Mandatory minimum intelligence for Senators?

Mandatory minimum sentences have generally proven to be a horrible idea, and widely recognized as so.  Unfortunately, not recognized by the one person with the most power to change this– Republican Senator Charles Grassley, the new chair of the Senate Judiciary Committee.  Great editorial on the matter in the NYT:

For more than a year, members of Congress have been doing a lot of talkingabout the need to broadly reform harsh federal sentencing laws, which are a central factor in the explosion of the federal prison population. It’s an overdue conversation, and one of the few in which Democrats and Republicans find some agreement — but, so far, they have nothing to show for it…

But Mr. Grassley, for reasons that defy basic fairness and empirical data, [emphases mine] has remained an opponent of almost any reduction of those sentences. In aspeech from the Senate floor this month, he called the bills “lenient and, frankly, dangerous,” and he raised the specter of high-level drug traffickers spilling onto the streets.

Mr. Grassley is as mistaken as he is powerful. Mandatory minimums have, in fact, been used to punish many lower-level offenders who were not their intended targets. Meanwhile, the persistent fantasy that locking up more people leads to less crime continues to be debunked. States from California to New Yorkto Texas have reduced prison populations and crime rates at the same time. A report released last week by the Brennan Center for Justice found that since 2000 putting more people behind bars has had essentially no effect on the national crime rate.

Evidence?  We don’t need no stinkin’ evidence.  At least not for United States Senators.  Sad and pathetic.  And, of course, it is stupid policy that leads to needless suffering.  But hey, now Grassley doesn’t have to worry about drug dealers spilling out onto the streets to harass him.

Photo of the day

From Big Picture’s photos of the month:

Steam rose as the air temperature dropped below that of the sea in Stonington, Maine. (Sean Proctor/Globe Staff)

ADHD and the brain

Seven years ago when my oldest son was diagnosed with ADHD, I (naturally) did a lot of research on the matter.  The one piece of evidence that most convinced me to start him on medication was a study suggesting that the white matter of the brain of a child with ADHD was more likely to resemble the white matter growth of a “normal” child when the ADHD child actually receives medication.  Now, I don’t exactly know what David’s white matter looks like today, but in our N of 1 world, medication proved to be a great thing.  Rather than fundamentally changing David’s personality, the medication allowed David’s best side (a part of David always there, but too infrequently shown) to be the dominant side, rather than his worst side, which was making life difficult for the whole family.

I was very much thinking of our own family’s experience while reading about the latest research suggesting that ADHD medication may “normalize” the brain:

Dr. Mark Bertin is no A.D.H.D. pill-pusher.

The Pleasantville, N.Y., developmental pediatrician won’t allow drug marketers in his office, and says he doesn’t always prescribe medication for children diagnosed with attention deficit hyperactivity disorder. Yet Dr. Bertin has recently changed the way he talks about medication, offering parents a powerful argument. Recent research, he says, suggests the pills may “normalize” the child’s brain over time, rewiring neural connections so that a child would feel more focused and in control, long after the last pill was taken.

“There might be quite a profound neurological benefit,” he said in an interview…

In arguing for “normalization,” Dr. Wilens cited a major review in the Journal of Clinical Psychiatry in late 2013, which looked at 29 brain-scan studies. Although the studies had different methods and goals, the authors said that, together, they suggested that stimulants “are associated with attenuation of abnormalities in brain structure, function, and biochemistry in subjects with A.D.H.D.” [emphasis mine]

But other A.D.H.D. experts challenge this conclusion. Dr. F. Xavier Castellanos, director of research at the New York University Child Study Center, called assertions that stimulants are neuroprotective “exaggerated,” adding: “The best inference is that there is no evidence of harm from medications – normalization is a possibility, but far from demonstrated.”

Obviously, this is still far from settled research, but our own families experience certainly supports Wilens’ conclusions.  I cannot speak to what David’s focus is like in school, but out of it, he has now become pretty much indistinguishable whether he is on a full dose or half dose (or on rare occasion, no dose) of Adderall.  Dare I say, it’s almost as if his brain has “normalized.”  Now, David still has ongoing issues with organization and getting assignments in on time (which drives his parents crazy!!), but as for the basic behavioral improvements that we attribute to medication, they’ve been huge, and I do foresee a time when his brain no longer needs this drug to be “normal.”

Too many overdoses

A 39-year old neighbor of mine recently died from an opioid overdose, leaving behind three young daughters.  The thing is, similar overdoses happen throughout the United States literally dozens of times a day (seriously– 20,000 Americans a year die from overdoses of heroin or opioids) and we’re doing all the wrong things to solve the problem.

At this point, the evidence is pretty close to overwhelming that the most successful treatment follows a medical model of addiction and treats opioid addicts with the very effective drug Suboxone (basically eliminates the cravings, but doesn’t get you high itself).  Meanwhile, most American jurisdictions, especially those where these overdose deaths are a full-blown epidemic, ignore medical science and insist on 12-step programs.  In addition to the fact that these programs are all distinctly religious (not exactly separation of church and state for court-mandated– or often strongly coerced– treatment) this approach just doesn’t work well at all.  For one, it was designed for alcohol, which affects the brain very differently than opioids.  Additionally, all the best evidence suggests that the failure rate from these programs is awful.  But that’s what we keep doing.

Anyway, an amazing story on this ran recently in HuffPo.  It’s really, really long (I wonder how many pages this would be in the real world), but really really good.  Here’s some of my favorite parts from the first two chapters (out of 8):

A heroin addict entering a rehab facility presents as severe a case as a would-be suicide entering a psych ward. The addiction involves genetic predisposition, corrupted brain chemistry, entrenched environmental factors and any number of potential mental-health disorders — it requires urgent medical intervention. According to the medical establishment, medication coupled with counseling is the most effective form of treatment for opioid addiction. Standard treatment in the United States, however, emphasizes willpower over chemistry.

To enter the drug treatment system, such as it is, requires a leap of faith. The system operates largely unmoved by the findings of medical science. Peer-reviewed data and evidence-based practices do not govern how rehabilitation facilities work. There are very few reassuring medical degrees adorning their walls. Opiates, cocaine and alcohol each affect the brain in different ways, yet drug treatment facilities generally do not distinguish between the addictions. In their one-size-fits-all approach, heroin addicts are treated like any other addicts. And with roughly 90 percent of facilities grounded in the principle of abstinence, that means heroin addicts are systematically denied access to Suboxone and other synthetic opioids…

“The brain changes, and it doesn’t recover when you just stop the drug because the brain has been actually changed,” Kreek explained. “The brain may get OK with time in some persons. But it’s hard to find a person who has completely normal brain function after a long cycle of opiate addiction, not without specific medication treatment.”

An abstinence-only treatment that may have a higher success rate for alcoholics simply fails opiate addicts. “It’s time for everyone to wake up and accept that abstinence-based treatment only works in under 10 percent of opiate addicts,” Kreek said. “All proper prospective studies have shown that more than 90 percent of opiate addicts in abstinence-based treatment return to opiate abuse within one year.” In her ideal world, doctors would consult with patients and monitor progress to determine whether Suboxone, methadone or some other medical approach stood the best chance of success.

A 2012 study conducted by the National Center on Addiction and Substance Abuse at Columbia University concluded that the U.S. treatment system is in need of a “significant overhaul” and questioned whether the country’s “low levels of care that addiction patients usually do receive constitutes a form of medical malpractice.”

Where buprenorphine has been adopted as part of public policy, it has dramatically lowered overdose death rates and improved heroin addicts’ chances of staying clean…

“If somebody has a heroin dependence and they did not have the possibility to be offered methadone or Suboxone, then I think it’s a fairly tall order to try and get any success,” said Dr. Bankole Johnson, professor and chair of the Department of Psychiatry at the University of Maryland School of Medicine. “There have been so many papers on this — the impact of methadone and Suboxone. It’s not even controversial. It’s just a fact that this is the best way to wean people off an opioid addiction. It’s the standard of care.”

But as the National Center on Addiction and Substance Abuse study pointed out, treatment as a whole hasn’t changed significantly. Dr. A. Thomas McLellan, the co-founder of the Treatment Research Institute, echoed that point. “Here’s the problem,” he said. Treatment methods were determined “before anybody really understood the a science of addiction. We started off with the wrong model.”…

There’s no single explanation for why addiction treatment is mired in a kind of scientific dark age, why addicts are denied the help that modern medicine can offer. Family doctors tend to see addicts as a nuisance or a liability and don’t want them crowding their waiting rooms. In American culture, self-help runs deep. Heroin addiction isn’t only a disease – it’s a crime. Addicts are lucky to get what they get.

Of course, it doesn’t have to be this way.  Other modern countries rely on a medical model and harm reduction principles and have way more success.  Of course, the ultimately failure is the literally thousands and thousands of lives lost every year that would not be if we actually took a rational, science-based approach to opioid addiction.

If you are more of a listener, there was also a terrific Fresh Air interview with the author.  And, Alec MacGillis provides a nice two-page summary.

%d bloggers like this: