DOING YOUR OWN RESEARCH

DOING YOUR OWN RESEARCH

If reading this book has raised your level of interest and you want more specific information, or you want the straight story about a new develop­ment, there is no substitute for doing your own research.

Reading both scholarly review articles and original research papers is much easier than most people believe. In fact, one of the first steps in writing this book was gathering such research. Much of the library work for the first edition was done by two college students, neither of whom had any previous experience using a medical library. Should you decide to investigate for yourself, here are some suggestions about where to begin.

Public libraries are not likely to have the sorts of journals and books you will need. Because there is such a vast amount of medical literature pub­lished, most universities with a medical school have a separate library just to house all this information. Find a medical library at a nearby medical school. If for some reason you cannot get to a medical school, check to sec if there is a college or university biology department nearby and use the

library they use.

Next, go to the library and make friends with the reference librarian, because you will need his or her help until you are familiar with the library and the search mechanisms. The most efficient way of searching the literature is to use MEDLINE or PubMed, databases of the National Library of Medicine, a US government institution that allows you  

search almost all the published medical literature on any subject you can think of related to health. You can search by author, title, subject, key­word, institution, and many other descriptors.

In most cases you will find far more information than you need. A good place to start is with reviews. Reviews are documents that consoli­date and summarize the research and literature available in a given area, and they are usually written in less technical language. Reading several recent reviews about the topic you are researching will help you form a base of knowledge about the subject. Practice using MEDLINE by start­ing out with simple concepts; for example, search for marijuana articles. There are hundreds of them, and many of the titles will be so technical that they might seem indecipherable. So tell the computer to select mari­juana review articles. This will reduce the number markedly.

If you have read Buzzed, then you know that one of the active ingredi­ents in marijuana is THC. Try searching for THC and you will get more articles. Refine your search by asking for reviews of THC and you will get articles different from those you did when you searched for marijuana in general. Play with the database and have fun. Search for all kinds of com­binations of keywords, like THC and learning, or THC and adolescent. You will soon have an idea of the enormous amount of information there is about just this chemical. Understand, though, that no one study tells the whole story.

As a final note, we caution you not to accept everything you read as directly applicable to the human condition. Often scientists employ very high levels of a chemical to test for toxic effects in animals, and sometimes the chemical levels they use in/on animals are hundreds or thousands of times higher than a human would ever use, taking into account the weight of the human compared to the animal. Consequently, some of the toxic effects seen in animals may not apply to humans. On the other hand, ani­mal experiments cannot reveal many subtle effects of chemicals, particu­larly psychological ones, and thus animal studies almost certainly miss some important effects that humans will experience. So, as you read a sci­entific paper, remember that it is just a small part of the literature about a drug, and while the data may be true, it is important to understand that data in the context of everything else known about the drug.

GETTING CONVICTED: THE PENALTY BOX

GETTING CONVICTED: THE PENALTY BOX

The penalty laws of most states and countries are built on a series of leg­islative acts that happened over a long period of time, and thus, they are complicated and not easily summarized. Possession of modest amounts of marijuana can result in a slap on the wrist in some places and serious jail time in others. The same is true for other drugs, although they are usually taken more seriously, even in very small amounts. Often the prosecuting attorney has some leeway about the level of crime with which to charge an individual. The problem is that it is difficult to be sure of (1) the latest changes in the law, (2) the attitude that the prosecu­tor is taking toward drug crimes, and (3) whether that individual will be charged under state or federal statutes. Thus, conviction for the posses­sion of a small, recreational amount of heroin or cocaine could result in either a modest sentence or a huge fine and a long prison term, depend‑

ing on the exact circumstances and the mood of the legal officials over­seeing the case.

It is important to recall that in some states and in the federal system there is structured, or guideline, sentencing. That means that once an individual is convicted of some drug crimes, the sentence is regulated by law and might not be alterable by the judge no matter what the circum­stances. Coupled with the fact that there is no parole in the federal system (and increasingly in the state systems), a conviction can mean long prison time, even if the prosecutor and judge wish it were otherwise.

Here's an example of how things can go terribly wrong as a conse­quence of alcohol, a prescription drug, and harsh laws. One of us (WW) testifies as an expert in legal cases, and a recent one illustrates how the law, the prosecutor, and the courts can interact to ruin the life of an indi­vidual. A man was at a party with his neighbors outside of his home. He consumed a modest amount of alcohol throughout the evening, but at some point he decided to go to bed and took his nightly medicine, which included the sleeping pill zolpidem (generic for Ambien). Before going to bed, he came back to the party but soon appeared intoxicated. He then prepared for bed and went to sleep. Shortly thereafter, he awoke and came out of the house without his shoes, false teeth, or hearing aid, clearly hav­ing just awakened. But he had a gun, which he had retrieved from his bedside where he kept it. He fired twice as he yelled an obscenity to the individuals at the party. No one was hurt. The police were called, and he was arrested.

The man was charged with aggravated assault, and everyone thought he was intoxicated with alcohol. In the law of most states, that is consid­ered "voluntary intoxication" and thus is not a defense against any charges. His defense team argued that he was not intoxicated with alco­hol, but with his prescribed zolpidem, which is known to produce odd behaviors such as sleep driving, sleep sex, sleep shopping, sleep eating, and so forth. If it were the zolpidem, that would be "involuntary intoxica­tion," and that is a defense against such charges.

The jury heard the case and decided that he was intoxicated by alcohol and was therefore guilty. Now, here is where the disaster occurred. In that state, commission of many crimes (such as aggravated assault) with a gun is a mandatory ten-year sentence. If the gun is fired, the mandatory sen­tence is twenty years. In this case the prosecutor chose to charge the man for each of the six people present at the party, and the law requires that the mandatory sentences apply to each charge and be served consecu­tively. This means the man (who has not been sentenced at this writing)

must, by law, be sentenced to 120 years in prison. The judge has no discre­tion in this case.

This is a terrible example of the interaction of intoxication, harsh laws, vigorous prosecution, and finally, the presence of a gun where a sleepy, intoxicated person could access it and fire it. This man had no history of behavior like this and was a decorated soldier. It is very likely that the zolpidem produced the bizarre behavior, but the prosecutor and jury did not see it that way.

The lesson from this is that if a person chooses to intoxicate himself and then commits a crime, that intoxication is usually not a defense against any crime he committed, no matter how impaired he was at the time of the crime.

DRUG LAWS

DRUG LAWS

The drugs in this book are subjected to a variety of laws. Tobacco and alcohol are legal to possess and use in the United States, as long as you are at least eighteen years old (for tobacco) or twenty-one years old (for alco­hol). The same pertains for many of the over-the-counter cold medica­tions that can be used as precursors of methamphetamine and for dextromethorphan—if you show identification and are at least eighteen years old, you can possess amounts for personal use. Most herbal drugs we discuss (except ephedrine) can legally be purchased and possessed by anyone.

Most of the other drugs are covered by the Controlled Substances Act. According to this federal law, some substances cannot be purchased or possessed by anyone, while others can be used if they have a prescription from a doctor. There are different "schedules" that are based on the dan­ger of abuse, and the medical use. These are described in what follows. These drugs can be purchased and possessed only with an appropriate

license from the Drug Enforcement Administration (DEA) or a prescrip­tion from a physician.

· Schedule I: Drugs in this class have no currently accepted medical use in the United States, a lack of accepted safety for use under medical supervision, and a high potential for abuse. They cannot be purchased or possessed by anyone. Some of the drugs in this category are all forms of marijuana (natural and synthetic), heroin, all serotonin­related hallucinogens (LSD, psilocybin, and all their derivatives), MDMA and all its congeners, and all cathinone derivatives (bath salts). These can be possessed only for research purposes with an appropriate license.

Schedule II: Substances in this schedule have appropriate medical use but a high potential for abuse that may lead to severe psychologi­cal or physical dependence. This includes many opiates, such as methadone, morphine, opium, oxycodone, fentanyl, meperidine, and codeine; some sedatives like pentobarbital; and stimulants that are used clinically, including amphetamine, methamphetamine, and methylphenidate.

· Schedule III: Substances in this schedule have a potential for abuse less than substances in Schedules I or II, and abuse may lead to mod­erate or low physical dependence or high psychological dependence. Drugs in this class include combination products containing some opiates like hydrocodone with acetaminophen; buprenorphine for­mulated with naloxone (Suboxone), which is used to treat opiate addiction; the anesthetic ketamine; and testosterone.

·  Schedule IV: Substances in this schedule have a low potential for abuse relative to substances in Schedule III. Drugs in this category include many benzodiazepine sedatives, including diazepam (Valium), alprazolam (Xanax), and triazolam (Halcion).

·  Schedule V: Substances in this schedule have a low potential for abuse relative to substances listed in Schedule IV and consist primarily of preparations containing limited quantities of certain narcotics.

This list is not comprehensive, but it provides enough examples. The penalties that result from purchasing or possessing them vary by the schedule and by how much you have in your possession, so you should consider this only as an introductory guideline. You need to understand that if you purchase or possess anything in these schedules without a doc‑

tor's prescription, you are breaking the law. In addition, state laws may differ from federal laws. For example, marijuana is scheduled much lower by most states, but many states have broadly liberalized availability for medical purposes (although it is not completely legal in any state).

We have a word of caution about the scheduling of drugs. While this list describes the various schedules for drugs, placement at a given level in the list does not necessarily represent the degree of safety of the drug. For example, marijuana is a Schedule I drug, but it is almost impossible to die from it acutely. On the other hand, benzodiazepines are Schedule IV drugs, and with regular use over a period of time, an individual can become very tolerant to them. At that point, stopping their use can be almost impossible without medical help. If you take one of these drugs, get good information about it and don't depend on the level of scheduling to keep you safe.

Not all psychoactive drugs are controlled substances and, therefore, are on these schedules, but they do require a prescription. In most situations, you are breaking the law if you possess these drugs without a prescription and particularly if you give or sell them to another person.

GETTING SEARCHED

There's this joke about a very large canary: Where does an eight-hundred­pound canary sit? Anywhere he wants to! Likewise, a law-enforcement officer will search just about anywhere if he really wants to do it. Eventu­ally the courts could decide whether the search was legal, but if an officer has reason to believe that a crime is being committed, he may well initiate the search process and let the lawyers settle the issue later.

Laws in the United States on the subject of a search are extremely com­plicated, in part because the legal rights of individuals have been defined over the years by many different court cases. However, there are a few general principles that govern when someone can legally be detained and searched.

First is the "expectation of privacy." The expression "A man's home is his castle" applies here. To search a residence usually requires more strin­gent legal prerequisites than searching elsewhere. Often a search warrant signed by a judge is required, unless there is evidence of a major and immediate threat to public safety.

Next is the automobile. This is the place where most individuals con‑

front the law. An officer will see a traffic violation in progress, stop the vehicle, and then come to suspect that illegal drug activity is being car­ried out. If an officer reasonably believes that a crime is being committed, then he probably has the right to detain the occupants of the car until a legally proper investigation can be carried out. Remember, this officer can stop and hold someone if he believes that a crime is being committed, even if he is wrong!

A court official gave us an extreme example: Say a murder has been committed in the course of a bank robbery and the killer is driving away in a 2007 blue four-door sedan. In the heat of the moment, an incompe­tent 911 operator becomes confused and broadcasts that the killer is leav­ing the scene in a 2003 red pickup truck. An officer down the road sees a 2003 red pickup truck and stops it, removes the occupants, and searches the truck for weapons. He finds illegal substances. Was the search legal? Probably, because the officer had reason to suspect that the occupants were criminals. He was wrong, but with good reason, and the occupants may well be convicted for whatever offense they committed.

There are equally odd outcomes in which convictions are not possible because the officer was found to have no reason to search a vehicle. That is why most officers ask permission to search a car before doing so. That permission usually makes the search legal and any evidence is thus legally obtained. If permission is not given, then the officer may choose to detain the individuals further and call for a drug dog or other assistance to examine the vehicle. This issue then gets very complicated.

The practical side of all this is that a law officer has quite a lot of power to detain and arrest, because the lawmakers have decided it is in the pub­lic good to be able to temporarily detain potential criminals and, to some extent, to ask questions later. Even if an officer is eventually found in court to be wrong, the suspected individuals would have suffered loss of time and perhaps arrest, legal bills, and considerable life discomfort.

Finally, there is the situation when a person is out in public and walk­ing about. This is the least "private" act, and so there is the least expecta­tion of privacy. In this case a law officer has much more leeway in searching a person for the protection of the officer herself and for that of the general public. For example, imagine that an officer sees a person walking down the street in and out of traffic, in an erratic manner. She has the right to stop and talk to that person to ensure that he and the driving public are safe. If in the process of that stop the officer suspects

 that the individual may be carrying a weapon, she could search him by doing a pat down. If in the course of that search the officer feels some­thing she recognizes to be an illicit drug, the officer can seize the drug. Can the person be convicted of a drug-law violation? It is very likely that he can because the search was legal.

The same rules might apply at a concert. Let's say that two students are obviously intoxicated and fighting. An officer moves to stop the fight, the students resist, they are appropriately searched for weapons, and illicit substances are discovered. If the officer chooses to charge them, there is a good probability that the charges will stick.

Do law-enforcement officers have a pathological agenda to harass driv­ers and students at a concert, looking for drugs everywhere? Rarely. Most law officers see their work as a job, not a mission. Think of all the traffic laws that are broken every day and how seldom stops occur. Think of how seldom someone who is innocent of any law violation is stopped in a car or interdicted at a concert. By and large, the legal community just does its job.

LEGAL ISSUES

IT IS SAID that your life can change forever in a matter of seconds. When a person mixes alcohol or other drugs and the legal system, the combina­tion can easily become life-changing. For a variety of reasons, the law­making bodies of most countries, especially the United States, have decided to suppress illegal drug use by making drug laws harsh and cer­tain. All who deal with drugs in an illegal manner are thus at risk for penalties that can disrupt their own lives and those of their families.

The use of almost all the drugs discussed in this book could involve violations of the law, depending on the circumstances. Many of these drugs are illegal in all circumstances—manufacturing, distribution, and possession. Others are legal when prescribed, but not for recreational use. Still others, such as alcohol, can be legal for adults, but their use is prohib­ited for underage individuals and for activities such as driving a car or operating a boat.

This chapter is written to inform readers about very basic laws and principles that come into play around drug issues. It is not intended to give advice about dealing with the law-enforcement community or the judicial system. If you feel that you need that advice, find a good lawyer and ask her all of your questions before you become legally involved.

THE PRINCIPLES

I While laws exist regarding the rights of a law officer to search some­one's car or home, this very complicated issue is often decided in the courts in individual cases. Generally you have the greatest "expecta­tion of privacy" in your home. There is less expectation of privacy in a car, and the least when you are out in public.

2. If a law-enforcement officer suspects you of a crime and really wants to search you or your car, you will be searched, whether or not you give permission. If you give your permission, the search will almost certainly be considered legal. If you refuse permission, the search may or may not be legal, but it may happen anyway. The debate over whether the search was permitted and legal will begin in the court system. The easiest way to avoid trouble is to avoid situations in which a random and unexpected search will yield anything illegal.

3. A person who is innocent of any crime but is with someone arrested for possessing drugs may become involved with the legal system until her innocence is proven. By that time, she may have incurred large financial burdens (e.g., an expensive lawyer), terrified her family, and spent some time under arrest.

4. 'the penalties for drug-related activities can be horrendous, especially in the United States federal judicial system, and particularly for selling drugs. Many casual drug users do not realize that simple possession of a modest amount of a drug can automatically be considered "intent to distribute," whether or not they actually plan to sell the drug.

5. You do not have to be on government property to be in violation of federal law. The federal drug laws apply everywhere in the United States and US territories at all times.

6. State and federal laws can be extremely strict about the use of guns in the commission of crimes. The possession of a gun—even just having one in the vicinity of a drug-law violation canadd many years onto the sentence for the original crime.

Many people believe that they are "safe" from serious legal consequences because they know the local officials, or because they believe the penal­ties are not serious. They are wrong. First, it a local official were to inter­fere with a prosecution, she could be prosecuted for obstruction of justice or public corruption. Second, an arrest by a state or local officer can eas­ily be referred to federal prosecutors not subject to local political influ­ence. Third, in many states and in the federal system there is no parole. Even worse, in some cases "minimum mandatory" sentencing laws give the judges practically no leeway for reduced sentences.

8. Your rights as a US citizen do not apply in foreign countries, and the legal consequences of drug-law violations in some places can literally mean death.

HOW PEOPLE TAKE OPIATES

HOW PEOPLE TAKE OPIATES

Most opiate drugs enter the bloodstream easily from many different

routes because they dissolve in fatty substances and so can cross intocells. Heroin and fentanyl represent one extreme—they are so fat-soluble that they can be absorbed across the mucosal lining of the nose. Most other opiates are not quite that fat-soluble and cannot be absorbed well after snorting. However, some opiates including the natural ingredients of the opium poppy form a vapor if heated and can be absorbed into the body if they are smoked—that is the basis of the use of the "opium pipe" as the traditional device of ancient as well as more recent history. Almost all opiates can be absorbed from the stomach, although injection is a much more efficient route for some, like morphine, that are more poorly absorbed from the stomach than others.

Intravenous injection is the route that delivers opiates into the blood­stream the fastest. Because intravenous injection is more difficult and more dangerous than other routes, many users do not start this way. Instead, they start by skin-popping—injecting drugs subcutaneously (just beneath the skin). Heroin powder is dissolved and injected. Morphine, fentanyl, and meperidine almost always appear as legally prepared injec­tion forms that have been diverted from medical use. Snorting heroin has become a common route for new drug users. In part, users are avoiding the stigma—and risk of infectious diseases including hepatitis and AIDS—that come with injecting a drug. In part, they may believe mistak­enly that they cannot become addicted if they don't inject drugs. Pre­scription opiates like codeine, hydromorphone (Dilaudid), oxycodone (Percodan, OxyContin), meperidine (Demerol), and, of course, metha­done (Dolophine) are available as pills. Sometimes drug users resort to grinding up pills of codeine, hydrocodone, or methadone and injecting the suspension when they cannot get opiates any other way. This is an extremely risky business because the other pill components do not dis­solve in saline. Injecting particles into a blood vessel can irritate the blood vessel, thus setting off a chain of reactions that lead to vascular inflamma­tion and permanent damage. In addition, a pill particle can lodge in a small vessel and block off the blood supply to an area of the body.

THERAPIST FACTORS

THERAPIST FACTORS

Frequently we are asked what therapist variables lead to success in recruiting. The following four principles are devoted to such factors.

Principle 16: An important recruitment variable is the extent to which the therapist shows interest in the family through hir willing-ness to expend considerable effort in engaging thenz. From our experience, there are a number of therapist characteristics and atti-tudes that lead to more favorable recruitment rates. These include the following:

I . The therapist must be energetic. The recruitment process can be demanding in time and effort. Rather than expecting to sit in his office, the therapist should be willing to get out into the field and make home visits.

2.   Enthusiasm for the work is obviously essential. Sager et al.'26 noted a reluctance by many of their therapists to work with -poorly motivated- families.

3.   The therapist must be persistent and able to tolerate rebukes by family members.

4.   Flexibility and lack of rigidity are necessary, since they allow therapists to adroitly counter family resistance moves.

5.   The therapist must be convinced of the value of his endeavor and feel that it will be helpful to the family. This conviction will be conveyed to clients, and will help to change their negative -set.-

Principle 17: Providing incentives to therapists for each success-fully recruited case increaser the rate of success. Early in the life of our project the therapists began to complain that they were paid to do therapy and the recruitment effort was demanding an inordinate amount of their time. If this objection had been allowed to dictate our procedures, we would have been left with an unacceptably small, select sample, composed of -easy- or highly motivated families. Thus we were forced to rearrange our priorities and shift incentives. We did this by making a portion of the therapists' pay contingent upon successfully recruiting families—a bonus system. This had the double advantage of (1) reordering therapists' priorities through tangibly demonstrating the importance we placed on enlisting families, while also (2) providing them with reimbursement for the time they spent in recruiting activities. They were, of course, paid in addition for the time they spent doing therapy. However, money need not be the only incentive, and other programs might be able to establish alternative, nonmonetary procedures (see Chapter 16).

Principle 18: The program must be structured in a way that does not allow therapists to back down from enlisting whole families. This is a crucial point. We are convinced that if we had not held firmly to our requirement that the total family—or at least the IP, both parents, and siblings living in the home—be involved, the therapists would have settled for less. Without this mandate, we estimate that one-third of our families would have arrived incomplete, and treatment would have commenced without one or more important members. It would have been too easy to proceed with only the most willing participants.

Vignette 15. Adherence to Principle 18 sometimes had unexpected benefits. In one interesting example (in a case seen by David B. Heard, PhD) the recruitment requirement prevented a potential problem from developing in our research and treatment design. The addict in this case was in trouble with the law (although we did not know it at the time) and had a court hearing pending. Heard devoted great energy, including seven individual interviews plus numerous telephone calls, toward getting the IP to agree to engage his family. As the situation developed, it appeared that all members except the stepfather would agree to participate (the natural father was de-ceased). However, Heard could not make direct contact with the stepfather. This process went on for approximately 21/2 months with no results. Eventually the addict was caught selling drugs at the treatment center and was discharged for disciplinary reasons. He defected to another program and soon thereafter went to jail. We later learned from a counselor in that program that (1) the addict had been facing serious legal charges for some time, and (2) he had no "stepfather." The person the addict was trying to bring in as his stepfather was his uncle. Apparently the addict was trying to avoid prison by presenting a case to the judge that he was motivated to change, had entered a treatment program, and that his effort was earnest to the point where he could claim, "See, even my family is involved with me in treatment." However, he knew that we would not accept him in the family program without a father figure, so he tried to get the uncle to pose as stepfather. The plan failed because the uncle refused to take part in the masquerade. The point is, if Heard had not persisted in his demand for inclusion of the "step-father," the rest of the family would have come in and treatment would have progressed under the false assumption (by the therapist) that the nonexistent stepfather would eventually participate.

Principle 19: A mechanical approach to recruitment it insuf-ficient to guarantee success—flexibility and skill are crucial if the therapist is to avoid getting deadlocked. While the initial interview procedure described in Chapter 3 can probably be handled by most experienced clinical interviewers, recruitment of the whole family is more difficult. The latter demands a certain level of skill in dealing with families—essentially the kind of experience one gets in per-forming family therapy. Not only must one be able to show proper empathy and effective joining techniques, but one must also be able to respond to family interaction patterns.

The importance of recruiter skill cannot be overestimated. We do not agree that positive results are primarily due to "highly moti-vated therapists.- Therapists must be able to adapt the basic princi-ples of recruitment flexibly and creatively in order to meet the unique requirements of each case. Simply -plugging away- is insufficient. As in Vignettes 10 and 11, a skillfull recruiter can sometimes get results with a minimum of well-directed effort, much like the judo flip succeeds when direct overpowering will not.