Slate eBook Club - Best of 2003

by Slate. com

  Michael's reaction may be the rule for teenagers, not the exception. For an adult who has lost his wife, his job, his health, and his home, admitting to a loss of control might help him recognize that quitting drugs is the only way to solve his problems. But a teenager may not be "in denial" when he says he can control his intake. Most teenagers can. Conversely, forcing a teen to assert that they have no control may do more harm than good, if they have only been experimenting with drugs but are convinced, via treatment, that they are serious addicts. If a teenager has been persuaded that she's powerless and has a 90 percent chance of relapse, she's far less likely to exercise self-control when confronted with a drink or drugs. In fact, a 1996 study published by Bill Miller, professor of psychology at the University of New Mexico, found that those adults who most accepted the idea of personal powerlessness had the most severe and dangerous relapses. Since teenage identities are fluid anyway, encouraging them to view themselves as powerless addicts may cement an anti-social identity that a teen was just trying on for size.

  The core problem with teen treatment programs is that most teen drug or alcohol users are just not out-of-control addicts. More than one teen in six who's forced into treatment does not even fit the criteria for a "substance abuse disorder" (the less serious diagnosis for an abuser), and most also don't have substance dependence (the psychiatric term for addiction) at all, according to SAMHSA. More troubling, SAMHSA statistics also show that about three-quarters of the U.S. teens now being sent to treatment programs are diverted there by courts or schools, rather than being referred by professionals. In other words, many have problems no more serious than those of their friends who've escaped detection.

  In addition to labeling kids as addicts, drug programs may also surround them with the worst possible influences. Studies show that teens are more subject to peer pressure than adults—and more influenced by the people around them. Teen treatment programs remove teens from a healthy peer group and surround them with other problem kids, virtually guaranteeing that their role models will be negative. Group therapy during such treatment invariably involves discussions of their drug experiences—which only makes the hard-drug users seem "cooler" because their stories are so much more exciting. Worse, aside from providing a way for relatively inexperienced kids to learn about different ways of getting high and obtaining drugs, these programs frequently offer kids new connections. One 17-year-old girl from Florida told me that she hadn't used cocaine until after treatment—her new best friend from rehab scored it for her.

  There are treatments for teens that don't reinforce the labeling or peer problems inherent in most drug programs. Research presented at a spring conference held by the National Institute on Drug Abuse compared teens who'd been sent to traditional group sessions with peers to teens who received family therapy, with a third group who had both kinds of care combined. The kids in the peer-group sessions used 50 percent more marijuana after treatment, while the kids in the combined treatment used 11 percent more pot. The teenagers treated with their parents, however, decreased their marijuana use by 71 percent.

  The greatest irony in the current well-intentioned treatment efforts is that they ignore the few things we do know to be effective in helping teens stop getting high, and chief among them is finishing their education. The better educated someone is, the less likely he is to become an addict or to have a lengthy course of addiction if he does. So removing kids from school and placing them with a more deviant peer group in an unproven therapy is madness—and not much smarter than simply expelling them and tossing them on the street. Not only is the education provided in treatment programs often inferior to that in ordinary school, but having a drug-related disciplinary record diminishes the chances of admission to a decent college.

  Ultimately, it's clear that the vast majority of teenagers (even those with the very worst problems) simply "mature out" of drug use. This natural recovery process is seen in statistics from the annual federal household survey of drug use, which, for example, find that while 18.4 percent of the population ages 18-24 in 2001 qualified for a diagnosis of alcohol or other drug abuse or dependence, only 5.4 percent of those over 26 meet these criteria. Since less than 2 percent of the total population annually receives treatment (including self-help), most of these young people are clearly recovering on their own.

  Why, then, do we insist on herding teenagers into inappropriate treatment programs when allowing them to finish school works better? Do parents really want their pot-smoking, experimenting binge-drinkers (who are actually typically more moderate than their own parents were at their age) tossed into "therapy" with heroin injectors and told that they are powerless to resist?

  Studies show that family therapy and behavioral one-on-one counseling work better for teens than programs modeled on adult addicts. Even for kids with genuine drug addictions, these sorts of treatments may be more helpful, and it's long past time that such programs were implemented in communities rather than debated in the academy. For kids with minor drugs problems or—as is more often the case—for kids who are just being kids, the philosophy must be: First, do no harm. Although we may hate the idea, leaving kids alone and letting them grow out of their habits makes far more sense than testing, punishing, and "curing" them—by making them worse.

  Estrogen Uncovered

  Have women been the unwitting victims of the medical establishment's experiment with hormones?

  By Eliza McCarthy

  Updated Friday, Aug. 22, 2003, at 1:43 PM PT

  Hyperion Books recently published The Greatest Experiment Ever Performed on Women: Exploding the Estrogen Myth, by Barbara Seaman. Generally speaking, a new volume on estrogen would hardly merit a mention. After all, such books are a dime a dozen. On Amazon.com, for example, there are 448 books listed under "Women's Health, Menopause," and 95 under "Contraceptives, Oral."

  But a book by Barbara Seaman on the topic is something special. Published in 1969, her first book, The Doctors' Case Against the Pill, caused an anti-estrogen sensation. At that time, the Food and Drug Administration had received reports of blood clots, strokes, and other less serious side effects, such as nausea, associated with the birth-control pill, but most doctors failed to mention these risks to their patients. Seaman's book, containing chapters such as "The Silence That Could Kill You," changed all that: After its publication, congressional hearings were called to discuss the then high-dose Pill; pharmaceutical companies subsequently lowered the Pill's concentrations of estrogen and its oft-ignored hormonal cousin, progestin; the FDA also required that companies include those now-ubiquitous patient-information inserts listing a drug's potential risks.

  All these years later, after writing several more books and co-founding the National Women's Health Network, a feminist activist group, Seaman is back to estrogen. It is a tumultuous time in the public life of the hormone: Last summer (in case you were hibernating or are a man) the government announced that it was halting a portion of its Women's Health Initiative, a 15-year study, in part devoted to investigating hormone use, of more than 100,000 postmenopausal women. In the WHI, it turned out, postmenopausal women taking hormone therapy containing both estrogen and progestin ran a 24 percent increased risk for heart disease, even though hormones had been thought to protect the heart. The study also confirmed that combination therapy increases the risk for breast cancer by 24 percent; surprisingly, the hormones also doubled the risk for dementia, when they had been hypothesized to prevent cognitive decline. (Interestingly, no such risks have been discerned among women taking only estrogen; these women are still being tracked, with many doctors predicting the results will turn out to be similarly disappointing.)

  As a result of the WHI findings and of the writings of estrogen skeptics like Seaman and Dr. Susan Love, the conventional wisdom on estrogen, particularly on postmenopausal hormone use, has recently been transformed: Whereas the hormones were once presented as potential lifesavers, they are now looked upon with intense suspicion. News anchor Ann
Curry's reaction on a recent episode of Today is representative of the shift: "What accounts for this … immoral positioning, immoral development?" she asked Seaman. "I think many of us are angry about what has transpired."

  Seaman is angry, too. In her book, Seaman places the blame for what she calls the "dirty secrets" of estrogen's history on drug manufacturers and doctors who recommended hormone products for what they "hope or believe they can do, not for what they know the products can do," the marketers who sold the drugs with extravagant claims, and what she sees as the wimpy media that failed to adequately report data on negative side effects. As for the millions of women who've taken estrogen over the years, Seaman believes they were used as "lab animals."

  The not so subtext of all these arguments is clear: The drug companies are reckless and greedy; the media are complicit; the patients are dupes. These are familiar tropes of health-care activism. But do these claims, in the case of estrogen, hold up?

  As a skeptical health writer, I was ripe for proselytization. And Seaman's book does raise lots of good, if familiar, questions about the influence of money on estrogen-research and marketing. Still, Seaman's book did not convince me that all women should swear off estrogen products entirely. (Seaman says her goal isn't to inspire estrogen aversion, but with chapter titles like "Poison by Prescription" one has to wonder.) Nor did the book convince me that the medical establishment is incapable of improving its hormonal record. On the contrary, Seaman, perhaps unwittingly, tells the story of a medical establishment that has—admittedly with prodding from advocates like her—learned to look more critically at the question of estrogen. We've come a long way from the early days of the Pill, when women were told, essentially, not to worry their pretty little heads about it, to the huge gold-standard clinical trial that is the WHI.

  The book does include loads of fascinating research, particularly on the shoot-first-ask-questions-later development of hormonal drugs. Seaman writes of grisly hormone experiments done on prisoners at Auschwitz (according to Seaman's source, the prisoners' "rutabaga soup" was likely laced with estrogen); the development of the synthetic estrogen DES in England (DES was used by millions in the United States to "prevent miscarriage," when, horribly, it didn't—and exposed both the pregnant women and their children to serious health problems later in life); and the creation of the birth-control pill after tests conducted on what Seaman portrays as helplessly vulnerable Puerto Rican slum dwellers.

  But Seaman's fixation on estrogenic details to the exclusion of other health data does her cause a weird kind of disservice. In using the word "experiment," Seaman implies that the many forms of estrogen—from the Pill to postmenopausal hormone therapy—have been foisted on women despite inadequate or even nonexistent evidence. In using the word "greatest," she suggests that this is the largest and worst of such "experiments" ever done unto women. But Seaman provides little context for these claims. Nowhere is there a comparison with other medical experiments like, say, the government's 40-year "Tuskegee Study of Untreated Syphilis in the Negro Male," in which researchers withheld known cures from sick men simply to observe the ailment's natural progression. OK, so the study was done on men, but it's a pretty good yardstick with which to measure nasty portions of medical history. Nor does she ever compare estrogen's safety profile with that of other drugs. While it's frightening that postmenopausal hormones could cause up to 6,000 more cases of breast cancer a year, let's put this number in perspective. One hundred thousand people may die annually in the hospital from adverse drug reactions. (And the truth is, postmenopausal hormones only raise an individual woman's yearly breast cancer risk—yours, mine—by one-tenth of 1 percent.)

  Seaman also writes with an odd kind of childish faith that finding absolute Scientific Truth should be a piece of cake, and risk-free to boot. Yet before the 1960s, when government agencies enacted more stringent controls over drug experiments, some researchers—not just those working with hormones—experimented with a derring-do that would make us queasy today. For example: In 1941, after testing penicillin on a measly eight mice, English researchers tried it out on a man sick with septicemia. (After a brief rally, the man died.) A mere two years later, the drug was being mass-produced. Estrogen is clearly not the only drug that was put on the market before its benefits and dangers were known to an absolute certainty.

  So what do we know for certain about estrogen-containing drugs?

  We know that today's lower-dose contraceptive pills, patches, and injections are not as dangerous as the earlier version of the Pill. They do slightly increase the risk for blood clots and strokes—according to recent studies, an extra 1 to 3 women per 10,000 annually will develop a blood clot while on the Pill, and an extra 1 to 4 per 100,000 women will suffer a stroke, with smokers at particular risk. On breast cancer, some research, though not definitive, suggests that women on the Pill (particularly those who start the Pill before the age of 20) may have an increased risk of breast cancer, one that dissipates after they stop taking the drug. Yet women who take the Pill actually develop fewer ovarian and endometrial cancers. Besides, today's Pill is nearly 100 percent effective at preventing unwanted pregnancy, if taken faithfully.

  As for postmenopausal hormones, Seaman's right that the hormones have only a very few clear-cut benefits: They do reliably quash menopausal hot flashes and may also alleviate vaginal dryness. But no one's studied a "safe" length of time to take the drug for these symptoms. Furthermore, the WHI found that despite hot-flash relief, women on hormones reported no better quality of life than women taking a dummy pill.

  In light of this shaky rationale for hormone therapy, researchers are looking to other drugs to do some of what hormones were supposed to: It seems that the cholesterol-lowering drugs called statins may fit the bill—some clinical trials show that they reduce the risk of death from heart disease (even among people with normal cholesterol levels); they also may somehow reduce fracture risk, researchers speculate; and, at least in a test-tube, they keep breast-cancer cells from proliferating. But let's not get ahead of the data—if there's one message to glean from the estrogen saga, it's this.

  Wake Up, Little Susie

  Can we sleep less?

  By David Plotz

  Posted Friday, March 7, 2003, at 2:08 PM PT

  On most days, my accumulated sleep deficit and post-lunch stupor gang up on me around 2 p.m., and I begin my slow fade. My eyes droop. Saliva dribbles onto my sweater. If I were trying to write this sentence at 2 p.m. on a normal day, it would read something like: "If I were tryyyyyyyyyyyyyyy … "

  But today, I am bright-eyed and bushy-tailed, a chatty Kathy with my officemates, eager to spend all afternoon banging on the keyboard. (I normally prefer chewing my fingers off to writing.) I am not exactly wired, but I'm more alert, more focused, more Plotz-like. Today I am my own Superman, dosed on 100 milligrams of modafinil.

  Every year, we need the same amount of sleep, and every year we get less. Since the invention of artificial illumination, sleep has been a bear market. There are many reasons we catch fewer Z's: Round-the-clock workplaces, longer commutes, brighter lights, 24-hour Krispy Kreme stores, the Home Shopping Network—the list goes on. According to University of Pennsylvania professor of psychology David Dinges, Americans probably sleep about six and a half to seven hours per night, compared to the more than eight hours our bodies want.

  We have learned to cope with a regular sleep deficit, but we pay a price (and not just $4.05 for the venti latte). Studies by Dinges and military scientists have proved that performance deteriorates when you sleep less than eight hours. People who rest seven or six or five hours a night may not feel tired, but their thinking and dexterity are suffering. We medicate ourselves with caffeine, a drug that raises alertness but at a cost of jitteriness, irregular heartbeat, and addiction. Folks who really need to stay awake dope themselves with amphetamines—stimulants that can ward off sleep for days but cause terrible crashes when they wear off. (And we don't know what long-term damage the
y cause.)

  The military is enthralled with the possibility of doing away with shut-eye. The supersecret Defense Advanced Research Projects Agency is investigating drugs that would keep soldiers awake for a week. The Air Force prescribes "go pills"—small doses of the amphetamine Dexedrine—to pep up long-haul pilots. (But hopped-up pilots may be dangerous: The American pilots who accidentally bombed and killed Canadian soldiers last spring were taking go pills.)

  Avoiding sleep for a week might be necessary in an extreme situation like war, but the run-of-the-mill, office-working, wannabe Superman requires something different. We don't want a pill that will keep us Exceling and Power Pointing for three days straight. We just want something that makes us feel alert through an entire normal day—a drug that makes us feel as lively for the 18-hour-day we have to live as for the 16-hour-day we ought to live.

  Hence my rendezvous with modafinil. The drug, made by Cephalon, is marketed under the creepy, pharma-Orwellian name Provigil. The FDA approved it in 1998 to treat narcolepsy, but it is starting to have a underground life as a pick-me-up for the routinely sleep-deprived. The military has tested it heavily, particularly on pilots.