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Can Insects Help Save the World?

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The world population is predicted to reach 9.8 billion people by 2050. Try to visualize all those people…and all those mouths. Can we make enough food to feed everyone, especially when we can’t even feed everyone right now (it’s estimated 828 million went hungry in 2021)?

Human-caused climate change is also predicted to cause sea level rise of a foot by 2050. While this doesn’t sound like much, the costs are predicted to be in the billions, not to mention the cost to human lives. And sea level rise is only one of a host of potential causes from climate change, including an even more dire food security situation. And the impacts of climate change impacts will only get worse unless we do something about it NOW.

This could be the world’s coastlines in a few decades. Photo credit: Kelly Sikkema Unsplash.

2050 is not that far off and things can only get worse for the future if we don’t do something about it now. Wouldn’t it be great if there was a way to help solve both problems at once…? 

Surprise, there very well might be 🙂 Insects are an underutilized food source (for both humans and animals) with a ton of potential benefits: environmental, nutritional, economic, and social. 

“Insects as food”, or entomophagy, which literally means  “the eating of insects” (ento = insect, phagy = to eat), is certainly novel to Europe and the U.S. But if you live in countries in Africa, South East Asia or many other places entomophagy is nothing new. If you’re from Thailand or Cambodia, you may be used to chomping on some fried crickets, or if you’re Mexican, chapulines (grasshoppers) may be something that’s familiar (and delicious) to you. It’s estimated that currently some 2 billion people eat insects for food every year, and over 1,900 species have been documented as edible.

Chapulines for sale in Mexico. Photo credit: Wikimedia.

So what’s all the buzz about (don’t worry, plenty more bad bug puns to come lol)? And if eating insects for food is so widespread, why are people just talking about this now? Why do I think insects as food can help save the world?

Insects may be a climate-friendly, healthy, and safe alternative livestock (yup, as in alternative to cows, pigs, chickens, and fish). In 2013, the Food and Agriculture Organization (FAO), entitled “Edible insects: Future prospects for food and feed security.”  In my opinion, this report can be considered one of the most significant efforts to introduce the very real concept of “insects as food and feed” to a global audience. The report is comprehensive of all the research and knowledge on insects as food and for use as animal feed and covers almost all angles from nutritional, economic, environmental, regulatory, and more (there has been a surge of new research in this area since first publication of the report but a lot of the conclusions are still valid).

The cover of the FAO report.

Just a few highlights taken directly from the report and other studies (I’ll spend future posts doing a deeper dive into the evidence behind these issues. This is just an intro after all):

Environmental Benefits

  • Lower environmental impact of raising insects compared to traditional livestock.
    • Lower feed to protein conversion ratio – more weight gain/amount of feed.
      • Insects are cold-blooded and this means that insects are extremely efficient at converting feed to body mass. For example, on average, insects can convert 2 kg of feed into 1 kg of insect mass, whereas cattle require 8 kg of feed to produce 1 kg of body weight gain.
    • Lower green-house gas (GHG) emissions than traditional livestock.
    • Lower water requirements than traditional livestock.
    • Insect farming is less land-dependent – insects can be raised vertically, thus maximizing land use.
  • An important component of a circular economic model.
    • Globally, >1/3 of the food is lost or wasted, resulting in an economic loss of $1 trillion USD, and contributing to 10% of GHG emissions. Food waste ends in landfill rotting and emitting the potent harmful GHG methane. Insects can be raised on plant and food waste and unsafe food/the inedible portion of the food, thus simultaneously reducing the environmental impact of food waste and producing a useful commodity. 
    • For example, black soldier fly (BSF)  larvae  (BSFL) raised on food and other organic waste can then be used as animal feed or processed as food. In 2019, a company in Ecuador produced the largest plant in Latin America to use BSFL larvae to produce animal feed and fertilizer.

Economic Benefits

  • Large potential for growth.
  • Opportunities to strengthen small holder farmers and local supply chains.
    • Insects can be produced locally as animal feed (both for livestock and aquaculture) thus reducing dependence on costly, international supply chains and markets for animal feed. This also creates economic opportunities for smallholder farmers.

Nutritional and Health Benefits

  • Insect protein can be a healthy, cheap alternative to meat.
    • Insects are higher in edible protein by mass than traditional livestock, and they are rich in nutrients and vitamins.
    • For example, cricket protein has higher levels of iron, calcium, zinc, manganese, and B vitamins than most other meat-based protein sources and these are especially essential for women of reproductive age and young children. 
  • Insect protein powder can be produced as a nutritional supplement or added to other low-protein or processed foods.
    • Insects may be particularly important as a food supplement for undernourished children because most insect species are high in fatty acids, fiber, and  micronutrients (copper, iron, magnesium, manganese, phosphorus, selenium and zinc).
  • Insects pose a low risk of transmitting diseases spread from animals to humans.

Social and Livelihoods Benefits

  • Improved livelihoods.
    • Insect farming can provide entrepreneurship opportunities in developed and developing economies. The technical requirements and capacity for starting an insect farm are relatively minimal and can be done in locally, which makes it accessible to many people, including those in agriculture-poor areas.
    • Insect gathering and rearing can offer an important livelihood diversification strategy. For example, insects can be directly and easily collected in the wild and sold to buyers.
  • Creates economic opportunities, both as entrepreneurs and employees, for women, youth, individuals with disabilities  and other marginalized groups.
    • Insect agricultural work is less time and labor-intensive than traditional agriculture which means practically anyone can start an insect startup. This presents opportunities to engage with women and other groups marginalized from formal economic sectors.

Clearly there’s a lot of good to raising insects for food and feed, even in addition to fighting nutrition and climate change! So what do you think about edible insects now? Been bitten by the bug yet? Have I whet your appetite for creepy crawlies enough to want to learn more?

Just to ground-truth things a bit as well. While the pro-insect arguments are compelling, there are a number of outstanding questions that need to be considered. For example, how do we get past the “Yuck!” factor?  How do we efficiently and effectively produce edible insects so that they can have the maximal amount of environmental, health, and economic benefits? Can (or should) we raise insects on an industrial scale and if we do, have we learned from our mistakes with traditional livestock? These (and many others) are important questions that I don’t think we have the answers to yet.

Also the reality is I don’t ever anticipate edible insects completely replacing meat. I personally love meat and fish and wouldn’t want to be deprived of them forever. You can imagine a future dinner in a week being a mix of different protein sources. For example, eating chicken, pork, or beef 2 nights, fish 1 night, lab-based meat substitute 1 night, insect-based protein 1 night, and vegetable or plant-based protein 2 nights. We can still enjoy meat but we need to drastically reduce consumption of it and introduce other more sustainable alternatives, like edible insects. This type of diverse diet is not very common right now but I still think it’s a good idea for a better world!

But back to the title of this post: can insects really help save the world? Maybe, but not definitely not by themselves. When it comes to combating climate change, hunger, poverty, inequality and all the rest of the world’s ills, a silver bullet simply doesn’t exist. What we need is a silver bullet machine gun! Insects as food and feed may just be one of the many silver bullets we use. My next few posts will take a look at why and how in greater detail. Until then, the ants go marching 2 by 2, hurrah, hurrah…

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Welcome to Dr. Simon Says Science (And MORE)

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There’s a lot of darkness in the world right now. There seems to be an endless supply of conspiracy theories, fringe ideas become centered, urgent issues being ignored, and evidence and reason that is denounced and derided. What is the response to this? Cynicism? “The world is doomed so who cares anyways.” Blind optimism and the hope that things will just work out? Ostriching? That is, sticking your head in the sand and pretending the problem will go away? No to all of these.

The answer is the same as for any challenge: hard work and steady, incremental change. When you’re stuck in a hole do you bury yourself? No, you climb out! And the only way to counter bad ideas is with good ideas. Good ideas is our way out of the hole we’re in.

Good ideas tend to create more! Photo credit: Pexel

That’s what I want to do here. Share a couple of my favorite “good ideas.” Or least what I see as good idea. Maybe you’ll agree, maybe you won’t, but that’s the fun of free thought. In the end, I want try to make the world a better place for more people, even if it’s just a tiny bit.

Ok, first some background.

My name is Dr. Derek Simon. The “Dr.” is from my Ph.D. in Cellular and Molecular Biology, which I earned from the University of Michigan in 2013. I have always loved science and nature, and I always knew I wanted to be a scientist one day. Hence the title of this blog, “Dr. Simon Says Science (And More).” Get the bad joke? Simon Says… read my blog 🙂

This is me 🙂

I was the type of kid that would spend his summers turning over rocks looking for creepy crawlies underneath, or catching fireflies and frogs and putting them in jars so he could watch and study them. My parents had a video of me when I was seven years old asking me, “Derek, what do you want for Christmas?” I responded with, “A bug kit. And That’s all.” Even back then, we all knew… 

As a youngster I dabbled in nearly all the sciences: geology (trips to rock quarries and an accumulation of 3 huge boxes of rocks that to this day are still in the basement of my parent’s house), chemistry (I started a fire on my kitchen table by mixing two random chemicals together1), entomology (the aforementioned backyard expeditions for bugs), microbiology (culturing bacteria from doorknobs and my dog’s saliva on homemade agar petri dishes), physics (I made a homemade tennis ball launcher in physics club that used lighter fluid as fuel), and more. 

I eventually refined my passion to “curing disease” and discovered cellular and molecular biology, or how life works at the molecular level. I was amazed by the incredible complexity of the cell, and how the vast diversity of biological life, behaviors and structures are all ultimately derived from the same collection of molecules, participating in an insanely complicated molecular dance that has evolved over hundreds of millions of years.

My first lab experience was as freshman in college. Since then, I had been in labs nearly continually up through my post-doctoral work in my early 30s. At various points in my career I studied the endocrinology of aging and prostate cancer, the development and cancer of the adrenal gland, cellular signaling pathways in cancer, and most recently the neuroscience of drug addiction at the Rockefeller University. = But truth be told, I don’t do this type of science anymore. 

A few years ago I hit the wall in academia. As a kid, I thought “curing disease” was just finding that one magic pill through mixing stuff together at random until…“Eureka!” Oh, how wrong I was. As a real scientist, I learned how much work (just to be clear, oftentimes incredibly repetitive and tedious work) it takes to even figure out something tiny. As a grad student, I would make the joke that “if A is the discovery of something new, like a novel molecule or gene, and M was the drug given to a patient to treat their disease, your entire thesis project might take you from C to D, maybe to E if you were lucky…”

As you can imagine, after over 10 years “at the bench” as we say, I got burned out by doing the type of research I was doing and no longer felt the passion for the work. To me, moving from C to D didn’t feel like accomplishing anything or helping anyone. Though I still believe strongly in basic research in general. There are so many dedicated, hard-working scientists that make unseen contributions to our world everyday, but for me, I didn’t want that life anymore. 

So I looked for a different path. 

The one I found was a fellowship through the American Association for the Advancement of the Sciences (AAAS; they also publish the journal Science, by the way) and somehow wound up at the United States Agency for International Development (USAID). I could not be farther from my field but I loved the work anyway.

Five years later I am still working as a contractor for USAID (honestly, I’m ready for another change) but through my diversity of experiences on this new path, my passions have spanned in so many different and unexpected directions. I am thankful I made that unplanned transition because I have been exposed now to a whole constellation of amazing ideas that never would have occurred to me on a more traditional scientific path.

Some of those ideas could very well help save the world one day.

That’s what this blog is about: ideas on cool and interesting things that I think may help to make the world a better place.2 My goal for this blog is to simply share a few of my favorite ideas that are not necessarily in the mainstream right now but I think could have a real potential to help the world in the future. And most importantly, I want to discuss the data and research behind them: why do I think these are good ideas and what is the evidence for that?

Photo credit: Mikhail Nilov

I have so many interests in so many areas but I will mostly stay within my past and present fields: the biomedical sciences and international development. I will try to be focused on topics within these very deep buckets while at the same time remaining flexible to write about anything cool I happen to stumble across (tech, psychology, philosophy, so much knowledge out there…). I also don’t plan to claim these ideas as my own, but when it comes to good ideas, the more people talking about them the better!

But before I share a few of the things I may write about, I think I should share some of my values and assumptions. After all, if I’m writing a blog about good ideas to make a better world, how exactly do I define that “better world”?

At the core of my beliefs is that I think all people are equally important and have equal value, regardless of who they are or identify as, where they live, and under what circumstances they were born. I believe all people should have the same right to pursue a life of their choosing and be given the same opportunities and chances for happiness and fulfillment as everyone else. I will make no attempt to prove these values scientifically but this is simply the foundation for the topics I will pursue in this blog. Sadly, I do not think many people in the world explicitly share these values and even worse, some people actively believe in the opposite or promote a world-view that either intentionally or not, is moving us farther from these values. But I don’t care about those people. I’m not going to try to convince anyone about my values. They are are simply my working assumptions for the things I want to talk about: how can we make the world better for everyone? How can we make life on earth (not just for humans either, mind you) more equitable, safe, healthy, peaceful, prosperous, and sustainable?

Ok, so now that’s out of the way: what are some of my ideas?

One of my favorites that I’ll focus on for the first few posts is related to climate change and food security: entomophagy or the eating of insects as food. (ento = insects, phagy = to eat). My passion for bugs continues 30 years later since that Christmas “bug kit” video and my summer bug catching adventures…

Fried crickets from Vietnam. One of many types of edible insects in the world. Photo Credit: © Derek Simon 2020

Now, I’m not the first to argue that eating insects is a great idea. Actually, Medium itself has already curated a bunch of edible insects articles published here. And eating insects itself is hardly a new idea. It’s been practiced by cultures all over the world and throughout human history. What’s “new” about it is making it mainstream. I’ll argue that we should rotate in more insects into our diet, and cut back on environmentally-destructive cattle and pigs.

But that’s just a taste (pun definitely intended) of things to come. I also want to talk about a whole range of issues, many that I’ve worked on directly or indirectly in my career. These include: drug addiction and why it should be treated as a medical ailment and not a criminal disorder (the focus of my old blog posts and some of post-doctoral research), the virtue of the social business model over the standard profit-driven model, the strengths and flaws of international development and how to make it better, and plenty more.

Thanks very much for reaching the end of this and I hope to keep you engaged and learning! After all, anyone who’s alive is still learning; we’re all just figuring it out as we go. I hope you join me on this learning journey as Dr. Simon Says Science (and so much more).

And now, let’s start digging out of that hole we’re in 🙂

© Derek Simon 2022

Endnotes:

  1. I know now that the reaction was potassium permanganate and glycerine, a very intense redox reaction. Actually, I found this video on youtube of it. Isn’t the internet great?
  2. Truth be told, I actually started blogging way back in 2015 or so but gave it up a few years ago. A lot of my old posts were on neuroscience, drug addiction, and other topics. You can still find them in my “archive” (i.e. the drop down on the right).

The Problem with Vivitrol®

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Fascinating post by guest contributor Amy Dunn, graduate student at the Rockefeller University!

What is Vivitrol®? This question is posed in countless ads depicting attractive young people across target states, such as MA, NY, NJ and PA. The ads do little to answer the question – instead just giving a drug name and a website. Vivitrol®, made by the Boston-based company Alkermes, is the brand name for the drug naltrexone and is used to treat both alcohol and opiate addiction.

Opiates like heroin or oxycodone work by stimulating the mu opioid receptor in the brain. This leads to the euphoric and rewarding effects that are characteristic of these drugs. The two most popular medications for treating opiate addictions, methadone and buprenorphine, both work by stimulating that same receptor in a slightly different way. This relieves the cravings, but doesn’t cause the same “high” as heroin or oxycodone. Methadone and buprenorphine are known as agonist, or replacement, medications. Dr. Simon Says Science wrote an excellent article for Addiction Blog that compares methadone and buprenorphine and explains how they work in greater detail. Naltrexone, on the other hand, is an antagonist of that same receptor – meaning that it completely blocks the effects of any opioid. While it seems counterintuitive, medications that stimulate the mu opioid receptor and medications that block the mu opioid receptor have both been proven to be effective treatments for opiate addiction.

Naltrexone was approved by the FDA in the 1980’s and was originally formulated as a daily pill, however it was difficult to get people to adhere to taking their medication. Because naltrexone is a mu opioid receptor antagonist, it can lead to unpleasant feelings that are the opposite of the euphoria felt with an opiate agonist. People with addictions could stop taking the medication if they wanted to get high instead. Because of these adherence issues, the drug bounced around between companies. In addition to these issues with compliance, it was difficult for companies to market an addiction medication because of the social stigma. Addiction is often seen as a moral problem instead of a medical one, which makes selling medications for addictions very difficult.

Naltrexone became far more practical when it was reformulated as an extended-release injection. The extended-release injection lasts for a month, greatly reducing the problem of adherence. Vivitrol®, the brand name for the extended-release naltrexone introduced by Alkermes, was first approved in 2006 for the treatment of alcohol addiction. Following a successful clinical trial in Russia, it was also approved for treatment of opiate addiction in 2010. Despite poor initial sales, the popularity of Vivitrol® has grown rapidly in the past couple years.

 

Vivitrol® is still far less utilized than methadone and buprenorphine, but this is expected probably because it is much newer on the market. Importantly, not everyone responds well to methadone or buprenorphine, and having another option for the treatment of opiate addiction should be a good thing for everyone. However, a disturbing pattern has emerged in the past couple years regarding the ethics of Alkermes’ marketing strategies and scientific data. They are missing key scientific data, and actively engaging in strategies to undermine the use of agonist medications that compete with Vivitrol®. While these marketing strategies may or may not be illegal, they still raise important questions about the ethical obligations of pharmaceutical companies to their patients.

The Science on Vivitrol®

In order for the FDA to approve a drug, a drug company must first prove that the drug is effective through a clinical trial. Clinical trials are very tightly regulated in the US which makes sense because you’re testing a drug that is technically still experimental and could be dangerous to people. Not only do you need to prove that your drug is safe, but you also need to prove that it is at least as effective as other drugs out there that treat the same condition. This is where there are holes in the data on Vivitrol®.

The clinical trial that convinced the FDA to approve Vivitrol® was done in Russia.3 Clinical trials are done in other countries for many reasons. Companies may be trying to skirt the tight regulations here in the US, or they might just need to work with a patient population that is found more commonly in other places. The FDA reviews the study design and the data to see if they want to approve the drug regardless of where the study was done. The clinical trial on Vivitrol® was designed to see if Vivitrol® was effective for treating opiate addiction, but did not compare it to either of the other approved medications for opiate addiction (methadone or buprenorphine). Neither of these agonist treatments is available in Russia. In fact, both are illegal because they are opiate agonists. Alkermes only needed to prove that Vivitrol® was more effective than placebo in this case. The results were promising – almost 90% of the addicted persons who received the naltrexone shot remained abstinent during the test period, compared to just over 60% of the control group. This was enough evidence to get FDA approval, however to date there are no clinical trials comparing Vivitrol® to either methadone or buprenorphine. In addition, there was no follow-up study examining the long-term outcomes of the participants of the clinical trial in Russia.

Since it has been approved, there have been several other clinical trials examining the efficacy of Vivitrol® in different populations (although none of these studies compared it to buprenorphine or methadone). There are still concerns about adherence to Vivitro®, as well as the possibility that a person could take a dangerous amount of opioids in order to overcome the blockade effect. Because it’s an antagonist, if an addicted person takes naltrexone while they still have opiates in their system, the naltrexone will both stop the euphoric effects of the opiate and also cause withdrawal symptoms. In fact, a person has to be over a week opiate-free and have already gone through withdrawal before they can begin naltrexone treatment.

However, no medication is ever perfect. While there are still unanswered questions about Vivitrol®, it is clearly an addition to the toolbox that healthcare providers can use to help people fight addictions. It is important that these scientific concerns are discussed and addressed, and that these issues are clearly presented to the public so that people can make informed decisions about their medications.

The Marketing on Vivitrol®

(www.vivitrol.com)

To understand more about how Alkermes is advertising Vivitrol®, we can look at a screenshot of their main website listed on their advertisements (www.Vivitrol.com). This language – “the first and only once-monthly, non-addictive medication” is problematic.  While they are correct in characterizing naltrexone as “non-addictive”, this wording implies that the other medications that are available (methadone and buprenorphine) somehow are addictive. This same language is often used in a 2016 investor presentation as well, where they describe agonist therapy as “maintain[ing] physiologic dependence on opioids”. This is scientifically correct; a person who is using agonist medication may indeed be dependent on their medication. This simply means that they would experience negative physiological consequences if they abruptly stopped use. It does not mean that they are addicted. “Addiction” is a physiologic dependence combined with compulsive drug-taking despite negative consequences. Alkermes is conflating these two terms in a way that is confusing, and is meant to manipulate the consumer into equating agonist therapies with addicting opiates of abuse. While their statement that agonist therapies lead to dependence is not incorrect, it is still reinforcing a very damaging stereotype that agonist therapy is just “replacing one drug with another.” This stigma against agonist therapies is a major hurdle for the treatment of opiate addictions. Alkermes actively reinforces and uses this stereotype in order to promote Vivitrol® as the “only non-opioid treatment.”

In addition to portraying Vivitrol® as a better and safer alternative to agonist therapies in the public sphere, Alkermes is also deliberately promoting this view in the political realm. This is noted in the slide from an investor presentation that outlines their marketing strategies, above.  NPR and Side Effects Media published an excellent article detailing their investigation into Alkermes’ political involvement.  They describe Alkermes lobbyists presenting to government committees on addiction therapy and promoting the idea that agonist therapies are “replacing one drug with another”. There is overwhelming scientific evidence supporting methadone and buprenorphine as effective treatments for keeping people with addictions off of heroin and able to live their lives without experience frequent drug cravings. Despite this, there are many decision-makers in the government who do not want to support their use in treatment. Republican Rep. Tim Murphy described agonist therapy as “government –supported addiction” at a meeting in March 2015. He has received political donations from Alkermes. Tom Price, the new Health and Human Services Secretary, received a great deal of criticism for his statement that agonist therapy was “substituting one opioid for another” – despite the department’s website explicitly stating that it supports these kinds of evidence-based treatments.

Alkermes’ strategy of reinforcing of this stereotype leads to real policy consequences. The NPR and Side Effects Public Media report describes several bills that contain language steeped in these stereotypes – specifically instructing treatment providers to strive for “the goal of opioid abstinence.” This is beneficial for Alkermes, as Vivitrol® is the only non-opioid treatment available. The science however, does not indicate that opioid abstinence leads to better outcomes for patients than maintaining their agonist therapies. The report includes drafts of several bills that even mentioned Vivitrol® by name, although it was later removed because of ethical concerns. Alkermes lobbyists have also supported tightening regulations for methadone and buprenorphine, which is incredibly problematic given how restrictive the regulations already are for treatment providers.

Alkermes may not be making explicitly false claims in its marketing, but it is certainly playing off of existing harmful biases in order to further their sales. Whether or not this is illegal is debatable; it is illegal under the Federal Trade Commission for companies to “mislead” consumers. At the very least, it is incredibly unethical for a company to be so actively promoting stereotypes and policies that harm the very patients that they claim to be helping. This falls under the larger umbrella of the issues of advertising, pricing and political involvement of the pharmaceutical industry in our country. While there are no easy fixes, it is important that companies like Alkermes are held responsible for their unethical behavior and that consumers are able to make informed decisions about their treatment based on the available research.

About the Author: Hello! I’m currently finishing my 3rd year of graduate school at Rockefeller University. I’m studying the cell signaling changes caused by drugs of abuse and investigating the ways we can use those different pathways to treat addictions. In addition to learning more about the science of addiction through my research, I’m also interested in learning about the different political and social issues surrounding drug addiction. All of the views and opinions here are entirely my own and definitely don’t reflect those of my lab or institution! My email address is adunn@rockefeller.edu.

Response to the June 2017 New Yorker Article on the Opioid Epidemic

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At this point, I would think that knowledge about the vastness and seriousness of the prescription opioid and heroin epidemic, the biggest threat to American health and well being since the HIV/AIDS epidemic, would be common knowledge. Of course, given the abundance of shiny Internet things to tantalize easily distracted Americans, this is unfortunately not necessarily the case. Thankfully the New Yorker, with their characteristic excellence in reporting, has just released a superb and humanizing article on the opioid epidemic in their June 5 & 12, 2017 issue.

Read the article here.

The piece puts a much-needed human face to the horrors and misery of opioid addiction and the too-frequent death by overdose. Margaret Talbot, the article’s author, zeroes in on Berkeley County, West Virginia, in the heart of a region of the country hardest hit by the epidemic. I don’t want to give away much (because you should actually just read the article) except that the stories are heart wrenching yet balanced, and thorough in way that only the New Yorker can deliver. While the article is largely about the lives of people affected by and fighting against the epidemic, I was disappointed with a couple of points that were either made incorrectly, weakly, or not at all.

First, the article barely talks about how the epidemic arose in the first place. It mentions Purdue pharmaceuticals, the bastards behind Oxycontin (drug name: oxycodone), and that prescription opioid abuse led to heroin addiction but does not describe how the surge in addiction to prescription opioids occurred in the first place. The article describes the main problem with Oxycontin is that it can be crushed and snorted but a 2010 formulation of the drug reduced this risk. While this is indeed true, the article neglects to mention that when someone is first prescribed an opioid like Oxycontin for chronic pain (as was the case in the late 90s and early 2000s despite any evidence for the effectiveness of opioids in the treatment of chronic pain), the addictive potential of opioids often led to opioid substance abuse disorder in people who took it as prescribed (see this comprehensive article for more info). This is the big point, many of the people that eventually abused opioids started down that road by taking the drug as prescribed! Talbot incorrectly frames the big picture problem but she then goes on to correctly describe how those addicted to prescription opioids found their way to the cheaper and more abundant heroin.

The article goes on to mention the CDC’s release of guidelines on opioid prescription but fails to cite that this guidance came out as late as March, 2016, well after the epidemic had already taken root and thousands were already addicted and dying of overdose (I wrote an article on the CDC’s guidelines last year and highly recommend you read that article too if you want to learn more). The CDC’s guidance is mainly about the point I made above, that the over-prescription of opioids is the real cause of the epidemic, not just the crushable version of Oxycontin, and the limitation of opioid prescription is one of the huge policy interventions that is needed.

Later in the article, Talbot introduces us to Dr. John Aldis, a retired U.S. Navy Physician and resident of Berkeley County, WV who took it upon himself to educate people on how to use Narcan (generic drug name: naloxone), the treatment for opioid overdose. Dr. Aldis makes the critical point about the importance of medication-assisted treatments such as Suboxone (generic drug name: buprenorphine) and methadone. I appreciated the point made in the article that some patients may need these vital treatments long-term, or even for life, to combat the all-consuming single-mindedness of opioid addiction. However, beyond this passing mention, I felt that medication-assisted treatment was only weakly covered. There is still a great deal of ignorance about these treatments. Indeed, current HHS secretary Tom Price falsely characterized them as “replacing one opioid with another” and was majorly criticized by addiction experts. The reality is that there is overwhelming scientific evidence (I’ve written plenty on this site) describing the effectiveness of methadone and buprenorphine at 1) keeping addicts off of heroin, 2) allowing them to be able to live their lives without suffering from withdrawals and cravings, and 3) most importantly, keeping them alive. Talbot could have done a much better job of really hammering these points home but she seemed reticent, for some reason, to discuss it in detail in this article.

Finally, the article repeatedly emphasizes the importance of rehab clinics and tells the story of a huge victory for Martinsburg, WV (a town in Berkeley County) when the city council agrees to open a clinic in the town itself. I do not want to discount the importance of an addict assessing their addiction and taking an active role to end it, but this article does miss another critical point: rehab clinics only exist because addiction medicine is not part of medical school curricula and most hospitals are ill-equipped to treat those suffering from addiction. I feel this article could have really made the case for the importance of training for doctors in addiction medicine and the necessary shift that needs to happen for addiction treatment, a move away from overpriced (and often ineffective) private rehab facilities, and to public hospitals. Unfortunately, this point was not made.

Despite these missed opportunities, I commend Talbot and the New Yorker for a well-written article and thank them for this important piece that I encourage all to read.

 

The Laws You Never Heard Of that Will Help to Fight the Opioid Epidemic

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When a politician is in his or her final few month in office (because either they lost their re-election or simply decided not to or can’t run), they call this the “lame duck” period. President Obama’s last few months in office were anything but “lame”.

On December 14, 2016, in a rare move of bipartisanship, Obama signed into law the massive 21st Century Cures Act. This law provides a boost in funding for NIH (which includes $1.8 billion for the cancer moonshot initiative), changes to the drug approval process through the FDA, and ambitious mental health reform. This huge bill has the stated purpose of “To accelerate the discovery, development, and delivery of 21st century cures, and for other purposes.”

I’m willing to bet many people were totally unaware of this legislation that could help millions. There are some parts that are controversial and, as with any large piece of legislation, some provision that benefit this interest or that have been worked in (the changes to drug approval at the FDA will likely benefit Big Pharma). I’m not a health policy expert so I’m not about to go through and discuss line-by-line the winners and losers in this law (if you want a more in depth discussion: NPR, Washington Post, and PBS have all written articles on the law).

There’s one piece of the law that I am particularly thrilled about: $1 billion over 2 years for treatment for opioid addiction. That’s rights billion, with a “B”. The money is to be distributed to states in the form of block grants (block grants are in essence a large allocation of federal money to be used for a specific purpose given to states but the details of how that money is used is decided by the states themselves).

This is an unprecedented amount of funding earmarked exclusively to fight the opioid epidemic that is still raging in the US. The funding is to be used for expanding and increasing accessibility to treatment, such as life saving medication-assisted treatments such as methadone and buprenorphine. The federal money will also be used to train healthcare professionals to better care for people dealing with addiction, and a comparatively smaller amount for conducting research on how best to fight the epidemic, and other provisions.

I’ve written about methadone and buprenorphine and their effectiveness ad nauseam on this site and I am personally and thrilled to see a massive federal effort to increase access to these vital tools in the fight against the opioid crisis

The Cures Act comes on the heels of another promising piece of legislation, the Comprehensive Addiction and Recovery Act (CARA), signed into law by President Obama on July 13, 2016. This law includes provisions to expand the availability of naloxone–the medication used to save people from the effects of opioid overdose–to first responders, improve prescription drug monitoring programs, make it easier for healthcare providers to administer, dispense, or prescribe medication-assisted treatments, and other provisions.

The combination of these two pieces of legislation is a promising and much needed initial federal response.

However, this huge boost in funds for treatment in the Cures Act is only for 2-years. President Trump’s budget for FY18 would add $500 million for opioid addiction but most analysts think this is just a sneaky way of making it seem as if he’s supporting addiction treatment when the money has already been written in as part of the Cures Act. Further, his cuts to the Department of Health and Human Services (which contains the NIH and other agencies that administer the Cures and CARA laws) would make it difficult to launch any type of  effective response to the crisis.

Regardless of how things shake out, Trump’s massive cuts for everything that’s not the Department of Defense will likely hurt the fight against the opioid epidemic too. The real question is by how much?

 

Methadone Maintenance Therapy Works-End of Story

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helping hands (pixbay.com)

I hate to be condescending but how the scientific community perceives a phenomena and how the public at large perceive the exact same thing can be starkly different.

For example, there is still a debate over the scientific legitimacy of global warming and climate change. Of course, this flies in the face of reality. In the scientific community, there is no more debate over climate change than there is over heliocentricity (the theory that states the Earth revolves around the Sun). Study after study comes to the came conclusion, the scientific evidence is overwhelmingly in favor. But I’m not writing to debate climate change.

The same type of dichotomy exists for replacement/maintenance therapies for addiction. Methadone and the related compound buprenorphine (Suboxone, one of its formulations) are still considered controversial or ineffective or “replacing one drug for another.”

 

In brief, methadone (https://en.wikipedia.org/wiki/Methadone) is a compound that acts on the same target as heroin (the mu opioid receptor) but unlike heroin, it acts for 24hrs. Dr. Vincent Dole, a scientist at the Rockefeller University in New York, and his colleague, Dr. Marie Nyswander, had the brilliant idea of using this very long-acting opioid compound as a way of treating heroin addiction. Indeed, methadone has the advantage of not producing the intense, pleasurable high that heroin produces but is still effective at curbing cravings for heroin and eliminating withdrawal symptoms. Dole and Nyswander published their first study in 1967 and methadone has been an approved—and effective—treatment for heroin addiction worldwide ever since.

 

 

However, controversy over the use of methadone exists. Even the opening of a methadone clinic can incite protests. The persistence of negative attitudes towards methadone and the stigma against treating addiction as a medical disease has prevented addicts from receiving proven medical treatments that are effective at curbing cravings and actually keeping them off of heroin and in treatment programs.

 

So just for a moment, let’s suspend our preconceived notions about what methadone is or how it works and let’s just ask our selves two simple questions:

 

Does methadone work?

 

Does methadone keep addicts off of heroin and in treatment?

 

The answer is a resounding YES!

 

Many controlled, clinical studies have examined the effectiveness of methadone

But a comprehensive, comparison of methadone versus control, non-medication based treatments has never been considered amongst the various studies.

 

Researchers at the Cochrane Library performed this type of comprehensive analysis. Data was considered from 14 unique, previous clinical studies conducted over the past 40 years. Researchers compared methadone treatment versus control, non-medication based treatment approaches (placebo medication, withdrawal or detoxification, drug-free rehabilitation clinics, no treatment, or waitlist). 11 studies and 1969 subjects were included in their final analysis.

 

Read the full paper, published in 2009, here.

 

The results were clear. Methadone was found to keep people off of heroin and in treatment more effectively than control treatments. Urine analysis confirmed methadone-treated addicts were more likely to be heroin-free and regularly seeking treatment.

 

Of course, as I stated above, this is nothing new. But it’s important to note that abstinence therapies or treatments that encourage addicts to go “cold turkey” don’t really work. A medical treatment exists to help addicts fight their cravings so theirs brains are not fixated on obtaining heroin and these people are able to regain normal daily functions. And in time, methadone doses can be tapered down as intensity and frequency of cravings decrease.

 

The debate now should not be whether methadone works, but on how to use it effectively and to expand its use so that as many people as possible can benefit from it.

 

Most importantly, methadone helps an addict to return to normal life. End of story.

5 Facts on the Opioid Epidemic: National Drug and Alcohol Facts Week

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Spilled prescription medication --- Image by © Mark Weiss/Corbis

Spilled prescription medication — Image by © Mark Weiss/Corbis

Well, I’m a little late to the punch on this one but National Drug and Alcohol Facts week has been going and ends tonight. This public awareness campaign is now in it’s seventh year and is all about shattering the myths about addiction.ndafw_logoI might as well throw my belated hat in the ring and share 5 facts about the opioid epidemic.

Fact #1: The opioid epidemic in the U.S. has hit all demographic groups, regardless of race, gender, age, location, or socioeconomic status.

Fact #2: Prescription opioid pain medications like oxycodone can be just as addictive as heroin, even if taken as prescribed.

Fact #3: There is no scientific evidence that prescription opioids are effective at managing chronic pain; they are extremely effect for short-term, acute pain.

Naloxone_(1)Fact #4: Naloxone is a drug that counters the effects of opioids and can immediately reverse an overdose; you cannot get addicted to naloxone.

Fact #5: Buprenorphine and methadone are opioids that can help a person to fight their heroin addiction by satisfying their craving for the drug.

To learn more, here’s a short “Best of” from Dr. Simon Says Science on the Opioid Epidemic. Check out the posts below for oodles of info on opioids.

  1. What is naloxone? Should it be available over the counter?
  2. The CDC Fights Back Against the Opioid Epidemic
  3. Is Methadone an Effective Treatment for Heroin Addiction? YES!
  4. Morphine and Oxycodone Affect the Brain Differently
  5. Important: CDC Releases Report on Heroin Epidemic
  6. Methadone Maintenance Therapy Works-End of Story
  7. Paper Review-Initiation into Injection Drug Use and Prescription Opioids
  8. New Review Paper-The Prescription Opioid and Heroin Epidemic

 

The Science of Sexual Orientation

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Happy New Year!

I figure I’ll kick things off with something a little different than my usual science of addiction posts.

My new job deals with supporting LGBT rights in the developing world and there’s a lot of work be done! In fact, as of June 2016, 77 countries or territories criminalize homosexuality and 13 countries or territories penalize homosexual behavior by death. But why is this? Why is someone who is attracted to and has sex with someone of the same sex so controversial in so much of the world? Well..I’m not about to begin to answer that question because I’ll be writing all week (hint, hint: religion is a huge factor).

Instead, I’ll present some of the key findings from a relatively new (April 2016) review article about the science of sexual orientation by JM Bailey and colleagues in the journal Psychological Science in the Public Interest. This is by far one of the most comprehensive and most even handed review articles written on the subject. The authors take an extremely academic approach because let’s face, the science surrounding sexual orientation has been used and abused by both pro- and anti- gay rights folks. (note: this article does not really discuss with transgenderism or gender identity issues)

This article is too long to go into all the details so instead I’m just going to present the main highlights that I prepared for a research report a few months back. Enjoy!

Download the article here. It’s Open Access!

jm-bailey-et-al-2016

Brief Summary:

Political controversies pertaining to the acceptance of non-heterosexual (lesbian, gay, bisexual) orientation often overlap with controversies surrounding the science of sexual orientation. In an attempt to clarify the erroneous use of scientific information from both sides of the debate, this article 1) provides a comprehensive review of the current science of sexual orientation, and 2) considers the relevance of scientific findings to political discussions on sexual orientation.

Top Takeaways from the Review:

  • The scientific evidence strongly supports non-social versus social causes of sexual orientation.
  • The science of sexual orientation is often poorly used in political debates but scientific evidence can be relevant to specific, limited number of issues that may have political consequences.

(wikimedia.org)

(wikimedia.org)

The scientific evidence strongly supports non-social versus social causes of sexual orientation (nature vs nurture).

Prevalence of non-heterosexual orientation (analysis of 9 large studies): 5% of U.S. adults.

Summary of the major, scientifically well-founded findings supporting non-social causes:

  • Gender non-conformity during childhood (before the onset of sexual attraction) strongly correlates with non-heterosexuality as an adult.
  • Occurrence of same-sex behavior has been documented in hundreds of species and regular occurrence of such behavior in a few species (mostly primates, sheep).
  • Reported differences in the structure of a specific brain region (SDN-POA) between heterosexual and homosexual men.
  • Hormone-induced changes in the SDN-POA during development in animal studies and subsequent altered adult sexual behavior (the organizational hypothesis).
  • Reports of males reared as females but who exhibit heterosexual attractions as adults.
  • Twin studies suggest only moderate genetic/heritable influence on sexual orientation.
  • Several reports identify a region on the X chromosome associated with homosexuality.
  • The most consistent finding is that homosexual men tend to have a greater number of biological older brothers than heterosexual men. (fraternal-birth-order effect)

The science of sexual orientation is often poorly used in political debates, but scientific evidence can be relevant to a specific, limited number of issues that may have political consequences.

The question of whether sexual orientation is a “choice” is logically and semantically confusing and cannot be scientifically proven. It should not be included in political discussions.

Examples of scientifically reasonable questions include:

  • Is sexual orientation determined by non-social (genetic/hormonal/etc.) or social causes? (nature vs nurture)
  • Is sexual orientation primarily determined by genetics or environment?

Specific cases in which scientific evidence can be used to inform political decisions:

  • The belief that homosexual people recruit others to homosexuality (recruitment hypothesis). This type of belief was espoused by by President Museveni of Uganda in 2014 and was used to justify Uganda’s notorious anti-homosexuality bill (since repealed).
    • No studies exist that provide any type of evidence in support of this hypothesis.
  • Proponents of conversion/reparative “therapies” argue that sexual orientation can be changed through conditioning and reinforcement.  Gov. and VP-elect Mike Pence  allegedly supported these types of bogus “therapies” in Indiana.
    • Studies reporting successful “conversion” suffer from methodological errors such as selection bias and/or unreliable self-report data and are therefore scientifically unfounded.
    • No evidence exists that a person’s sexual orientation can be changed at will.

 

The British Medical Journal (BMJ) Calls for an End to the “War on Drugs”

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war-on-drugs-no

A recent editorial in the British Medial Journal (the BMJ) has called for an end to the “War on Drugs”, which costs about $100 Billion/year and has failed to prevent both drug use and drug proliferation.

The article points out how the “War on Drugs”, the term used to collectively describe the laws penalizing drug use, has had a wide-range of negative effects. For example, the US has the highest incarceration rate in the world and about half of those arrests are due to drug-related arrests.

The health effects have been drastic as well. Stigma against opioid replacement therapies like methadone has resulted in increased deaths due to opioid overdose in countries that limit access. Stigma and discrimination against addicts, as well of fear of punishment for for usage, often leads away from health care services to unsafe drug-use practices that can spread HIV and Hepatitis C, and other unintended poor-health outcomes.

Importantly, the editors call for rational, evidence-based, drug-specific approach to regulation and strong involvement of  the scientific and medical communities. Obviously, the risks of something like marijuana are much lower than for heroin but how will drug policy reflect this? Research is required to support any efforts in order to identify the best practices and strategies.

The editors point out that a recent article in the Lancet “concluded that governments should decriminalise minor drug offences, strengthen health and social sector approaches, move cautiously towards regulated drug markets where possible, and scientifically evaluate the outcomes to build pragmatic and rational policy.”

Above all, a change in drug policy must benefit human health and there will be no “one size fits all” approach. The road ahead is difficult but one thing is certain, the road that led us here is a dead end. The “War on Drugs” has failed; the call now is to develop a national and international drug policy that won’t.

The NIH Announces a Commitment to Research on LGBT Health

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lgbt-med

Every person has a right to live a healthy life. One part of that vision is equal access to health care for all. But unsurprisingly, not everyone have the same ability to receive health care due to things like socioeconomic status, race, gender, or even sexual orientation. Indeed, LGBT people often have less access to health care than their non-LGBT counterparts, most often due to discrimination and stigma [1].

The Director of the National Institute on Minority Health and Health Disparities, part of the National Institutes of Health (NIH), announced “the formal designation of sexual and gender minorities (SGMs) as a health disparity population for NIH research.” Read the full announcement here.

What does this mean? That the NIH is officially recognizing that LGBT people have less access to health care and that improved research on LGBT-specific (defined here broadly as sexual and gender minorities) health issues is essential to improved health care.

The long-overdue announcement was supported by an important report released by the non-partisan National Academies of Science (NAS) in 2011. The report identified gaps in the research on the health of LGBT persons and made recommendations for improving this research that could benefit not just LGBT people, but the health care system overall.

LGBT individuals have unique health challenges that many doctors do not understand or address. For example, certain types of cancer seem to be more prevalent among gay men compared to straight men, which means different cancer screenings would be important for gay men [2].

The new designation by NIMHD will hopefully increase research and knowledge about the health challenges of LGBT people and will hopefully result in improved health care for all people, regardless of sexual orientation, gender identity, or gender expression.

Selected References

  1. Hatzenbuehler ML, Bellatorre A, Lee Y, Finch BK, Muennig P, Fiscella K. Structural stigma and all-cause mortality in sexual minority populations. Social science & medicine. 2014;103:33-41. doi: 10.1016/j.socscimed.2013.06.005.
  2. Quinn GP, Sanchez JA, Sutton SK, Vadaparampil ST, Nguyen GT, Green BL, et al. Cancer and lesbian, gay, bisexual, transgender/transsexual, and queer/questioning (LGBTQ) populations. CA: a cancer journal for clinicians. 2015;65(5):384-400. doi: 10.3322/caac.21288.