Noteworthy News Articles on Mental Health Topics, July 6-10, 2000

Grandparents' Law is Left Intact Nationwide
Detroit Free Press, 7/6/2000

WASHINGTON -- In a case of keen interest to millions of grandparents nationwide, the U.S. Supreme Court on Monday struck down a Washington state law that had allowed a Washington couple to visit their grandchildren although the children's mother objected. In a 6-3 decision, the high court ruled the Washington law, one of the most liberal in the country, was "breathtakingly broad" in that it would allow anyone, even people without a familial relationship, to petition for visiting rights. But the justices left open the possibility that less extreme laws around the country upholding the rights of grandparents might withstand their scrutiny.
    Bloomfield Hills attorney Richard Victor, the founder and head of the Grandparents Rights Organization, applauded the decision, noting it essentially upholds the status quo, which allows grandparents in every state to ask for visitation rights. "We are significantly relieved, because we know this is over: the issue of whether grandparents' visitation is constitutional," he said. "I'm ecstatic." All 50 states have adopted grandparents' rights laws, permitting grandparents and sometimes others to seek court-ordered visiting rights under various circumstances. In its decision Monday, the high court recognized the importance of those rights and acknowledged many grandparents play an important role in the lives of children. "In 1998, approximately 4 million children -- or 5.6 percent of all children under age 18 -- lived in the household of their grandparents," Justice Sandra Day O'Connor wrote in the majority opinion. O'Connor is one of six grandparents among the nine justices.
    At issue Monday was a case involving Gary and Jenifer Troxel, a couple from Anacortes, Wash., who have fought since 1993 for the right to visit with their two granddaughters, Natalie, now 10, and Isabelle, now 8. Their son, Brad Troxel, fathered the girls with his girlfriend, Tommie Granville. The couple later separated, and Brad Troxel committed suicide in 1993. Granville later married a man who adopted the girls. Gary and Jenifer Troxel wanted to see their granddaughters more often than Granville and her new husband would allow. So the grandparents sued and were awarded visitation of one weekend a month, one week during the summer and four hours on the girls' birthdays. But Victor noted Monday that the couple could not sue under Washington's grandparents' visitation law because it, like Michigan's law, allowed visitation only in the case of divorce or the death of a parent -- not when the children were born out of wedlock. Washington had another law that allowed any person to seek visitation with a child. Gary and Jenifer Troxel won their visitation rights under that law -- and that was the law struck down Monday by the high court.
    But, of most interest to other states, the high court upheld the other Washington law that dealt just with grandparents' visitation. That law is similar to laws in the 49 other states, Victor said. "This decision today affects two people in the entire world," Victor said. "It has no effect on any other law in the country." In its decision Monday, the justices said states must be careful in helping grandparents and others with close ties to children win the right to see them regularly against parents' wishes. "So long as a parent adequately cares for his or her children ...there will normally be no reason for the state to inject itself into the private realm of the family," O'Connor wrote. But the dispassionately worded ruling in one of the most emotionally charged cases stopped short of answering all questions the state courts face daily in visitation battles over children. The court did not give parents absolute veto power over who gets to visit their children.
    The case drew briefs from the 30-million member AARP, an advocacy group for middle-aged and older Americans, as well as dozens of organizations interested in the definition of family, from gay groups that recognize same-sex unions to fundamentalist Christians who strongly advocate for traditional families. The case produced six different opinions from the nine members. Chief Justice William Rehnquist and Justices Ruth Bader Ginsburg and Stephen Breyer joined O'Connor, while Justices David Souter and Clarence Thomas took somewhat different tacks. Justices John Paul Stevens, Antonin Scalia and Anthony Kennedy each wrote dissenting opinions.

St. John's Wort Has Its Own Set of Problems
Barrie S. Cassileth, Los Angeles Times- 7/6/2000

St. John's wort for the treatment of depression sounds like a great alternative to prescription drugs with their high costs, relatively lengthy kick-in time and sometimes major side effects. After all, it's been used for centuries, and not only that, it's also an herb--a natural product--and natural products are safe. Right? Wrong. The assumption that natural equals safe, and that long-term use enriched by many anecdotal reports means effective, fall among the most dangerous beliefs we hold dear. Back in colonial times, bloodletting therapy, which probably killed George Washington, was an example of the many medical methods made no less deadly by virtue of its entrenched respectability. Many natural products or their components are poisonous. Understanding that medicinal herbs are not just plants with healing properties, but dilute (or weak) prescription medications helps us adopt a more realistic perspective. Like pharmaceuticals, natural products such as St. John's wort are drugs that can harm as well as help, create adverse effects, and interact with other medicines. Unlike pharmaceuticals, however, herbal remedies in this country are not subject to oversight by the Food and Drug Administration. As such, we don't always know what's in the bottle.
    St. John's Wort has been studied extensively in Europe, where it is prescribed and treated as a drug. Simultaneous analyses of multiple European studies indicate that St. John's wort effectively treats mild and moderate depression. We've found it helpful here, too. Americans eagerly seek this over-the-counter remedy for depression, which is the leading cause of disability in this country. Retail sales climbed by almost 3,000% during a recent single year. As Americans in ever larger numbers used this herbal remedy over time, reports of problems not captured in Europe's relatively brief studies began to surface. This cost-effective, readily available therapy, this natural, yellow bloom that vanquished our dark moods, turns out to create serious problems when taken with other medications.   To hammer home the point that herbs are not always the harmless, natural products we wish them to be, St. John's wort activates certain enzymes in the liver that decrease blood levels of some important medications. Through this action, St. John's wort reduces the amount of drug available in the body to treat HIV infections, to thin the blood and to keep heart transplants from being rejected. It also reduces the effectiveness of anti-seizure drugs, birth control pills, antidepressants and chemotherapy. Potential consequences are serious. A few months ago, the FDA issued a public health alert about the dangers of taking St. John's wort with other medications. If you are healthy and on no other medications, St. John's wort probably will help relieve your depression and cause no major difficulties. But if you are taking any medication, stay on the safe side and assume that this otherwise helpful herb could cause serious harm by impeding the action of that medication.
    When considering St. John's wort or the use of any herbal remedy, consider what the capsule contains, potential interactions, possible side effects and whether information on effectiveness exists. What's in the capsule? Check whether the capsule contains enough of the right ingredients and whether it includes contaminants or unwanted matter. St. John's wort usually is standardized for one of its chemicals, hypericin. But it turns out that other of the herb's ingredients, as yet undocumented, reduce depression. Hypericin does not.  While herbal product companies may tout "standardized" to enhance the image of their products as safe and reliable, the word has little meaning with St. John's wort and other herbs. Moreover, studies of the amount of active ingredient present in samples of the same product from the same manufacturer show wide variations. Contamination, from soil compounds such as heavy metals, or with other botanical or animal products, remains a problem--another artifact of the absence of regulation. Purity and consistency are not current hallmarks of herbal remedies.

Drug interactions
Possible with almost any prescription medication. Just as interactions between drugs occur, so too herbs (remember, they are dilute drugs) are likely to interact with some medications. Because not all herb-drug interactions are known, it's best to err on the side of safety and avoid herbal remedies if you are on prescription medications. And be sure to check with your doctor.

Side effects
St. John's wort has caused gastrointestinal disturbances, allergic reactions, dizziness, fatigue, dry mouth, confusion and over sensitivity to light. Because all herbs and other food supplements are exempt from government regulation and control, these dangers are not likely to be listed on the label. Herbal remedy labels may make almost any claim short of curing disease. Reporting side effects is not mandated.

Effectiveness information
The U.S. government classifies herbal remedies as food supplements. Unlike foods or drugs, food supplements are not regulated by any federal agency under a law passed by Congress in 1994, and manufacturers are not required to evaluate or note safety or efficacy data. Studies conducted elsewhere, such as the European research on St. John's wort, may not meet the rigorous standards applied to drugs in the U.S. An ongoing study supported by the National Institutes of Health will provide missing information about the long-term effects of St. John's wort, whether it reduces severe depression in addition to mild or moderate depression, and how it fares in comparison to prescription medications for depression. As increasing numbers of well-known U.S. and European companies produce and market herbal remedies, more and better research, accurate claims and consistent, pure, effective products will ensue. Until then, seek information about herbs on objective Web sites or publications that do not sell botanical products.

Nature and Nurture Affect Children After Divorce
Rueters- 7/6/2000

NEW YORK—Researchers have come one step closer to sorting out the ongoing debate over nature versus nurture--at least when it comes to how divorce affects children. According to a report in the July issue of Developmental Psychology, genetics--the nature part of the equation--is more likely to affect academic achievement and social adjustment after divorce. Environmental factors, which can include how a child is nurtured, appear to influence behavioral problems and drug use. Until recently, researchers have assumed that the well-known effects of divorce on children were purely a result of environmental factors--the financial strains, single parenthood and changes in the parents' relationships that come with divorce.
    Dr. Thomas G. O'Connor from the Institute of Psychiatry in London, UK, and colleagues studied nearly 400 biological and adoptive families over 12 years to examine whether genetics affected children's self-esteem, social skills, academic achievement, emotional health, and the likelihood of drug use after divorce. Researchers can examine the influence of both genetics and environment in looking at biological families. The behavior of children who are adopted cannot be attributed to the family genes. O'Connor and colleagues found that children in biological families who had been through divorce by the child's 12th birthday were more likely to exhibit behavior problems including aggression, delinquency, depression, anxiety and withdrawal than children whose parents were not divorced. These children's schoolwork and social lives tended to suffer more, and they were more likely to use drugs earlier.
    Like the children of biological parents, adopted children of divorce had more behavior problems and used drugs earlier. Significantly, though, there were no differences in academic achievement and social skills, the study found. Because the effect of divorce on children in the adopted and biological families was different, there is reason to suspect some genetic component in determining how children cope with divorce, O'Connor's group suggests. The researchers plan to keep following the same group of children to see how genetic factors might affect their lives over the long term, including their likelihood of dropping out of school and of getting divorced in adulthood.

Connecticut Panel Urges More Funding to End Mental Health `Crisis'
Associated Press, 7/7/2000

HARTFORD, Conn.--A panel appointed by Gov. John G. Rowland to repair the state's troubled mental health care system says a major investment is needed to bring treatment to those in need. The system is crippled by inadequate public funding, cost-cutting by managed care companies and a rise in the number of people needing treatment, the Blue Ribbon Commission on Mental Health said in its 205-page report. The result is long lines of patients waiting to get into psychiatric wards and emergency rooms and long lines of patients waiting to get out, the panel said. Children with mental health problems languish in detention cells and thousands of people live in homeless shelters and prisons without treatment.
    The commission recommends the governor and Legislature increase funding across the spectrum of services for children and adults. That includes creating housing programs and alternatives to jail for adults; expanding community-based services for children; and increasing Medicaid reimbursement rates. The panel also recommends that the state expand the capacity of Whiting Forensic Institute in Middletown, and that it bring home all 350 children currently being treated out of state. Commission members acknowledged that the recommendations could be costly, but said the discussion should focus on how best to solve the problems. ''Once you put a price tag out there, that becomes the discussion how many X-millions are needed to fix the mental health system,'' said Dr. Wayne Dailey, a spokesman for the state Department of Mental Health and Addiction Services and one of the main authors of the report. They are also arguing that the solutions are urgently needed.
    ''Is there a crisis? Yes. Twenty percent of the people in the state of Connecticut have some form of mental illness,'' said Mental Health Commissioner Thomas Kirk, a co-chairman of the commission. ''If this was another kind of illness people would say, `My God! We have an epidemic!''' Officials now estimate that for every person in Connecticut receiving psychiatric care there are at least two others who need help they're not getting. And the numbers are growing 600,000 adults with some form of mental illness and about 85,000 children. Because the commission was composed of patient advocates as well as state officials, the report also addresses broader issues, such as refocusing the state's philosophy on recovery and prevention rather than just treatment. ''Until every person in this room believes in recovery, we will not change this system,'' said Yvette Sangster, a patient advocate.

Yale Study Examines Links Between Schizophrenia and Smoking
Diane Scarponi, Associated Press, 7/7/2000

NEW HAVEN, Conn.--A Yale School of Medicine study is expanding upon what scientists know about the link between schizophrenia and nicotine addiction. The study may help scientists develop drugs to treat schizophrenia and to help people stop smoking, said Dr. Tony George, the lead author of the study. ''If we can develop drugs that act like nicotine but don't have associated problems, then we might be on to a new family of antischizophrenia drugs,'' George said Friday. Doctors have long noticed that almost all schizophrenics are heavy smokers. They have tried to find out why so they might understand what is going on in a schizophrenic's brain. In schizophrenics, cognitive functions in the higher part of the brain are impaired, leading them to have trouble with memory, concentration and reason. At the same time, the dopamine, or ''reward'' pathways in the lower part of their brains, are operating on overtime, making them susceptible to addictions and risky behavior.
    The problem is that too little dopamine activity is going on in the front of the brain, where the cognitive functions lie. This leads to too much dopamine activity in the lower part of the brain, leading to paranoia, addictions and compulsions, George said. The study, using rats, showed how both dopamine pathways in the brain are linked to other reward pathways called opioid pathways. Both kinds of pathways are receptive to nicotine. By smoking, schizophrenics may be stimulating activity in those pathways and improving their cognitive ability. When rats were injected with a substance that blocks opioid systems, the nicotine's effects also were blocked.
    George said the finding shows the link between the two systems and raises the possibility that drugs could be developed to exploit it.  ''If there's a common biological explanation to nicotine addiction and schizophrenia, related to opiate pathways, maybe a drug to block opiate pathways would be effective in treating nicotine addiction and schizophrenia,'' George said. Dr. Gregory Dalack, who also has studied the affects of smoking on schizophrenics at the veterans hospital in Ann Arbor, Mich. and the University of Michigan, said this study adds to the understanding of the complicated interaction between nicotine and the brain. "It's a complicated system,'' Dalack said. ''A great deal of this still needs to be understood. These animal models are helping to tease out what is going on.''
    The study was funded in part by the National Alliance for Research on Schizophrenia and Depression. ''Hopefully, what comes out of this is there will be a chemical, a treatment that will help them maintain a more comfortable personality,'' said Constance Lieber, president of the group. The National Institute of Drug Abuse and the National Institute of Mental Health also helped fund the study, which appears in this month's issue of the journal Neuropsychopharmacology.

For Prozac, a New Name and Use
Susan Okie, Washington Post- 7/7/2000

Prozac, the world's best-known antidepressant, was approved yesterday by the Food and Drug Administration to treat women who suffer from severe mood swings, irritability and various other symptoms before their menstrual periods. The drug's maker, Eli Lilly and Co., plans to market it for that purpose under a new name--Sarafem--to send a message to women and their doctors that the condition, medically known as Premenstrual Dysphoric Disorder, or PMDD, is different from depression. As many as 3 million American women may suffer from PMDD, which is estimated to affect between 3 percent and 5 percent of women during their reproductive years. Although up to 70 percent of women are bothered by at least some complaints--such as irritability or bloating--preceding menstrual periods, those with PMDD represent the extreme end of the spectrum. To qualify for the diagnosis, a woman must have at least five symptoms on a monthly basis that are severe enough to interfere with her work or social functioning. The possible symptoms--including mood disturbances, difficulty concentrating and physical problems such as headaches or weight gain--generally occur in the latter half of a woman's monthly cycle.
    Fluoxetine (the chemical name for Prozac) was proven effective for women with PMDD in two studies in which subjects were treated either with the drug or with a placebo. In one study, those who received 20 milligrams of fluoxetine daily reported a 36 percent reduction of their symptoms, on average, while women taking the placebo had a 7 percent reduction, said Thomas P. Laughren, the FDA's team leader for psychiatric drug products. "That effect is pretty big" compared with what is usually seen in such trials, he said.
    One potential disadvantage for women who want to take fluoxetine for PMDD is that the drug is to be taken daily throughout the menstrual cycle, not just on days when the user doesn't feel well. That's because in the studies that documented fluoxetine's effectiveness, women took it daily for up to six months. Researchers are studying whether fluoxetine will help women with PMDD if they take it for only part of the month, said Laura Miller, a Lilly spokeswoman. The studies also excluded women who were taking birth control pills, so the drug's effectiveness for PMDD in such women isn't known. Laughren said women who remain on fluoxetine for longer than six months should be periodically reevaluated by their doctors.
    Fluoxetine belongs to a class of drugs called selective serotonin reuptake inhibitors (SSRIs), which work by altering levels of serotonin, a chemical that transmits signals between nerve cells in the brain. The first studies suggesting that SSRIs helped women with PMDD appeared a few years ago, and Laughren said some doctors are already using Prozac and related drugs for that purpose. Side effects of fluoxetine experienced by some women in the studies included nausea, fatigue, nervousness, dizziness and difficulty concentrating. Some women on SSRIs also report reduced sexual desire or satisfaction. "Certainly, there are women for whom premenstrual symptoms are severe enough that it is a really significant problem, and it may be worth the choice to medicate on a daily basis," said Amy Allina, program director of the National Women's Health Network. But, she added, "we don't want to see antidepressants that have other serious side effects used as a first line of treatment.

Treatment of Choice for Insomnia
Kathleen F. Phalen, Washington Post 7/7/2000

Nearly 62 percent of Americans experience some type of sleep problem several nights a week, according to a recent poll by the National Sleep Foundation (NSF). Prominent among these problems is insomnia, which the National Institutes of Health defines as difficulty falling asleep, waking up too early, or waking up frequently during the night and having trouble getting back to sleep. Insomnia can be caused by stress, noise, extreme temperatures, medication side effects, misuse of caffeine and alcohol, exercise, smoking or eating before bed. A person's biological clock can go haywire by starting to work a night shift or bringing a baby into the home. For women, hormonal changes during menstrual cycles, pregnancy and menopause can also severely affect sleep. Insomnia can last for just one night or drag on for years, and it can lead to depression, irritability, poor judgment and impaired concentration and memory. The American Academy of Sleep Medicine (AASM) says more than 35 million Americans suffer long-term insomnia and 20 to 30 million experience shorter-term episodes of sleeplessness.
    A majority of the people suffering from sleep problems told the NSF poll that they had not considered getting help. That's not wise, according to Thomas LoRusso, medical director of the sleep disorders program at Inova Fair Oaks Hospital and the Northern Virginia Sleep Diagnostic Center in Fairfax. "Once insomnia is chronic, patients become conditioned to not sleeping and the problem feeds on itself," he says, but even in such cases, "with behavioral therapy we can teach them new ways to sleep." Insomnia is often a symptom of such illnesses as arthritis, depression, kidney disease, heart failure, asthma, restless leg syndrome, Parkinson's disease and hyperthyroidism. That's one reason it's smart to determine the cause of sleeplessness: You may discover a second medical problem that needs attention.
    When no underlying cause is evident, Martin Szuba, medical director of the insomnia program at the University of Pennsylvania in Philadelphia, says he may refer the patient to a sleep laboratory for overnight tests. "Remarkably, most insomniacs sleep better when they come to the lab, because they are negatively conditioned to their own sleep environment," he says. Sleep labs measure air movement, oxygen levels, leg muscle movement and brain wave activity, according to Szuba, and the tests can rule out conditions such as sleep apnea, which is interrupted breathing during sleep.
    Phyllis Zee, an associate professor of neurology and director of the sleep disorder center at Northwestern University Medical School in Chicago, says we often misperceive how much we sleep. "If you wake up three or four times during the night, in the morning you think you didn't sleep at all," she says. "Really you probably slept about four hours." LoRusso offers insomnia patients several suggestions: Keep a regular sleep schedule; avoid napping; don't exercise in the four to six hours before bedtime; take the clock out of the bedroom; get up if you're not asleep after 15 minutes in bed. "It's not important what time you go to sleep, but keep a regular wake-up time, even on weekends and holidays," he says. "As soon as you get up, get into bright light. This helps set your biological clock." Szuba says it's important to avoid stressful activities in bed. "Don't bring work in there, don't fight with your spouse in bed," he says. "And 'white noise' devices--machines that make background sounds like waves or light rainfall--can also help."
    As for medication, both LoRusso and Szuba say short-term courses of the newer prescription sleep medications like Sonata or Ambien are very helpful because they do not have the side effects--memory loss and difficulty concentrating--common to other sleep drugs and they are fast-acting. "This is a significant advance over the standard sleep medicines," says Szuba. "They . . . can be taken in the middle of the night." Still, some doctors prefer an older class of prescription drugs, including Halcion.

Behavioral Changes
Joyce Walsleben, director of the New York University Sleep Disorder Center, says that if an insomniac has a bad night, he is likely to worry about it all day long. So she has her patients make a worry book. "For a half an hour each day, they write down all the thoughts in their head. When they go to bed, they can't go there because the worries are in the book." Walsleben, a psychologist, also uses a technique called sleep restriction. For a patient who thinks he needs a minimum of four hours of sleep and must be out of bed by 5 a.m., she says, "I might say, 'You can't go to bed until 1 a.m.' " Instead of thinking about how he can't fall asleep, the patient worries about being able to stay awake that long. This approach is very effective, she says, but it can take two or three weeks before the patient gets four hours of sleep. Once that minimum is achieved, she moves the patient's bedtime back in 15-minute increments until he is getting a full night's sleep. She has found the herb valerian effective in relieving anxiety and stress. "It has been very well studied in Europe," she says. "The problem is, here in the U.S., [production] is not well regulated" to guarantee purity and potency.

Alternative Treatments
Insomnia can be caused by a disruption of the body's yin-yang balance, says David Molony, a licensed acupuncturist, Chinese herbalist and executive director of the American Association of Oriental Medicine in Catasauqua, Pa. "If you're taking a lot of drugs or vitamins, that can suck up your yin," he says. "It's like the brain is spinning out of control." To correct this imbalance, Molony often combines acupuncture, herbs and dietary changes, like not eating ice cream before bed and avoiding spicy foods and caffeine.
    There has been considerable controversy about melatonin's effectiveness for insomnia, but Molony says the hormone, which is available without a prescription, works for many of his patients. A study presented last month by researchers from the Massachusetts Institute of Technology showed that melatonin improved the sleep of insomniacs who had low levels of the hormone at bedtime. Kava might also help, Molony says, but such herbal remedies are subtle. "They don't hit you over the head with a hammer, they tickle you with a feather," he says.

Resources
American Association of Oriental Medicine: 888-500-7999, www.aaom.org.
National Sleep Foundation: 1522 K Street NW, Suite 500 Washington, DC 20005; www.sleepfoundation.org.
American Academy of Sleep Medicine: www.aasmnet.org.
Treatment of Choice is a weekly description of mainstream and nontraditional therapies for common ailments. To ask questions or suggest topics for coverage, send e-mail to health@washpost.com (type "treatment of choice" on subject line) or faxes to 202-334-6471. You may also reach us by U.S. mail at Treatment of Choice, Health Section, The Washington Post, 1150 15th Street NW, Washington, DC 20071.

Advocate of Moderation for Heavy Drinkers Learns a Sobering Lesson
Sam Howe Verhovek, New York Times- 7/9/2000

SEATTLE--After she founded a self-help program called Moderation Management seven years ago, Audrey Kishline became a national spokeswoman for the notion that problem drinkers could be taught to cut back without abstaining altogether. Groups like Alcoholics Anonymous that favor abstinence sharply criticized her and the book she wrote, "Moderate Drinking: The New Option for Problem Drinkers." Now Ms. Kishline says she may well become a spokeswoman again, probably from behind prison bars.
    Having pleaded guilty to two counts of vehicular homicide after a binge drinking episode last March during which she became so intoxicated she barely remembers climbing into her pickup truck, Ms. Kishline said through her lawyer that she has a new message: "Moderation Management involves a lot of alcoholics covering up their problem." Ms. Kishline, 43, was driving the wrong way down an interstate freeway near Cle Elum, in central Washington, and smashed head-on into a car, killing Danny Davis, a 38-year-old electrician, and his 12-year-old daughter, La Schell. Prosecutors said her blood alcohol level was three times the legal limit. With her plea last week, Ms. Kishline, who is in a treatment program in Oregon, is almost certainly headed to prison when she is sentenced on Aug. 11. The prosecutor is seeking four and a half years, although the maximum penalty is life.
    Ms. Kishline declined a request for an interview, but in a statement she made with her lawyer at the Kittitas County Courthouse, she expressed profound remorse and described herself as "a housewife and mother who woke up in a trauma unit of a hospital on March 25th to find out that I am the cause of the deaths of two innocent people." But she added: I am giving this statement in a public forum because I pray that my story can touch at least one other alcoholic. When I failed at moderation, and then failed at abstinence, I was too full of embarrassment and shame to seek help. In self-pity I gave up and believed my nightly drinking at home could hurt no one but myself."
    Controversial through all the years that she wrote newspaper opinion page pieces and appeared on television talk shows, Ms. Kishline has again inflamed a debate over moderation versus abstinence by offering her own calamitous story as an example of denial in action. And many of those who debated her in the past have seized on her experience to warn about what they call the delusion behind the idea that alcoholics can be taught to drink without harm. "This dreadful tragedy might have been avoided if Ms. Kishline had come to this realization earlier," said Stacia Murphy, president of the National Council on Alcoholism and Drug Dependence, a nonprofit group based in New York City. "Unfortunately, the disease of alcoholism, which is characterized by denial, prevented this from occurring. While this does not excuse Ms. Kishline's actions, it provides a harsh lesson for all of society."
    But far from depicting Ms. Kishline as an example of the failures of Moderation Management, people involved with the organization note that she had also tried abstinence and failed. And the worst incident occurred, in her own depiction, after she had joined Alcoholics Anonymous. "Isn't it ironic that her most extreme case of intoxication came after she quit Moderation Management?" said Stanton Peele, a board member of Moderation Management who is a psychologist in Morristown, N. J. "A. A. didn't have the answers for her either." Indeed, despite Ms. Kishline's troubles, the concept of Moderation Management was recently accepted as a treatment technique by the Smithers Addiction Treatment and Research Center in Manhattan. Officials at Smithers, known for its treatment of celebrities like the baseball player, Darryl Strawberry, have decided to adopt Ms. Kishline's program as one approach. The willingness to try something new has been prompted, in part, by stricter managed care reimbursement standards, which have led to the closure of half of the nation's rehabilitation centers, say officials at St. Luke's-Roosevelt Hospital, which runs Smithers.
    Ms. Kishline founded Moderation Management in 1993 and published her book, subtitled, "The Moderation Management Guide for People Who Want to Reduce Their Drinking," a year later. An advertisement for the book said: "Based on her own unsatisfactory experience with abstinence-based programs, Kishline offers inspiration and a step-by-step program to help individuals avoid the kind of drinking that detrimentally affects their lives." Her program calls for 30 days of abstinence, and suggests refraining from drinking for at least three days a week. Overall, she wrote, women should not have more than three drinks a day or exceeding nine drinks a week; men, she said, should have nor more than four drinks a day or 14 drinks a week. Among tips to reduce drinking are alternating alcoholic with nonalcoholic drinks. Moderation Management, with chapters in 14 states and Canada, describes its aim as helping people who have experienced mild to moderate alcohol problems, but who are not alcoholics, reduce their drinking. The group says moderate drinking is a "reasonable and attainable recovery goal for problem drinkers." Among the tenets are: "Never drive while under the influence of alcohol."
    Alcohol treatment experts have clashed over the moderation approach, with some calling it useful for some kinds of drinkers, while others say it gives alcoholics the false and dangerous hope that they can learn ways to continue drinking. The group got national attention two years ago when a computer programmer confessed in an Internet chat site for group members that he had killed his 5-year-old daughter by setting his house on fire in a custody dispute with his former wife.
    Ms. Kishline cried in court as she pleaded guilty to the vehicular homicide charges. She had also been accused of hit-and-run driving for forcing another vehicle off the highway, but that charge was dropped. Now she is contemplating writing another book, stressing that moderation is not a viable option for people with serious alcohol problems, said her lawyer, John Crowley. During the proceeding, grieving relatives of Mr. Davis and his daughter watched, clutching pictures of Mr. Davis and LaSchell, who was killed 10 days after her 12th birthday. And they listened carefully to Ms. Kishline's statement afterward. "If it helps one person to stop, then go ahead, do it," Will Davis, Mr. Davis's brother, said of Ms. Kishline's new message. "But no matter what she does now, it's not bringing Danny back." Said another relative, standing nearby. "Its not bringing LaSchell back."

Speak, False Memory: A Book Review of "Freud's Megalomania" by Israel Rosenfield
Adam Phillips, New York Times Book Review- 7/9/2000

Freud showed us new ways of being curious about people's lives. And if his reticence about his own private life has been a provocation for some people, he has also helped these people by providing them with forms of suspicion, methods of investigation. He has told them where to look to find a scandal--in a denied (that is to say, shameful) erotic life and in the aggression of a wish for prestige. He did everything he could to show us how stagy we are, that we are in love with disguise and dressing up; that we are at our most ingenious in our concealment of ourselves. It would not have been news to Freud--as Israel Rosenfield intimates in his fascinating first novel, "Freud's 'Megalomania'"--that people have something to hide or that the person one is most adept at hiding things from is oneself.
    People tend to be at their most Freudian in their unmasking of Freud. The wish to expose him or to discredit his work--to reveal him as scurrilous in his personal life and duplicitous in his professional life--seems merely to confirm one of his more useful suggestions: that we get to know people better by thinking of them as secretive. If the "megalomania" of Rosenfield's title trades rather archly on the so-called Freud wars, alluding to the notion that Freud's will to power was a little more pressing than his truthfulness, it is also a tribute to Freud as someone who saw the self consumed by its appetite for self-deception. Megalomania, as Rosenfield insists, one way or another, is the deception that there is not self-deception going on.
    In Rosenfield's novel, "Megalomania" refers to the title of a newly discovered, newly translated last work of Freud's, a manuscript he supposedly gave to his mistress as a legacy for their illegitimate daughter, whom he had effectively disowned. It is part of the very real artfulness of the novel that Rosenfield knowingly and amusingly exploits both the crassest of our suspicions about Freud and the most familiar of modern fictional conceits, the reported finding of a crucial document. If Freud's work is about the opportunism of memory, about the past as our most essential and uncertain resource, Rosenfield's novel uses a false memory--a fictional piece of Freud's past, something that never happened--to show and tell some very interesting things not simply about Freud and psychoanalysis but about the power of influential people in our lives. The novel urges us to look at ourselves looking at Freud and wonder what we want (or wanted) from him and what he wanted from us.
    "Freud's 'Megalomania'" is carefully framed to sustain our expectations, but also to keep us mindful of the pleasures of pastiche. We know this isn't real, but Rosenfield makes us want to know just how good he is going to be at inventing it. (We are put in the position, that is to say, of a certain kind of analyst.) The novel is introduced by a Prof. Albert J. Steward, who tells us the provenance of this manuscript--both how it fits into the turbulent trajectory of Freud's work and how this hidden chapter in the history of psychoanalysis is of a piece with a more troubled personal history. But Professor Stewart is no Freudian. The first paragraph of his introduction is one stark sentence, "I never liked Freud." Yet even this simplest of statements causes us to wonder whether he is referring to the work or the man.
    Indeed, at the very beginning of the novel it seems--wrongly, as it turns out--that we are being led by an all-too-familiar guide. "For a long time I believed," Stewart writes, that Freud "had been guilty of some of the worst intellectual brainwashing in history." But of course, like anyone telling us a story, Stewart has a number of complicated agendas. This in not to be merely the history of a lost manuscript, of a period in Freud's life. It also involves Stewart's own fraught relationship with another brilliant "Leader…Teacher… Master…Man," his professional colleague and friend Norman Dicke. Dicke is a neuroscientist and, like Freud, the inventor of another explanation-of-everything, called appropriately, Loop Theory. ("We are loops and we loop" is one of Dicke's many memorable pronouncements.) For Stewart, as for Freud in his final and fortunately discovered work, the question is not "Are these so-called geniuses, the Freuds and Dickes of this world, telling us the truth about ourselves and everything else?" but "What makes us so susceptible to these kinds of people?" How is it that we can be at once so stimulated and so hypnotized by their words?
    It is in "Megalomania" that Freud finally sees through--sees through into--the nature of authority. "We know too much," Rosenfield's Freud writes, with suitable irony, "to accept grandiose claims." What this Freud proposes in his last work--and the text of "Megalomania," which takes up almost half of the novel, is both a triumph of ventriloquism and itself a remarkable piece of lucid "Freudian" theory--is the concept of the "hallucinatory superego." "The hallucinatory superego," this Freud writes, "represents a special relationship between the individual and the totality of knowledge." This revelation becomes both a dismantling critique of Freud's own science and, by the same token, reinstates Freud as the supreme intelligence. "What we know and what we dare not say," he writes, "is that the worth of a man, his value, is his ability to fake it, to respond in circumstances in which his ignorance is total without revealing, for even a moment, just how ignorant he is."
    It is the megalomaniac--whom Freud in this book calls the psychotic and who is internalized as a hallucinatory superego, an Ubermensch authority figure--who seems to cure us of our consummate naivete, who makes us so hungry for instruction. The megalomaniac is the person who can convince us that he knows what matters. And knowing what matters makes us seem to matter. "It is not the content of the megalomaniac's thinking that is important to him," Freud writes in "Megalomania," " but his ability to create importance out of nothing. What is most striking about this fictional last work of Freud's--and it seems exactly right, as do so many of Rosenfield's judgments in this wonderfully contrived book--is that it is overtly autobiographical. It shows Freud making theory out of his most immediate life circumstances. And the novel is particularly poignant in its evocation, without cynicism, of Freud's ambition, and of the devastating impact of World War I on Freud's every impression. "Freud's 'Megalomania'" is, in short, a triumph of that false-memory syndrome called contemporary fiction.

Stress and the Art of Breathing
Carol Krucoff, Los Angeles Times- 7/9/2000

Think you know how to breathe? Try this simple test: Sit or stand wherever you are and take a deep breath. Then let it out. What expanded more as you inhaled, your chest or your belly? If the answer is your chest, you're a "chest breather," and like most people you're doing it all wrong. You may also be putting your health in jeopardy. The technique is so powerful that physician James Gordon teaches it to nearly every patient he sees, from people with advanced cancer to those crippled by arthritis to schoolchildren struggling with attention deficit disorder. He's taught it to refugees in war-torn Kosovo, to anxiety-plagued medical students at Georgetown University and to hundreds of health professionals who have attended his workshops on mind-body-spirit medicine. "Slow, deep breathing is probably the single best anti-stress medicine we have," says Gordon, a clinical professor of psychiatry at the Georgetown University School of Medicine and director of the Center for Mind-Body Medicine in the District of Columbia. "When you bring air down into the lower portion of the lungs, where oxygen exchange is most efficient, everything changes. Heart rate slows, blood pressure decreases, muscles relax, anxiety eases and the mind calms. Breathing this way also gives people a sense of control over their body and their emotions that is extremely therapeutic."

A Nation of 'Chest Breathers'
Obviously, everyone alive knows how to breathe. But Gordon and other experts in the emerging field of mind-body medicine, say that few people in Western, industrialized society know how to breathe correctly. Taught to suck in our guts and puff out our chests, we're bombarded with a constant barrage of stress, which causes muscles to tense and respiration rate to increase. As a result, we've become a nation of shallow "chest breathers," who primarily use the middle and upper portions of the lungs. Few people--other than musicians, singers and some athletes--are even aware that the abdomen should expand during inhalation to provide the optimum amount of oxygen needed to nourish all the cells in the body. "Look around your office, and you'll see so little movement in people's bellies that it's a wonder they're actually alive," Gordon says. "Then watch a baby breathe, and you'll see the belly go up and down, deep and slow." With age, most people shift from this healthy abdominal breathing to shallow chest breathing, he says. This strains the lungs, which must move faster to ensure adequate oxygen flow, and taxes the heart, which is forced to speed up to provide enough blood for oxygen transport. The result is a vicious cycle, where stress prompts shallow breathing, which in turn creates more stress. "The simplest and most powerful technique for protecting your health is breathing," says Andrew Weil, director of the Program in Integrative Medicine and clinical professor of internal medicine at the University of Arizona in Tucson. Weil teaches "breath work" to all his patients. "I have seen breath control alone achieve remarkable results: lowering blood pressure, ending heart arrhythmias, improving long-standing patterns of poor digestion, increasing blood circulation throughout the body, decreasing anxiety and allowing people to get off addictive anti-anxiety drugs and improving sleep and energy cycles."

New Focus on Alternative Therapies
There is little scientific research documenting the healing power of breathing, in part because its practice is so new in Western medicine. And unlike drugs or devices, breathing has no manufacturer who must sponsor studies to support its use. Increased interest in studying the effects of nontraditional healing therapies such as relaxation breathing led to the founding in 1991 of the Office of Alternative Medicine, now the National Center for Complementary and Alternative Medicine, at the National Institutes of Health. As a result, more medical scientists are beginning to examine the health impact of a variety of mind-body therapies such as meditation, guided imagery and Eastern exercises--yoga, tai chi and qi gong--which typically incorporate focused breathing. One of the few studies to examine a clinical application of yoga "belly breathing" found that menopausal women who learned the technique were able to reduce the frequency of hot flashes by about 50%. "The average breathing rate is 15 to 16 cycles [inhaling and exhaling] per minute," says Robert Freedman, a professor of psychiatry and behavioral neurosciences at Wayne State University School of Medicine in Detroit. "But with training, women can slow their breathing down to seven or eight cycles per minute, which can significantly reduce the frequency and intensity of hot flashes." Deep diaphragmatic breathing and other mind-body techniques can also significantly reduce symptoms of severe PMS as well as anxiety, depression and other forms of emotional distress, according to research by Alice Domar, an assistant professor of medicine at Harvard Medical School and director of the Mind/Body Center for Women's Health.
    To teach the technique, Domar has patients make a fist and squeeze it tight. "Then I ask them what happens to their breath, and they realize that they've stopped breathing," she says. "When we get anxious, we tend to hold our breath or breathe shallowly." Domar then shows patients how to breathe deeply into the abdomen, a process most women tell her runs counter to the "hold in your stomach" breathing they've done all their adult lives. Domar's favorite stress-reduction technique is a short version of this breath-focus exercise, which she calls a "mini-relaxation," or "mini." "You can do a mini when you're stuck in traffic, at a boring meeting, whenever you look at a clock or any time you pick up a phone," she says. "I have patients who do minis 100 times a day." Minis are also helpful for people with medical conditions, who can do deep breathing when they're having an IV started or undergoing chemotherapy.
    Pamela Peeke, an assistant clinical professor of medicine at the University of Maryland, incorporates breath work into her practice, in part by getting her patients to exercise. "It's very hard to walk and take little panicked breaths," says Peeke, who frequently takes patients out for a "walk and talk." In our stressed-out world, the fight-or-flight response that kept our ancestors alive has turned into a "stew and chew," contends Peeke, who studied the connection between stress and fat at the National Institutes of Health. If no physical response occurs after stress revs the body up for battle, chronically elevated levels of stress hormones stimulate appetite and encourage fat cells deep inside the abdomen to store what she calls "toxic weight." For this reason, Peeke says, "I'm an absolute crazy person about getting people to move." She encourages Eastern movements, such as yoga and tai chi, which rely on taking deep abdominal breaths. But she particularly urges patients to do aerobic activity to help neutralize the effects of stress. "When people learn to breathe properly, they can calm themselves," she says. "Then the stew doesn't have to turn into a chew."

A Technique With Many Applications
In hospitals, breathing techniques once were taught only to women for use during childbirth. Today, some hospitals have begun teaching relaxation breathing to patients of both sexes and all ages being treated for a wide range of conditions. At the Washington Hospital Center in the District of Columbia, nurse Julie Oliver incorporates breath work into support groups she leads, including one for people with congestive heart failure and another for parents of babies in the neonatal intensive care unit. "Using the breath to quiet the body can be very powerful," says Oliver, who is clinical manager of the hospital's guided imagery program. "Babies, especially premature babies, can sense how the mother and father feel," Oliver says. "If the parents go in full of muscle tension and start jiggling the baby, the baby gets too stimulated, and the staff may need to tell the parents to back away, which adds to everyone's stress."  Oliver had a chance to practice what she preaches recently, when her newborn stayed in intensive care for three days of observation.   "I was so anxious to see Joseph, I found myself getting all wound up," she recalls. So Oliver took a minute to do several relaxation breaths, combined with positive thoughts. "I was able to go in and take Joseph in my arms in a much quieter state of mind," she says.  Conscious breathing also was a part of her delivery. "Focused breathing pulls your attention away from pain and what's going on in your body," says Oliver, who teaches the technique to heart patients about to undergo procedures in the cardiac catheterization lab. She also teaches breathing to staffers. "It's an ideal form of stress reduction," she says, "because it doesn't take any time away from work, and you can do it anywhere."

Adultery Fallout: When a Parent Strays, Children Find Themselves in an Unhappy Spot
Vernonique Mistiaen, Chicago Tribune - 7/9/2000

Around his 12th birthday, David began to develop some obsessive nighttime rituals. He wouldn't go to bed before he had brushed his teeth many times; the water had to be the exact same temperature and the toothpaste a very precise amount. The whole process would take a good 15 minutes. Then David would insist that all the TV channels be set in a certain way. Every night the rituals became a little bit longer, a little bit more elaborate. And every night his father -- the only one who could settle David down -- had to stay at home a little bit later, which posed a problem because he worked as a club manager at night. Frustrated and bewildered, David's parents eventually took him to a therapist.
    "It seemed to us that David was carrying a secret," says Janet Reibstein, who treated him. "It also soon became clear that his parents had problems in their marriage," says Reibstein, a psychologist, psychotherapist and lecturer in social and political science at Cambridge University, England. "Once his parents came to treatment for themselves, David suddenly got better. He didn't have to keep his father at home." David had seen his father with another woman, Reibstein says. He was not quite sure what was going on, but instinctively felt she was taking his father away from his mother, and David wanted to keep him at home as long as possible. "Nobody had mentioned the affair -- the mother wasn't even aware of it -- yet, it seemed like David was bearing the symptoms."
    Julia Cole, a psychosexual therapist and counselor with Relate, the largest relationship guidance service in the United Kingdom ( www.juliacole.org ), is not surprised. Children rarely remain unaffected by their parents' affairs, she says, even when the liaisons are kept secret or at least hidden from the children. "Children are sharper emotionally than adults give them credit for. They pick up signs -- parents might be colder or more argumentative. They absorb the atmosphere like sponges. . . . Some couples I have seen describe the affair as being like a cancer eating away at the heart of their family. A child will have an awareness of that."
    Lisa Novelli's mother had two affairs when Lisa was a teenager. She and her older brother reacted very differently: "As I hated my father -- he was a terrible bully -- I was delighted," Novelli says. "My mother had always been a stoic, silent, long-suffering woman, who had never shown her criticism of him before." Novelli's brother, however, was devastated and very angry with his mother. "He was furious that our family unit was threatened by my mother's behavior. When my mother left he did not speak to her for five years, and even now at the age of 36 refuses to talk about what happened." About the impact of her mother's affairs on her own relationships, Novelli, who lives in St. Albans, England, says: "I have never had problems of `trust' or jealousy in any of my relationships, and feel, if anything, I am more likely to stray, looking for the `ideal partner.' "
    People usually think of an affair as a relationship triangle involving a couple and a third person, says Cole, author of the book "After the Affair," just published in the United Kingdom. "But it's more accurate to describe an affair like a stone being thrown into a pool. It creates ripples: Many other people are affected -- parents, in-laws, friends -- and those who are affected the most are the children."  Cole's views are backed up by a recent survey of more than 1,000 British men and women conducted by Relate and the women's magazine Candis. More than half of the respondents to the survey believe their children would be distressed and damaged if they strayed. (A quarter admitted to having had at least one affair. Among men, however, a third say they have had a liaison.) Of those who have had affairs or observed them in others, 35 percent noticed that the children became withdrawn; 31 percent of the childrencried more often, and 25 percent became more aggressive. Others reported problems such as truancy from school, eating disorders and running away from home.
    The impact of an affair on the children will depend on the type of romance, the circumstances, how parents handle it and the age of the children, Cole says. "But typically young children will regress. They may go back to wetting their bed and being clingy. Older children might become aggressive or withdrawn." Reibstein, however, believes that it is sometimes possible for people to segment affairs and marriage so successfully that children may not be affected, just as spouses may not. "Some parents can really keep affairs sealed off. I can think of a number of people who told me, `I was astonished to find out when I grew up that my father or my mother had an affair.' " Children, of course, will be distressed by marital disharmony, Reibstein acknowledges. "But then it is primarily what is associated with having the affair -- be it depression, preoccupation, discord, loyalty struggles or a threat to the marriage's survival -- which upsets children." When the affair bleeds into the marriage, however -- either that the liaison is discovered, the marriage is becoming unstable or the children instinctively know that someone else is taking their father's or mother's affection -- the impact might be devastating and long-term, Reibstein warns. "Young children will be affected because their need for time and attention might be subverted by their parents' marital drama. Older or adolescent children will be affected in more subtle ways: Their trust and belief in stable partnerships might be shaken." Even adult children might be affected by discovering their parents' affairs, Reibstein points out. "They may feel deceived and angry by their parents, duped by them into thinking they had a kind of marriage that they did not."
    Affairs -- more than separations -- open up fundamental questions about what a marriage is supposed to be, Reibstein explains.  "It is a crucible for questions of loyalty, fidelity and boundaries around the couple," she says. Whether parents have affairs might influence how their children will conduct their own marriage, Reibstein says. "It is a script that has been laid down and they will play it in their own lives, however they interpret it." For example, she says, citing a case from her 1993 book "Sexual Arrangements: Marriage and the Temptation of Infidelity," Michael is angry at his father's flings, and the memory of having to comfort his mother still haunts him. Yet he feels his father's behavior "made him want" to have affairs as well, although he feels very bad about them. Other people may react to their parents' affairs the other way and avoid them at all costs, she adds. "The script is still with them, but each script may call for a different denouement," Reibstein says. Cole also believes that parents' affairs influence their children's own relationships in the future. "The building of trust between children and their parents is the foundation to learning how to trust other people, and it will affect how they develop their own relationships later." She adds: "If your parents have problems trusting each other -- and affairs are primarily a breach of trust -- when you grow up, you may have problems on your own." You cannot escape the fact that problems between parents will affect their children," warns Cole. "If you say it won't happen, you are deluding yourself. All you can do is minimize the damages."

What Parents Can Do When Delivering the Bad News
Whether your children are small, teenagers or even adults, they want to see you as a caring person who would not willingly deceive another. "So telling your children that one of you has had an affair may be one of the most difficult tasks you ever have to undertake," says Julia Cole, a psychosexual therapist and counselor with Relate, the largest relationship guidance service in the United Kingdom. But it is much better that they hear it from you than from a friend on the playground who has heard it from their parents. Children may also intuitively feel that something is wrong. "When children don't get clear information about what's going on, they are left with their own interpretations of what is happening. They will feel confused, unsafe and often will blame themselves for the affair whether or not they know what is going on."
    What is the best way to tell your children you or your partner has an affair? Here are a few suggestions from Cole and Janet Reibstein, a psychologist, psychotherapist and lecturer in social and political Science at Cambridge University, England.
- "Be prepared to do it together, don't blame one another, and don't involve the child in a loyalty battle with statements such as: `He did this to me,' " Reibstein says. Cole agrees: "Tell them together and as a couple. If you tell just one child at a time or leave breaking the news to one partner alone, your child may feel he should take one partner's side against the other or keep the affair a secret from the other children, which is too heavy a burden for most children."
- Keep the information simple and put the affair in a context your children can understand -- and take responsibility for it, so they don't have to, Reibstein stresses. "For example, you could say: `We are having a hard time together, but we'll try to sort it out.' Depending of the age of the children, you could just name the emotional part without explaining the affair." Or, suggests Cole: "Explain that you have a close friendship with someone else and that this has caused you and your partner to feel unhappy." If you have not made up your mind about the future, don't make promises you may not be able to keep, Cole adds.
- Don't disparage your partner, however angry or hurt you may feel, Cole urges. "Your child needs to go on having a relationship with both of you whatever you feel. And you should never use your children as go-betweens for the two of you if you are not talking." It's also important not to cast your children in an adult role, she adds. "Some children may want to take sides or protect the partner who is left or hurt. It's not their role."
- Reassure your children you love them and offer lots of hugs and comfort. "They have to know that even in the worst situations they are still loved and cared for despite of everything," Cole says.
- If you are splitting up, she adds, keep your children abreast of any changes significant to them. "Your children will ask a lot of questions: `Are we going to leave our school, where are we going to live?' Adults feel rattled, too, but need to put their children first."

Heroin Blight: Drugs Getting Cheaper, Killing Younger Americans
Julia Campbell, ABC News- 7/10/2000

NEW YORK--Ricky Burrows, a young California-based musician who once had an obsession with the grunge band Nirvana, got hooked on heroin at 17. "Heroin has a fascination about it before you do it,’’ says Burrows, now 21. "I watched my friend do it, and the next thing I know, I’m the one with a needle in my arm." Heroin took Burrows, like an increasing number of young Americans, on an addictive ride and nearly killed him before, after eight months of addiction, he was able to kick the habit for good. Less than 2 percent of young people ages 12 to 17 has ever tried heroin. But the drug, now cheaper, more accessible and more potent, is fast surpassing cocaine as the drug of choice in many communities, especially among teenagers and young adults in the nation’s white, upper- and middle-class suburbs and small towns. Even more alarming to health officials is how deadly the drug has become.

Portland & Seattle: A Special Report
Heroin use has reached unprecedented levels in some cities, like Portland, Ore. and Seattle, where the number of fatal overdoses has continued to climb year after year in the last decade. The growth in heroin use and deadly overdoses in the two Northwestern cities has risen so sharply in the last decade that the Centers for Disease Control in Atlanta will publish a report later this month detailing the phenomenon. In 1999, Portland experienced its highest number of heroin-related deaths ever at 114 — nearly triple the number of fatal heroin overdoses a decade earlier, and more than three times the number of homicides there last year. In Seattle, the number of people who died from heroin overdoses in 1999 more than doubled over the last 10 years. "Clearly, the very large increases in [death] rates are extremely troubling," said Alonzo Plough, director of public health in Seattle and a contributor to the CDC report. Dr. Steve Jones, a leading CDC epidemiologist who is helping to publish the findings in the CDC’s Morbidity and Mortality Weekly Report, acknowledged that the report would soon be out, but declined to comment on the latest findings.

Heroin: A Drug of Choice for the Young
When a string of deadly heroin overdoses among teenagers hit Plano, Texas, three years ago, it was one of the first shocking signs that the once-taboo drug had found a new audience — young, chic, middle-class kids looking for a new high — and that it was killing them. Nineteen young people have died from heroin overdoses in the wealthy Dallas suburb since 1997. The national spotlight has since faded from the Texas community, but the addictive drug has quietly continued to bore a destructive path across the nation.   As the price of heroin on the street continues to drop and its purity rises, health experts say that teenagers and young adults are finding the drug more attractive. In a decade, the average age of first-time heroin users has dropped dramatically, from 27.4 in 1988 to 17.6 in 1997 — the youngest average since 1969. People scared off by the thought of injecting the drug, young people — and increasingly more girls — will try heroin now by snorting it, experts say. And the drug that was once thought of as the scourge of the inner city is becoming ever more popular with other segments of society, particularly America’s small towns and suburbs. "The idea that it only happens on a street corner in some godforsaken part of Manhattan is just wrong," said Terry Horton, the medical director and vice president of Phoenix House, a national drug treatment organization. "We have young, white suburban kids coming into the inner city neighborhoods and into the needle exchanges,’’ adds Rick Curtis, a professor at John Jay School of Criminal Justice, who is conducting a five-year study of heroin use in New York City. "They are not only using heroin but they are using it in fairly risky ways.’’ In contrast, there is virtually no increase in heroin use among the city’s African-American youth, he said.

From Plano to Portland
From pockets of the country, like New Castle County, Del., where 71 heroin-related overdoses, including 10 fatalities, occurred in the first half of 1999, to central Florida, Carroll County, Md. and Chimayo, N.M., heroin has taken its toll on young users. In 1997 in Plano, one of the nation’s most affluent suburbs, teenagers were snorting or ingesting (in the form of a capsule) a new drug they knew only as chiva, said Carl Duke, a spokesman with the Plano Police Department. "Kids hooked each other on it at parties and they didn’t even know what it was," he said. It turned out to be a purer form of heroin than previously available, marketed by dealers as a new party drug. In places like Portland, the price to get high has more than halved in the last 20 years to about $20, even as incomes have risen, making the drug much more affordable to the city’s young people. "You can work a minimum wage job and scrape a little on the side and be a heroin addict and not do a lot of crime to support your addiction," said Gary Oxman, a health officer in Portland’s Multnomah County and another contributor to the CDC report. And in Seattle, 723 people have died of heroin overdoses since 1994, the year heroin-addicted Kurt Cobain, lead singer of Nirvana, died of a self-inflicted gunshot wound and brought national attention to the so-called "heroin chic’’ trend. While the number of deaths dropped slightly in 1999 in Seattle — Portland’s rate of fatal overdoses also shows recent signs of leveling off — the number of annual deaths remains extraordinarily high, Plough said. The health official says that he hopes that the city’s aggressive overdose prevention and education programs will help turn the tide. "The slight decrease from 1998 to 1999 gives us cause for hope that what we are doing is working," Plough said. "But we are far from declaring victory. We have a lot of hard work to do. But I think we are on the right path."

A Kind of 'Generational Amnesia'
Where the thought of heroin might horrify other generations, Horton said, many young people today have a sort of "generational amnesia" about the drug. "Kids don’t seem to have the sense of the danger," he said. In Portland and Seattle, the popularity of heroin in the mid-1990s as a recreational drug and its "heroin chic" image — the gaunt, edgy look of models laid out in fashion magazines — helped establish the drug’s foothold among the young in those cities, health officials said. "It used to be that you really graduated to [heroin] after years of heavy abuse,’’ said Gail Nettels, an English teacher at a California high school for students who have had problems with substance abuse. "Now, it’s almost like they will try it right away. It is the only thing left that has a mystique. Heroin is one of those things where they can really say ‘Nobody understands me. My problems are too big. I’m going to shoot up heroin.’ Sometimes I think it has a lot to do with the melodrama of being a teenager."

Convinced to Inject It
Ricky Burrows, who had been sent by his parents from his native San Bernardino County to a Los Angeles area home for young people with drug and alcohol problems, said he never gave it a second thought when an older addict introduced him to the drug. The man, an assistant manager at the home were Burrows lived for a while, was supposed to be helping him stay sober, Burrows said. "He came to me one night and said he was going to be sick if I didn’t help him get some," said Burrows, who took his friend to the corner of 6th and Alvarado Streets in downtown L.A. to score the drug. Burrows, who graduated from Henry David Thoreau High School, the school where Nettels teaches, and has remained sober for three years, says he had been drug-free for months when his friend encouraged him to try heroin. He tried to smoke it, he says, but was convinced to inject it instead. "The guy I was with got really upset," Burrows says. "In his mind, I was wasting it. I didn’t inject myself the first time. I basically just turned my head and put my arm out."

Abuse Victims Are Guided Past Welfare Rule
Vicki Smith, Associated Press- 7/10/2000

BRIDGEPORT, W.Va. - Welfare laws force recipients to leave the house, get a job, and become self-sufficient - the very things batterers try to prevent their victims from doing. People who don't meet federal work requirements, regardless of the reason, can lose benefits. A program in the planning stages since 1997 is finally getting started, granting exemptions from the work rules to victims who disclose their abuse. Welfare caseworkers help identify victims, then refer them to programs offering support and guidance.   People who qualify can be exempted from work, training, or educational requirements, and can receive a check beyond the federal limit of five years. Exemptions last for six months and can be renewed indefinitely.
    ''West Virginia is one of only a handful of states to make a financial commitment to moving battered women through welfare reform,'' said Anne Menard, a consultant to the US Department of Health and Human Services. The state has used surplus money from its welfare program to hire what it calls a family violence option advocate in all 55 counties, as well as a full-time state coordinator.  It also is funding job training, parenting courses, and other services, for a total investment of $2.7 million. ''It's a visionary decision to provide this kind of funding,'' said Menard, who helped train the county advocates. ''The reality is, some states are very hostile to their welfare populations.'' The program also can exempt a parent from enforcement of child support or spousal support orders, both of which are required under welfare reform and both of which can escalate or renew abuse. Most women who are being abused are already working, Menard said. But those venturing into the work force because of welfare reform often see their abusers go to great lengths to maintain control.
    Advocates and welfare caseworkers are forging a new alliance through the family violence program, learning each other's job duties and restrictions as well as the dynamics of domestic violence. Already, bringing them together has paid off. During the training session, some advocates discovered why they had not been receiving referrals. In many cases, state Department of Health and Human Resources caseworkers were interviewing men and women together about their long-term plans for getting off welfare. ''They're not going to say anything if the guy's sitting right there,'' said an exasperated Sarah Thumm, Monongalia County's advocate. ''Caseworkers won't pick up on signs unless you have something as obvious as a big black eye.'' Initially, the decision of whether to interview people individually was left to the local caseworker. Soon, the state will make it standard procedure. Working out kinks like that is just part of the process, said Sue Julian, team coordinator at the Coalition Against Domestic Violence in Kanawha County. ''It has been very slow getting off the ground,'' she said of the family violence program. ''But it was really important for the state to take time to understand more thoroughly the possible implications of their policies."

Trading One Nicotine Fix for Another
Jessica Garrison, Los Angeles Times- 7/10/2000

Even before she gets out of bed in the morning, she's ready for her first fix. Eyes closed, sleepy fingers fumbling at the bedside table, she seizes the silver packet, expertly extracts a single white tablet and places it in her mouth. Dana Yudovin quit smoking 12 years ago, after a quarter-century of puffing a pack a day. But now she's hooked on the gum, gobbling up a dozen or more pieces a day. Sometimes she sleeps with the gum in her mouth, tucking it into a gap between her teeth where a removable dental bridge usually goes. Yudovin, 57, of Cambria, Calif., is among a growing number of Americans who have kicked one nicotine habit for another, albeit safer, one.
    Nicotine gum was intended as a temporary regimen for smokers as they attempted to wean themselves from cigarettes. But for nearly 10% of those who use the gum to quit smoking, it has become a habit of its own, according to Dr. John R. Hughes, a professor of psychiatry at the University of Vermont Medical School in Burlington who has studied nicotine addiction. Hughes and other doctors stress that with one exception, there is no evidence that regular use of nicotine gum poses any health risk. The exception is pregnant women, who risk exposing their fetuses to brain-cell loss and other developmental disorders. In large doses, nicotine can damage the cardiovascular and circulatory systems by raising the heart rate and blood pressure. Taken in the small, slowly delivered doses present in nicotine gum, however, the product "seems to have very few side effects," said Dr. Neal Benowitz a professor of psychiatry and medicine at the UC San Francisco medical school.
    Nicotine gum (which has been available over-the-counter as the brand name Nicorette since 1996 and was recently approved for sale as a generic product also) works by releasing nicotine into the bloodstream through the mucous membranes in the mouth. The amount of nicotine is small compared with the massive rush from a cigarette and is absorbed into the bloodstream much more slowly, but it's enough to reduce nicotine cravings in smokers trying to kick the habit, said Dr. Jack Henningfield, an associate professor of psychiatry at Johns Hopkins University Medical School in Baltimore. Many doctors, including Hughes, say the benefits of nicotine gum far outweigh the risks. Giving up smoking can add years to a person's life, while the chance of getting hooked on nicotine gum is fairly small and, for most, free of adverse medical consequences. Because ex-smokers can use the gum in the same way they once used cigarettes, turning to it when they are stressed or hungry or want to satisfy an oral fixation, researchers speculate that nicotine gum may be more habit-forming than other stop-smoking products, such as patches, that are available over-the-counter.
    The U.S. Food and Drug Administration approved nicotine gum for sale as a prescription drug in 1984. Sales of the gum rose from $60 million that year to $328 million in 1998. Three months ago, Watson Pharmaceuticals, a Corona-based company, received FDA approval to market a generic brand of nicotine gum. The company has said the gum will be sold under various names by large retailers at a slightly lower price than Nicorette. Nicorette costs about $60 for 108 pieces, and some regular users report spending more than $200 a month on their habit. (The gum does carry labels advising consumers that the product is not intended to be used for longer than 12 weeks without consulting a doctor. But many people ignore the advisory.)
    Meanwhile, researchers are developing an array of other products to assist smokers in quitting. Kenneth Warner, a professor of public health at the University of Michigan in Ann Arbor who studies the tobacco industry, says there are as many as 100 U.S. patents registered for non-cigarette, "nicotine-delivery systems," many intended to help smokers quit. Doctors still are uncertain whether nicotine gum produces a physical addiction or a psychological dependence. Patients may fear that if they stop chewing the gum they will resume smoking, Hughes said. "We see no problems from long-term nicotine gum use," said Mitch Nides, a psychologist and president of Los Angeles Clinical Trials, a private company that works with doctors on medical trials. Nides was a lead researcher in a 1987 study by the National Institutes of Health that set out to discover whether quitting smoking could slow the effects of chronic obstructive lung disease. As part of the study, Nides gave 350 local smokers unlimited supplies of nicotine gum for five years.  About 40% of the ex-smokers who tried the gum were still chewing a year later, he said. About 10% were still using it after five years.  Researchers were surprised initially to discover that some patients had transferred their nicotine habit from cigarettes to gum. They had believed that the very small amount of nicotine in the gum, plus the slow rate at which it entered the bloodstream, would not make it habit-forming. And scientists intentionally gave the gum an unpleasant taste to discourage long-term use. The patients didn't like the taste at first, Nides said. But over time, "they were like, 'Hey, this stuff tastes pretty good.' "
    For ex-smokers like Yudovin, the bother--and expense--of being hooked on nicotine gum is a trade-off she's willing to make to stay clear of cigarettes. "I tried several other nonsmoking programs, which did not work," Yudovin said. "I could not quit smoking and I was just about ready to give up, and then I found this." Yudovin, who began using nicotine gum as a participant in the NIH study, said she can't imagine giving up her chewing habit. "I am just so thrilled that I don't smoke. . . ." she says. "I plan to be on this for the rest of my life."

Though Many Kids Have Nightmares, Some Could Signal Unseen Problems
Javonna May-Mons, Fort Worth Star-Telegram-7/10/2000

Keisha Culp knows the fear all too well. While watching television one night last December, she was startled by her 3-year-old daughter's cries. Moving frantically through the halls, the Royse City, Texas, mother finally reached her daughter Briana's room and found her tossing and turning in bed, yelling the name of her 3-year-old cousin.  It was a nightmare. "I shook her and finally woke her up," Culp says. "She was trying to tell me what he was doing (in the dream), but I didn't understand what she was saying."
    Nightmares and children are like peanut butter and jelly; you can't have one without the other. According to Bruce A. Epstein, a pediatrician in St. Petersburg, Fla., 70 percent of children suffer from nightmares, and they are most common between the ages of 3 and 6. But what exactly is a nightmare, and how should parents handle them? Simply defined, a nightmare is a scary dream that frightens and usually wakes us. Nightmares occur during the rapid eye movement (R.E.M.) cycle of sleep, the point in which we dream. Like dreams, nightmares tend to correspond to personal distress. They may manifest as a real representation of a troubling issue, or as a symbol. Generally, nightmares are a combination of both, helping a child to work out issues that carry over from his waking hours.
    While most children's nightmares are nothing to lose sleep over, Ferber says that after age 5 or 6, recurring nightmares could signal a problem. "Regardless of his age, if your child's nightmares continue to be frequent and persist for more than one or two months, and if you can't identify and help him resolve the stress he is feeling, then you should seek professional help," he says.  Experts, including Dr. Richard Ferber, author of "Solve Your Child's Sleep Problems," also advise parents to determine whether their child has nightmares or night terrors, a hereditary sleep disorder. For children suffering from the more garden-variety sort of bad dreams, getting nightmares to go away is relatively simple -- but involves some time. Some psychologists say that comforting should be just the first step. In his book "Dreamcatching: Every Parent's Guide to Exploring and Understanding Children's Dreams and Nightmares" (Three Rivers Press, 1998, $14.95), Dr. Alan Siegel explains his remedy for recurring nightmares. It consists of what he calls the four R's: reassurance, rescripting, rehearsal and resolution.
    Reassurance is the most important of the four. It calls for comforting your child after he wakes up from a nightmare. You'll want to hold him and calm him until he is able to give you, if he's old enough, the details of his scary encounter. "Poetically, that breaks the spell of the nightmare," says Siegel, assistant clinical professor at the University of California at Berkeley's school of professional psychology. Enter the rescripting phase, creating a new ending for the nightmare. "For younger kids up through elementary school age, drawing the dream is very helpful because dreams are an incredible source of creativity," says Siegel, president of the Association for the Study of Dreams. "When you draw the dream, it breaks the spell, because you see it from a different perspective."  Another suggested part of rescription is the use of magical tools, Siegel says. The tools can be anything from a magic wand to a superhero and give kids a feeling of power.
    Siegel cautions against the use of violence in rescripting. He cites Ann Sayre Wismen, author of "Nightmare Help" (Ten Speed Press, 1990, $9.95), who says that suggesting the murder of a dream foe may also encourage violent solutions to life problems. He also warns against simply inventing a new ending to the dream without discovering the underlying problem that caused the dream. This is where the last two R's, rehearsal and resolution, come in.  Rehearsal involves putting rescripting to the test. Your child needs to review his new, happy ending and practice using his magical tools until he feels completely competent. In the last stage, resolution, parents work with their child to discover the source of the nightmare. By combining the three previous R's and deciphering the dream through exploration and brainstorming, parents and children can feel confident in overcoming emotional challenges.
    Siegel says the most important thing is never to say, "It's just a dream," because that "dismisses a fundamental, very powerful experience a child has had," he says. "You also don't want to say, 'Let's just create a new ending and that's the end of it,' because the problem that caused the dream may still be there." Parents should look at recent changes in their child's life that may be causing tension and distress, like a death in the family or a new school. For Keisha Culp, 3-year-old Briana's nightmare alerted her to daytime terror her daughter was experiencing because she was afraid of her cousin.