evidence, PEDro, PsycINFO and PubMed). The results in a nutshell? PEDro indexed 99% of the trial reports, CENTRAL indexed 98%, PubMed indexed 91%, EMBASE indexed 82%, CINAHL indexed 61%, Hooked on Evidence indexed 40%, AMED indexed 36% and PsycINFO indexed 17%.

Poor AMED comes a cropper here, outclassed as it is by a free resource like PEDro (a name almost as silly as Acubriefs, which sounds like the latest offering from Stanfield’s Ltd., Canada’s self-proclaimed, one-and-only “Underwear Company”). A library might feel quite justified in cancelling its subscription after reading about AMED’s poor coverage of physiotherapy research.

Given these contrasting evaluations of a database’s effectiveness, the question arises as to which evidence will have the most weight in the decision to cancel or retain? Our pair of studies illustrate how difficult it can be to play the database shuffle in making cancellation decisions. When budgets are tight and sacrifices must be made librarians are always ready to lend a hand, but attached to those hands should be sharp elbows.


References

1. Cogo E, Sampson M, Ajiferuke I, Manheimer E, Campbell K, Daniel R, Moher D. Searching for controlled trials of complementary and alternative medicine: a comparison of 15 databases. Evid Based Complement Alternat Med. 2009 May 25. PubMed PMID: 19468052. DOI 10.1093/ecam/nep038.

2. Moseley AM, Sherrington C, Elkins MR, Herbert RD, Maher CG. Indexing of randomised controlled trials of physiotherapy interventions: a comparison of AMED, CENTRAL, CINAHL, EMBASE, hooked on evidence, PEDro, PsycINFO and PubMed.Physiotherapy. 2009 Sep;95(3):151-6. Epub 2009 Apr 23. Review. PubMed PMID: 19635333.

Photo credit: CC licensed flickr photo by fabbio:  http://flickr.com/photos/fabiovenni/240530154/


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