Cough Medicine: A Bad Trip That Kills
Robert Salladay, Los Angeles Times- 4/4/2004

SACRAMENTO — Some users claim to see aliens conjured from the collective unconscious. Others temporarily lose their ability to walk. Some have written stories on the Internet: "I felt my soul being ripped from my body," and, "Are you a vampire? No, I just met God." But it's not heroin or PCP they are taking. It's cough syrup. An underground network of abusers — hooked on the potent ingredients in cough suppressants and cold remedies — is thriving in California and across the nation, while police and poison control officials report more and more young people getting high from what they call "robo-tripping" and "skittling."
      Abusers have been getting high from cough syrup for five decades, ever since the main ingredient in modern cough medicines — dextromethorphan — was patented. But in recent years coroners have issued warnings about the practice and health officials have started tracking statistics on it for the first time as the stories stack up: a teenager commits murder and blames cough tablets; a mother loses her son and finds out too late he was a robo-tripper.
      Poison control experts point to a four-fold increase in abuse cases since 2000, mostly among teenagers and young adults who have developed their own lingo for the culture — robo-tripping refers to the use of Robitussin to achieve a high and skittling is derived from Skittles candy, which resembles some cough tablets. "We're now seeing it in middle schools. We're seeing it at an earlier age," said Det. Wayne Benitez of the Palo Alto Police Department. Authorities need to "make people aware this abuse is going on and that this is not just a passing fad," he said.
      The situation is alarming enough to some California officials that legislation has been introduced to prohibit the over-the-counter sale of products containing dextromethorphan to anyone under 18 without a prescription. No state has outlawed sales of cough medicine to minors so far, even though products containing dextromethorphan — and incidents of people abusing it — have been around since the 1950s. But this year, New York and California have started exploring a prohibition for minors. California law already prohibits the sale to minors of spray paint, etching fluid, glue and dietary supplements containing ephedrine.
      Health officials estimate that at least a dozen people have died from dextromethorphan abuse in recent years. The statistics are compiled from news reports across the country about accidents, psychotic behavior and violence linked to abuse of the over-the-counter drug.
      On July 16, Misty Fetko said, she entered her son's room like she always did — to kiss him awake and get him ready for the day. But he did not stir. He was dead. Only after she received an autopsy report and read her son's computer journals did Fetko discover that he had overdosed on highly toxic levels of a prescription pain medication that, to her surprise, was a key ingredient of cough syrup. Except for one empty bottle of Robitussin found in his room the year before, there were never any signs of drug use. Her son was 18, and on his way to college in just two days. Fetko said she had yet to discover how he came across the pain medication, Duragesic, but his journals indicated that he had tried robo-tripping several times. "Carl was very artistic and very musically gifted, and I think some of the attraction," suggested in his writings, was that he thought it expanded his artistic ability and his creativity, said Fetko, who lives in Ohio but is working with two Southern California groups on the medication abuse issue.
      In September, 19-year-old Nathaniel Bell was convicted of first-degree murder for stabbing Jose Felix-Martinez "amid a blaze of drugs in an apartment illuminated by only a strobe light," wrote the Wichita Eagle newspaper. Bell admitted to police that he had taken up to 16 Coricidin cold tablets, which contain dextromethorphan, also known as DXM, as well as beer and cocaine. Felix-Martinez was 22, and died of stab wounds.
      In Pennsylvania, a 14-year-old boy killed his only brother by smashing his head with a claw hammer, then turned up the music in his room to muffle his brother's cries. The boy had been "eating pills" all day — Coricidin HBP Cough and Cold tablets, the Pittsburgh Tribune-Review reported. The boy was convicted of third-degree murder and is serving a 20- to 40-year sentence.
      In rare cases, public health officials have reported deaths from DXM overdoses. But they usually have been attributed to mixing DXM products with other drugs. In late 2002, two central Ohio teenagers died within weeks of each other after ingesting Coricidin tablets and morphine. The Franklin County, Ohio, coroner issued a warning to parents saying the deaths "represented a new trend."
       The California legislation emerged from a "There Oughta Be a Law" contest sponsored by Assemblyman Joe Simitian (D-Palo Alto), who asked his constituents to suggest problems that should be fixed. This is the third year for his contest, which has prompted hearings on high gas prices and a new law, effective this year, requiring car headlights to be turned on whenever windshield wipers are used.
      Benitez and a colleague, Lt. Ronald Lawrence, convinced Simitian the issue was important after uncovering a suicide pact by three students who had planned to overdose on cough tablets. Benitez would write his master's degree thesis on robo-tripping.
      In large amounts, cough suppressants can cause extreme anxiety, hallucinations and misperception about the outside world. Some users have likened it to opium or PCP overdoses, depending on the level ingested. Dextromethorphan can be purchased through the Internet in powder form, but most people obtain the drug by buying or stealing medications that contain DXM — an array of more than 125 products such as cough drops, syrup and tablets. State poison control experts consider the most dangerous in large amounts to be Coricidin HBP, which contains an additional antihistamine that makes abuse far riskier than with other DXM products.
      Even though the first DXM product was introduced five decades ago, California poison control officials recently started tracking abuse cases reported through their hotline. The California Poison Control System said among patients ages 6 to 19, there were 58 cases of DXM overdoses in 2000; that jumped to 284 last year. Dr. Ilene Anderson, a clinical toxicologist and pharmacist with the California Poison Control System, called DXM abuse among teenagers "a serious problem. We've seen a significant increase in the abuse and overdose of DXM-containing cold products in the last four years." A survey taken over the last decade by the Drug Abuse Warning Network, a federal monitoring agency, has shown a steady number of DXM abuse cases over the years. In 1994, there were 2,274 overdose cases of cough suppressants reported by emergency room doctors, compared to 2,311 reported in 2001. Newer figures were not available.
      The abuse of cough syrup appears to come and go in cultural waves, from bored Utah teenagers littering school fields with empty bottles to hard-core punk rockers taking a "vacation" from reality. Others have sought out specific hallucinatory plateaus — there are four, depending on the dosage — where reality distorts, reaching a point where sometimes aliens appear, or the user hears voices. On one Internet site devoted to DXM, "Raoul" wrote: "I got caught in a nasty time-loop. I experienced Hell. I thought that my basement was the only existent Universe and Jason and I were doomed to live it out in this horrible state for all eternity. God was finally punishing us for our foolish sins."
      Brad Strode, a 22-year-old from West Memphis, Ark., said he visits the chat rooms to warn people about some of the dangers of DXM. Strode said he started taking DXM pills a few years ago, enough to get on the fourth plateau where he heard voices talking to him "I just tell them it's not something you want to take," Strode said. "It's not something that is going to make you a better person. It's going to end up with long-term damage. Ten years down the road, you aren't going to have a heart left."
      Simitian's bill, AB 1853, passed its first Assembly committee hearing last week on a 11-4 vote, suggesting that it will receive support as it makes its way through the Assembly and state Senate, which are controlled by Democrats. Gov. Arnold Schwarzenegger, a Republican, has not taken a position on the measure. Drug companies and store owners oppose the Simitian bill, arguing that it would keep legal products from people who need them. Pharmaceutical firms, such as Schering-Plough, which makes Coricidin HBP, have been working with the federal Partnership for a Drug Free America on DXM-abuse education programs for teenagers, including an Internet site on its dangers. Drug firms say they would like to see drug and grocery stores voluntarily put DXM products behind the counter if they notice a problem. "It's sort of a sporadic thing that has peaks and valleys — very small peaks," said Virginia Cox of the Consumer Healthcare Products Assn., the industry trade group in Washington, D.C. "We don't have any data on the problem, and I think that is something we need more information on."
      A Los Angeles police detective who works on juvenile narcotics cases said he has not noticed a dramatic increase in DXM abuse, mainly because parents usually call poison control centers or take their child to an emergency room rather than call police. Det. Eric Sage said he has been disturbed by recent TV media reports that he said is hyping the problem of DXM abuse among teenagers. "I hate to see too many laws thrown down," Sage said. "When people ask me why kids use drugs, there are a number of different reasons. It's rebellion. It's curiosity. It's boredom. If we start putting too many laws and you say, 'You can't do this,' the first thing they think is, 'Bet me.' I think the best way is to limit sales, which makes it harder for them to get it."

Psychiatrists Key in Recent Child Murder Cases
Associated Press, 4/5/2004

TYLER, Texas -- Andrea Yates and Deanna Laney were both loving mothers who home-schooled their children and gave them names from the Bible. Both also suffered from severe mental illness that ultimately led them to kill their children. The verdicts they faced, however, could not be more different.
     Yates is serving a life sentence for murder for drowning her five children in the bathtub in 2001. Laney, who smashed her sons' skulls with rocks last May, killing two of them, was acquitted last week by reason of insanity. Experts in Texas law, psychology and jury behavior say the opposite verdicts are largely due to strikingly different psychiatric testimony in the cases.
     Psychiatrists in Yates' case disagreed on her sanity. But all five mental health experts consulted in Laney's case -- including two for the prosecution, two for the defense and one for the judge -- agreed she was insane, or unable to tell right from wrong. ``It's a lot easier for the jury in a case like to that to find someone guilty by reason of insanity because they can rationalize `Who are we to question the uniform conclusions of all the experts here?''' said Brian Serr, a law professor at Baylor University. ``In the Yates case, when you've got the experts disagreeing, now you're leaving it up to the jury to decide which experts to agree with.'' Another potentially significant difference: The jury in Laney's case learned that she believed God told her to kill the children. Yates said she was prompted by Satan.
      Dr. Park Dietz, the psychiatrist who testified at Yates' trial that she knew her actions were wrong and therefore wasn't insane under state law, testified last week that Laney was a ``textbook'' case of insanity. He concluded that psychotic delusions made Laney incapable of knowing right from wrong during the killings -- the legal standard in Texas for insanity. Dietz called Laney's description of her actions ``the most consistent accounting'' he had ever seen in more than a thousand criminal insanity evaluations. He also considered the sources of Yates' and Laney's promptings to kill. He testified that the deeply religious Laney, who like other Pentecostals interprets the Bible literally and believes that God is infallible, believed she was right to kill her children because God would never order her to do wrong. But in Yates' case, he concluded that if she believed Satan ordered her to kill, she must have known it was wrong. He also saw Yates' attempts to conceal her murder plans as a sign that she knew it was wrong.
     Experts said the nature of the crimes may have also swayed jurors. As brutal as both cases were, it may have been easier for jurors to stomach beating children to death than drowning them, they said. Stoning has an obvious biblical significance and the beatings were over relatively quickly. But Yates had to hold each child under water an average of three minutes -- longer for those who came up for air. Jurors heard testimony that the last children were drowned not only in water, but vomit, urine and feces left in the bathtub by their struggling siblings.
     Finally, prosecutors in the Yates case picked a jury willing to deliver a death sentence, while prosecutors in Laney's case chose not to seek the death penalty. ``A death-qualified jury will be significantly less understanding, less sympathetic to the defense of legal insanity,'' said George Parnham, a lawyer for Yates.

Fatal Heroin Overdoses on Rise in Massachusetts
Associated Press, 4/5/2004

BOSTON -- Fatal opiate overdoses among teens and young adults tripled in Massachusetts over a four-year period, and hospitalizations have doubled as cheaper heroin floods cities and suburbs, according to the state Department of Public Health. In 2001, 54 Massachusetts 15- to 24-year-olds overdosed on opiates, which include heroin and similar drugs -- up from 17 in 1998. There were 2,532 people between 15 and 24 hospitalized in 2002 for opiate use, up from 1,174 in 1998. The public health department monitors rehab admissions, emergency-room visits, overdoses and hospital discharge data.
     ``In all of those indicators we are seeing significant increased use of heroin and OxyContin, particularly among younger kids,'' Michael Botticelli, assistant commissioner for substance abuse, told the Boston Herald. ``We're hearing that kids are moving very quickly from OxyContin to heroin.'' Lowell police Capt. Robert DeMoura said ``it can happen to anyone's kids.'' He described catching a thief breaking into a minivan, and discovering that the culprit was a former wrestler he had coached who had turned to heroin use. ``Don't for one minute think I'm not worried about my kids getting hooked up on heroin,'' DeMoura said.
     Even as the state wrestles with a heroin epidemic, the state could lose more than $9 million in federal aid for drug treatment as a penalty for three years of cuts to substance abuse services, The Boston Globe reported. The Department of Public Health has cut nearly $11 million from drug treatment, and drug and alcohol abuse prevention. Gov. Mitt Romney is proposing another $2 million in additional cuts for next year.
     States that receive funds from the U.S. Substance Abuse and Mental Health Services pledge to maintain consistent levels of support for drug treatment. The agency told Massachusetts late last year that because of the cuts, the state could lose $9.2 million from the $34.3 it was to receive for next year. ``The potential loss of another $9 million in substance abuse funding would be disastrous to the Commonwealth,'' said John Auerbach, executive director of the Boston Public Health Commission. Federal authorities, who denied an appeal from the state last month, said they have little choice. ``As much as it may pain us to this, it's the law,'' said Mark Weber, spokesman for the federal agency.

Study Links ADHD Drugs to Growth Delays
Associated Press, 4/5/2004

CHICAGO -- New research bolsters evidence that stimulants like Ritalin used for attention deficit problems may stunt children's growth, but it does not address whether the affect is permanent.
Children who took stimulants during the two-year study grew more than half an inch less and gained over eight pounds less than those who weren't medicated. The study involved 540 youngsters with attention deficit hyperactivity disorder, who were aged 7 to 9 at the outset of the study and were randomly assigned to receive common treatments including medication, behavior management and a combination of the two. Girls generally reach their final height around age 16 and boys around age 18, so it's too soon to tell if the growth delays continued or were permanent, the researchers said.
     American Academy of Pediatrics' guidelines that recommend treating ADHD with stimulants and behavior therapy say evidence collected by following youngsters into adulthood indicates the drugs don't cause any significant height reduction. Weight loss, however, is a known potential side effect from long-term stimulant use.
     The study, led by University of California at Berkeley researcher Stephen Hinshaw, was funded by the National Institute of Mental Health and appears in the April issue of Pediatrics. Initial results after 14 months of follow-up, published in 1999, showed that drugs alone or used with behavior therapy were the most effective treatment. The 24-month follow-up found that drug treatment with or without behavior therapy remained superior, though the effect diminished somewhat over time. The researchers attributed this in part to patients stopping or starting medication.
     ADHD, the most common neurobehavioral disorder in childhood, affects 4 percent to 12 percent of U.S. school-age children. Symptoms may include short attention span, impulsive behavior, and difficulty focusing and sitting still.

Study Details Midwest Binge Drinking
Associated Press, 4/5/2004

CEDAR RAPIDS, Iowa -- Despite the publicity, a new study shows Iowa's binge drinking problem isn't entirely in Iowa City. The Quad Cities is listed as No. 6 and Cedar Rapids is listed as No. 7 in binge drinking ratings out of 120 largest U.S. metropolitan areas surveyed in the study released in this month's American Journal of Public Health. ``I'm very concerned and surprised,'' said Melissa Walker, coordinator of the Underage Drinking Task Force of Linn County. ``Unfortunately, there's a lot of work that needs to be done.'' Binge drinking is defined as imbibing five or more alcoholic drinks over a few hours.
     Of those surveyed in the Cedar Rapids area, 20.6 percent said they had engaged in binge drinking recently. Of those between 18 and 34, 36.2 percent were recent binge drinkers. The study said the number was 13.8 percent for respondents 35 and older. The Quad Cities reported 21.1 percent overall and No. 18 Des Moines reported 18.2 percent. The study did not look at Iowa City, which has been identified as having a binge drinking problem in similar studies. Nationally, the overall rate is 14.5 percent, the study said.
     More emphasis should be placed on telling the public about the dangers of excessive alcohol use, said Barb Gay, director of prevention services for the Area Substance Abuse Council.
``Kids who drink early and drink quite a bit do (often) go on to have substance abuse problems later in life,'' she said.
     The survey, which relied on data provided by states to the Centers for Disease Control and Prevention and focused on those 18 and older, had bad news for the Midwest as a whole. Six of the top 10 metropolitan areas are in Iowa, Illinois, Minnesota, Nebraska, North Dakota, South Dakota and Wisconsin.
     The study, which used 1997 and 1999 data, did not address the reasons for heaving drinking in particular geographic areas. Over consumption has more to do with societal acceptance and the availability of alcohol, said one of the study's authors, Robert Brewer, of the National Center for Chronic Disease Prevention and Health Promotion. ``In general, I think we give people mixed messages about intoxication,'' Brewer said. ``People often regard getting intoxicated as something not serious.'' Local drinking ordinances, religious views and perceptions about drinking are all factors in determining binge drinking rates, Brewer said.

The Altered Human Is Already Here
James Gorman, New York Times- 4/6/2004

In the popular imagination, the technologically altered human being is a cross between RoboCop and the Borg. The hardware that would make such a mating of humans, silicon chips and assorted weaponry a reality is, unfortunately, still on back order. Many people, however, have already made a different kind of leap into the posthuman future. Their jump is biochemical, mediated by proton-pump inhibitors, serotonin boosters and other drugs that have become permanent additives to many human bloodstreams.
      Over the past half century, health-conscious, well-insured, educated people in the United States and in other wealthy countries have come to take being medicated for granted. More people shift to the pill-taking life every year, to the delight of pharmaceutical manufacturers. Indeed, drug sales suggest how willing people are to pursue better living through chemistry. Last year retail drug sales worldwide were $317 billion. In the United States alone, consumers spent $163 billion on drugs. In North America, the use of drugs that affect the central nervous system, antidepressants and others, increased 17 percent. No group has escaped. Last week the Centers for Disease Control and Prevention reported that 10 million children took prescription medication for three months or longer in 2002, and preschoolers, another study found, are now the fastest growing group of children receiving antidepressants.
      This is a social change on the same order as the advent of computers, but one that is taking place inside the human body. Just 50 years ago, according to a report by IMS Health, a company that tracks the pharmaceutical industry, the two biggest-selling over-the-counter drugs were Bufferin and Geritol. The prescription drug business was tiny. In 1954, according to IMS, Johnson & Johnson had $204 million in revenue. Now it is about $36 billion. In 1954, Merck took in $1.5 million in drug sales; in 2002, that figure was $52 billion.
      To look at it in another way, Americans take so many drugs that some researchers — Dr. Christian G. Daughton of the Environmental Protection Agency's National Exposure Research Laboratory in Las Vegas, for example — are worried about the effects on the environment. What does it mean if the sewers run rich with Zoloft? Or to be more precise, what might happen to fish eggs if the rivers soak up waste water with discarded and excreted pharmaceuticals and personal care products, like shampoo? No one has the answer yet, but the idea that what runs through our collective bloodstream is a potential environmental hazard makes you look at your medicine cabinet in a different way.
      In short, while the Six Million Dollar Man is still a fantasy, Pharmaceutical Man is already here, and largely unnoticed. Swallowing a pill at a business lunch is likely to elicit little curiosity. A high-powered executive who did not have blood pressure or cholesterol problems might be suspect. There are concerns about the widespread use of antidepressants, but they do not seem to have affected sales. In fact, the group of antidepressants that includes Zoloft is the third biggest class of pharmaceuticals by sales in the United States, totaling $11 billion in 2003.
      Drugs in the top two categories — statins to reduce cholesterol levels and proton pump inhibitors to prevent heartburn, gastritis, ulcers and other digestive problems — had sales of about $14 billion and $13 billion, respectively. Critics of the national medicine cabinet have noted that behaviors and physiological changes that were once simply aspects of life — menopause, the inability to keep still as a child, baldness, decreasing potency in old men — have been medicalized, turned into syndromes or diseases.
      Dr. Thomas Szasz, a psychiatrist who in the 1960's defined himself as far outside the mainstream by arguing that mental illness was a myth, recently wrote a book called "Pharmacracy," about the invasive rule of medicine as it defines our lives. Last fall, the President's Council on Bioethics issued a report called "Beyond Therapy: Biotechnology and the Pursuit of Happiness." The report included material on genetics and embryo selection, but it also addressed performance enhancement and behavioral drugs. One of its concerns was the way everything in life becomes a medical problem. When new technologies, including drugs, come through doctors, the report said, many aspects of life become medicalized, raising concerns that "the pursuit of happiness and self-perfection would become part of the doctor's business." The report also cataloged "other aspects of human life that formerly had little to do with doctors and hospitals: childbirth, infertility, sexual mores and practices, aspects of criminal behavior, alcoholism, abnormal behavior, anxiety, stress, dementia, old age, death, grief and mourning."
      One might argue that any extension of medicine should be welcome. The prevention of heart attacks is obviously a worthy effort. Antidepressants can ease anguish, which for many people who take them is overwhelming. In many countries of the world, people would jump at the chance to worry about having too much medicine; they don't have nearly enough of it. Yet some of the new miracles of the pharmaceutical industry are not intended to save lives, but to improve and prolong them.
      Ana-Maria V. Zaugg vice president of corporate strategic planning for IMS Health, said that there were two streams of change in pharmaceutical research and use. Acute care is giving way to chronic or preventive care — managing cholesterol levels rather than treating heart attacks, for example. At the same time, disease treatment is being extended to treatment whose goal is to increase well-being. Drugs for baldness, incontinence, sexual performance and the effects of menopause may be included in the latter category. Both trends are expected to increase, Ms. Zaugg said. Some areas that she is confident will grow are drugs to improve male sexual performance, anti-Alzheimer's drugs, and drugs for incontinence and osteoporosis. If new psychostimulants and anti-obesity drugs appear in the future, she said, they will quickly take off. Compounds that increase intelligence and greatly improve memory will undoubtedly be best-sellers as well.
      Whether or not the growing use of drugs has altered our essential humanity, there is now almost no bodily system that cannot be adjusted by them. Blood, respiration, the nervous system, hormonal regulation, muscles and bones, the cardiovascular system, reproduction, sexuality — drugs are available to nudge them all in one direction or the other. It is not unusual for someone to begin the day with a cocktail of antidepressants, statins and blood pressure medications.
      The result does not yet seem to be the epidemic of dull, well-managed emotionless humanity that some forecasters have worried about. For instance, among professionals in journalism and publishing in the New York metropolitan area, who no doubt take as much Zoloft per capita as anyone on the planet, it is no small trick to find someone who is either calm or happy. Perhaps in the future, stronger drugs will produce the well-sedated zombies that will make the streets of Times Square disturbingly docile and well mannered, but it has not happened yet.
      There are concrete results of the medicated life, however. Dr. Isaac Schiff, chief of obstetrics and gynecology at Massachusetts General Hospital in Boston, said he found that "most people, men and women who are in their 50's, are taking something every day." He added, "One of the reasons is that our life expectancy has changed dramatically. Our whole concept of aging is very different." Dr. Schiff said that many people in their 40's and 50's "are now taking medication to prevent diseases in their 70's." In the case of osteoporosis, for example, the point of taking medication at age 50 is to prevent a hip fracture at age 75 or 80.
      What that means for medicine is that as old problems recede, new ones arise. Dr. Neal L. Benowitz, professor of medicine and chief of clinical pharmacology at the University of California at San Francisco, said that doctors had seen a shift in "what you can expect to die from." There are fewer deaths from heart attack, he said, and more from congestive heart failure, cancer and Alzheimer's. One problem, of course, is that it is the well-off and the well educated who are most likely to take advantage of the many drugs available. Another is that need can be manufactured by advertising. Even children know from television that if you are sad and worried, there is a pill for you. If you have heartburn there is a pill for you. It is a lot harder to find out that there are other ways to feel better, physically and emotionally, than taking drugs.
      By and large, however, the pharmaceutical road is paved with pretty good intentions. The president's report addressed "the pursuit of happiness." A similar report on the dangers of computers and other hard technology might have a different subtitle — the pursuit of power, perhaps. Even the dystopian fantasies of cyborgs and the overmedicated are fundamentally different. Drugs are an easy way to contentment and the absence of pain — even if they are ultimately unsatisfying. Hardware is something else. It enhances the senses, increases strength, adds weapons. As a cyborg, you can be your own telescope, your own computer, your own gun. It may not be so bad that the pharmaceutical human is arriving first.

Jittery? Peevish? Can't Sleep? What Are You Drinking?
Richard Friedman, M.D., New York Times- 4/6/2004

The patient was led reluctantly into my office by his girlfriend. Over the course of the past month, she explained, Adam had become uncharacteristically nervous and snappish. He hardly slept, and when he did she noticed that his muscles twitched. Adam's own account did not differ from his girlfriend's. He was a graduate student and he needed to study for his qualifying exams, he said, explaining his irritability.
      I noticed during the consultation that Adam was sweaty and nervous and that the muscles around his eyes twitched. He had already seen his internist, who told him that his physical exam and routine lab tests were entirely normal. This is nothing more than stress, his doctor declared. In my office, Adam's resting heart rate was 110, which is on the fast side for a fit 31-year-old man. His blood pressure was mildly elevated at 140/80, but just talking to a psychiatrist can be nerve-racking for many people.
      After a review of his psychiatric history, which was entirely negative, I asked him whether he was using any recreational drugs. Aside from experimenting with marijuana as a teenager, he said he had not. I never stop at the first denial, so I inquired about specific drugs like cocaine and amphetamines, which are well known to cause anxiety states. "No way," he said, and I believed him.
      Maybe this was just plain old-fashioned anxiety. After all, Adam was facing enormous academic pressure in a prestigious institution, and he felt that his future was riding on the outcome of an exam. So I gave him some reasonable advice about dealing with stress, and sent him on his way with a clean psychiatric bill of health.
      Two weeks later, I got a call from Adam's girlfriend saying that he was worse than ever. When I saw him, he looked haggard and anxious, and I was convinced that I had missed something important the first time around. Did he have an undiagnosed medical disease? Covert substance abuse? Exposure to an environmental toxin?
      In painstaking detail, we reviewed his medical and psychiatric history, but nothing stood out. Exasperated, I asked him to tell me what he did from the moment he got out of bed until he went to sleep: activities, diet, everything. Then I got it. After the habitual two cups of Starbucks coffee, Adam set to work. So far, so good. But as the academic pressure mounted, he had to work longer hours, and that meant more coffee — a lot more coffee than he had ever consumed in his life. In fact, for six weeks, he had been drinking up to 10 cups of Starbucks coffee daily.
      That is a lot of caffeine, considering that each large cup contains on average about 375 milligrams, according to a 2003 study of caffeinated coffee published in The Journal of Analytical Toxicology. With 10 cups a day, Adam was turbocharged with nearly four grams of caffeine. So Adam was not just nervous about his academic work; he was also suffering from caffeine intoxication.
      How, you might wonder, could such a ubiquitous substance be toxic? With an average of one to three cups of coffee a day, most people get 100 to 300 milligrams of caffeine. With chronic exposure, though, people become accustomed to the stimulant effects of caffeine. In contrast, a sudden increase in caffeine consumption can easily produce caffeine intoxication. In general, more than 1.5 grams of caffeine a day can cause the typical symptoms of caffeinism: anxiety, insomnia, irritability and palpitations.
      Caffeine is far and away the most widely used stimulant in the world. It is actually a member of a class of compounds called xanthines that includes theobromine, which is abundant in chocolate and theophylline, the major xanthine in tea. Caffeine works by blocking the calming and analgesic effects of the neurotransmitter adenosine in the brain. In moderate doses, caffeine enhances arousal and performance. At higher doses, caffeine blocks a majority of adenosine receptors and can produce anxiety and hypersensitivity to pain.
      Of course Adam's response to caffeine was an extreme example. But the effects of this popular stimulant encompass a broad spectrum, from the pleasant activation of morning coffee to the extreme agitation and anxiety of caffeine intoxication. Judging from the sheer number of consumer products spiked with caffeine, one would think we were a nation of narcoleptics, desperately trying to stay awake. From "enhanced" water to sports drinks to dietary supplements, caffeine is a common additive. And as the food and supplement industries search for new stimulants following the recent ban on ephedra, it would hardly be surprising to find caffeine use on the rise. After all, the hectic pace of our modern life practically demands that we can switch ourselves on and off. Sure, we can stave off fatigue with caffeine, but sometimes nature pays us back richly — with anxiety and sleeplessness if we are lucky or caffeine intoxication if we indulge in excess.

A Smokeless Alternative to Quitting
Salley Satel, M.D., New York Times- 4/6/2004

For decades, public health advocates have championed harm reduction for people who cannot stop taking health risks — or do not want to. Needle exchange is a classic example. Intravenous drug users get clean needles because, the reasoning goes, contracting and spreading AIDS is worse than making heroin use a little easier.
      But harm reduction for hard-core smokers is another matter. At issue is a form of smokeless tobacco, a popular Swedish product called snus (rhymes with loose) that satisfies smokers' nicotine addiction with negligible health risks of its own. But to many foes of smoking, it is not a lifesaver, but the devil's instrument. Snus, moist oral tobacco, comes in a tiny tea bag. It sits discreetly between lip and gum. Because it does not stimulate saliva production, there is no spitting. Even better, there is no smoke. "It is the tobacco smoke, with its thousands of toxic agents, that leads to cancer, heart disease and emphysema," said Dr. Brad Rodu, a pathologist at the University of Alabama at Birmingham. Eliminate the smoke, and you significantly reduce the risk.
      Snus, a Swedish version of snuff, is especially attractive to smokers because it produces nicotine levels comparable to smoking. Gum and the patch administer too little nicotine to reliably prevent craving and withdrawal symptoms. The health benefits are impressive. Forty percent of Swedish men use tobacco products. Yet Sweden has the lowest rate of lung cancer by far. Why? Largely because of snus, which represents half of all the tobacco that Swedish men use. (The other half smoke.) Snus has not caught on with women.
      Smoking opponents should herald snus. But instead, the very notion of harm reduction inflames them. "It's like trying to play God trading oral cancer for lung cancer," said Dr. Gregory Connolly of the Massachusetts Tobacco Control Program. Over 20 epidemiological studies show that smokeless tobacco is far safer for mouth cancer than cigarettes. Even traditional smokeless products bring one-third to one-half the risk. Users of snus, which contains low levels of tobacco-specific nitrosamines, a carcinogen, incur a risk of developing oral cancer no greater than nonsmokers, the journal Tobacco Control reported last year.
      What about gateway effects? Clearly, if using smokeless tobacco turns people on to nicotine and they "graduate" to smoking, it fails as a public health strategy. But Sweden has the best record of smoking reduction in Europe. Moreover, the proportion of current smokers who are former snus users is far less than the proportion of snus users who once smoked. In short, snus has largely been a pathway away from smoking, not vice versa. Dr. Lynn T. Kozlowski of the biobehavioral health department at Penn State, found that more than three-fourths of men from 18 to 34 who used smokeless tobacco never went beyond it to cigarettes or had used cigarettes before using smokeless products.
      Swedish snus and brands of compressed tobacco like Ariva, Exalt and Revel are available in this country but are hard to find. Most smokers have never heard of them, and many doctors are unfamiliar with the products. The government, rather than clearing the air, is muddying it. Last year, the surgeon general, Dr. Richard H. Carmona, told Congress, "There is no significant scientific evidence that suggests smokeless tobacco is a safer alternative to cigarettes." This is simply wrong in the case of smokeless tobacco in general, and snus in particular. "Tips for Teens" from the Department of Health and Human Services answers the question, "Isn't smokeless tobacco safer to use than cigarettes?" with an emphatic — and erroneous — "no."
      "I suppose you could argue that shooting yourself in the leg poses less of a health risk than shooting yourself in the head," a former president of the American Dental Association, Dr. D. Gregory Chadwick, said. "But do we really need to have that discussion?" Yes, we do. Experts have for years endorsed harm reduction as a pragmatic last resort for addicts, because they are convinced of the relative safety that accrues to the user and society. No one disputes that quitting is optimal. But that is not practical in every case. Snus in particular, and smokeless tobacco in general, provide clear, lifesaving advantages over smoking that antitobacco activists refuse to acknowledge.

Patterns: Violent Games Teenagers Play
Eric Nagourney, New York Times- 4/6/2004

They may be rated as suitable for young teenagers, but many of the video games sold for use at home are hardly kid stuff. Researchers from Harvard analyzed 81 "T-rated" games and found violence in almost all of them: the number of "deaths" per hour averaged 122. Under the guidelines of the Entertainment Software Rating Board, an industry group, T-rated games are for children 13 and over. The study, led by Kevin Haninger, appears online in the journal Medscape General Medicine. The authors also published a report this year in The Journal of the American Medical Association.
      The researchers made no effort to judge the quality of the games, said an author of the study, Dr. Kimberly M. Thompson of Children's Hospital Boston. Nor did they spend much time discussing how the games might affect the young players (though they noted that studies had linked video game violence and aggressive behavior). Instead, they simply rated the videos for every act of violence. Ninety-eight percent of the games contained intentional violence, with 42 percent showing blood, they said. Sixty-nine percent rewarded players for killing characters or required them to do so.
      Dr. Thompson said she believed that many parents would be surprised at the violence. "You really have to pay attention not only to the rating but to what's actually in the game," she said. The researchers also said the ratings board should consider adding new categories, like the PG and PG-13 ratings of the movies. The board president, Patricia Vance, said in a statement that "current rating categories serve consumers well, with sufficient breadth to capture the wide range of content offered."

New Lesson for College Students: Lighten Up
Sara Rimer, New York Times- 4/6/2004

BRUNSWICK, Me. — It was intended as a statement against the kind of perfectionism that drives some Bowdoin College students to spend two hours a day on the treadmill: plastered all over campus recently were photographs of naked undergraduate Bowdoin women — or at least their bodies, as the pictures had been shot from the neck down — in all their short, tall, thin, not-so-thin, fit and unfit, anonymous, unairbrushed glory. Far from being shocked, Craig W. Bradley, dean of student affairs, said he supported the women's group that came up with the poster campaign — anything to get students to stop worrying so much about body image, grades, careers. Mr. Bradley, along with other college officials, has been telling students to get off the treadmill. Go for a walk, go surfing. Read a novel just for pleasure. Eat ice cream. Hang out with the knitting club. Find your passion.
      Bowdoin's efforts reflect the ever-increasing attention colleges across the country are giving to undergraduates' personal growth and emotional well-being. It has been more than a decade since colleges became mindful of the new generation of students arriving on campus with serious mental health illnesses. But these days, as they respond to the rising number of students seeking help for stress-related conditions on campus and the expectations of consumer-minded parents, many colleges are extending the therapeutic culture far beyond treatment for clinical depression and bipolar disorders. Private and public colleges alike have begun offering a wide range of services and activities intended to help students negotiate what used to be considered the ordinary rites of passage: homesickness, sophomore existential angst, romantic relationships. There are now free massages and dogs to cuddle in exam seasons, biofeedback workshops and therapists available to help students work through their first C.
      At Harvard, the training given to graduate students who live in the undergraduate houses has in recent years expanded to include ways to help students fight perfectionism — a theme on many campuses — as well as negotiate matters involving race, class and sexual identity. At Amherst College in Massachusetts, students can have unlimited sessions with the counseling center's therapists. They are free to discuss more mundane concerns like their futures and their relationships — with family members, roommates, boyfriends and girlfriends — as well as more serious issues like depression and eating disorders. Washington University in St. Louis has established stress-free zones during finals, where students can get chair massages and listen to New Age music. Addressing the notoriously poor sleeping habits of undergraduates, the university recently celebrated Sleep Awareness Week by handing out sleep quizzes and reminding residential advisers not to brag about how little sleep they can get by on.
      Kevin Kruger, the associate executive director for the National Association of Student Personnel Administrators, with nearly 1,500 members, said the new services were the natural extension of the awareness raised by students with serious mental health problems. "This movement is an indication of colleges trying to be more proactive," Mr. Kruger said, rather than waiting for students to "flunk out, have a breakdown or whatever the outcome is going to be."
      But many college officials also acknowledge that they are responding to the heightened consumer mentality of many parents. "If you're paying a lot, you expect a lot in return," said Craig McEwen, dean of academic affairs at Bowdoin, one of the nation's top liberal arts colleges. "Unhappiness is not something you're supposed to feel." Some college officials say that these services are not only driving up higher education costs but some may also be an extension of a therapeutic culture that has gone too far.
      While it is important that colleges talk about "the whole student," said Steven E. Hyman, the provost at Harvard, and the former director of the National Institute of Mental Health, "that doesn't mean they should all be in group therapy." Dr. Hyman said he also doubted the value of the biofeedback and massage, suggesting that it might be more helpful if students learned to organize their lives. "It's a difficult tightrope to walk," said Dr. Hyman, who is a psychiatrist. "There's a risk that we will medicalize what are really developmental issues: negotiating independence, deciding what your goals are in life, having the courage to explore your interests rather than follow the straight and narrow path of careerism. At the same time, we have to be very careful that we don't miss serious treatable illnesses like depression, anxiety disorders and eating disorders."
      Colleges have been steadily increasing the availability of treatment and counseling, and students have responded. At the University of Michigan, for example, the number of students seeking counseling has risen 22 percent in three years, said Todd Sevig, director of counseling and psychological services. Some college officials see the contradiction inherent in their new efforts to offset stress and encourage the joys of reflection and unstructured time. After all, it was multitasking, hyperorganized, résumé building behavior that helped some students get admitted to their schools in the first place.
      "We admit only the most over-scheduled children and we boast of how many sports they play, how many clubs they organize, how many hours of volunteer service they provide," said Elaine Hansen, president of Bates College, in Lewiston, Me., in her inaugural address two years ago. How then, she went on, could Bates encourage those same children to risk "moments of woolgathering, daydreaming, improvisation" that she viewed as an essential component of a liberal arts education? Ms. Hansen said she had thought about calling off classes on the spur-of-the-moment so everyone could enjoy, say, a glorious spring day in Maine. But, she said: "If we do it without a conversation first about why we're doing it, we're afraid people will just go to the library and get caught up."
      In his January letter to parents, Bowdoin's president, Barry Mills, expressed his concern about what appeared to be a national increase in stress-related conditions among college students. Expanding on the president's letter, Dean Bradley spoke to the college's trustees recently about creating a culture that emphasizes the joy of learning for learning's sake, "a culture that can itself ameliorate the anxiety many students feel about grades, jobs, grad school admissions." At the same, Bowdoin officials say they do not want their students to relax too much. "You still have to accomplish," President Mills said. "You still have to succeed. This is not about relax and schmooze your way through Bowdoin."
      Many students here said they welcomed the emphasis on the joy of learning. And many said they were having fun at college. But they were quick to point out the realities of the world they live in. Travis Brennan, a Bowdoin senior who wants to be a lawyer, said all his love of learning would not get him into a good law school. What he needs, Mr. Brennan said, are high law board scores. "You have to be mindful that you're operating in a larger system," he said.
      In the 1960's and 1970's, with students demanding liberation from administrators, colleges relinquished their role as in loco parentis chaperones. Now, some of the students who once told administrators to get out of their lives are parents paying high tuition and expecting colleges to smooth over everything from their children's relationships with roommates to grades. Colleges, in the meantime, are coaching their students on how to manage their overmanaging parents. At Austin College, in Sherman, Tex., Rosemarie C. Rothmeier, director of student services and counseling, coaches pre-med students who are afraid to tell their parents that they hate organic chemistry and do not want to be doctors after all. One piece of advice, "Don't drop the bomb at Thanksgiving dinner."
      Some college officials say parents must share responsibility for their children's difficulties in coping with the inevitable stresses of college. "Rather than seeing late adolescence as a time of learning by trial and error," Mr. Bradley told the trustees, "many parents put great energy into trying to eliminate the error." He suggested that perhaps parents were creating a generation of students afraid to take risks.
      Another factor contributing to stress is the high price of education. "If you break it down, it's about $75 a lecture," said Karen Jacobson, a Bowdoin senior, quoting a faculty member who had made the calculation based on Bowdoin's $37,950-a-year price tag. Ms. Jacobson said she had sought her mother's advice about taking a dance class. "She said, `Are you sure you don't want to take something more intellectual?' " said Ms. Jacobson at a meeting of the college knitting club. Ms. Jacobson said she figured her mother might have been thinking, quite understandably, that she was not paying that much so her daughter could take a dance class. "I ended up taking statistics," she said. "I realized I needed it for grad school."

FDA Sat on Report Linking Suicide, Medications
Elizabeth Shogren, Los Angeles Times- 4/6/2004

WASHINGTON - Ten months ago, when concerns arose about a possible link between children taking antidepressant drugs and suicide attempts, senior officials at the Food and Drug Administration ordered their leading expert to head up an examination of the evidence. When the government scientist filed his report last winter, however, his bosses decided to keep it secret -- even though it found that children who took the drugs were twice as likely to be involved in serious suicide-related behavior as those who did not.
      Instead of revealing the findings, senior FDA officials ordered more studies, which were not expected to be completed until summer. They also squelched plans to have the author, Dr. Andrew Mosholder, present his conclusions to an FDA advisory committee when it took up the issue in February. And in March, when the agency issued a warning about the possibility of problems for young patients taking the drugs, FDA officials said no conclusive scientific evidence existed on the link between antidepressants and potentially suicidal behavior by children. Officials said they based their action on anecdotal complaints from physicians and families that had been presented to the advisory committee. They gave no hint that their own chief expert on the subject had examined the results of more than two dozen clinical trials conducted by antidepressant manufacturers, and that he had found an unusually high correlation between their use and potentially suicidal behavior in young patients.
      The report still has not been made public, but news of Mosholder's conclusions first surfaced in a CBS News report last week. His findings were detailed in an internal FDA document obtained by the Los Angeles Times and authenticated by government officials. In defending their decision to hold back Mosholder's report, his superiors questioned the reliability of the data on which he based his conclusions. They suggested drug companies, which manufacture antidepressant drugs and conducted the clinical trials in order to market them, might have been too quick to count some behavior as potentially related to suicide -- that is, too quick to raise questions about their products. Among the kinds of actions the officials said should not necessarily have been counted as potentially suicide-related were instances of children who deliberately cut themselves.
      Some FDA officials defended the decision to sit on the report and seek more analysis of the data, but some psychiatrists and congressional leaders were angered that the agency had kept Mosholder silent. "Evidence that they're suppressing a report like this is an outrage, given the public health and safety issues at stake," said Dr. Joseph Glenmullen, a Harvard psychiatrist who wrote a book on problems with the drugs known as serotonin reuptake inhibitors, which alter brain chemistry to manage depression. "They've been claiming that there's no evidence. Here's the evidence."

Congress Asks for Data
Senate and House committees have ordered the FDA to hand over documents -- such as the ones obtained by The Times -- that might illuminate what the agency knew about the possible link between the drugs and suicidal behavior. They specifically asked for any of Mosholder's reports, e-mails, correspondence or notes on pediatric or adolescent antidepressant trials. These members of Congress are concerned that the FDA may be keeping information from Americans that would help them better assess the possible risks of taking antidepressants or giving them to children. "It would have been very wrong for the FDA to withhold any information it had about unintended consequences that might result from the use of antidepressants, especially for children and adolescents," Sen. Charles E. Grassley (R-Iowa), chairman of the Senate Finance Committee, said in a statement. "The public deserves to know of every possible risk so that family members can closely monitor any changes in behavior," he said.
      Suicide is the third leading cause of death in teenagers ages 15 to 19. From 1980 to 1997, the rate of suicide among this group increased by 11%. Suicide is rare but growing among younger children. The suicide rate for those 10 to 14 years old increased by 109% between 1980 and 1997, according to the Centers for Disease Control and Prevention. Since peaking in the late 1990s, suicide rates appear to be declining among teenagers, but remain a serious problem. Experts say depression is the leading factor in suicide.
      Depression affects 1 in every 33 children and 1 in every 8 adolescents, according to the National Mental Health Assn. Although only one antidepressant, Prozac, is explicitly approved by the FDA for children, doctors routinely prescribe others to their young patients, and the use of these drugs by children has been steadily rising. The antidepressant drugs -- Prozac, Zoloft, Paxil, Luvox, Celexa, Lexapro, Effexor, Wellbutrin, Serzone and Remeron -- are taken by 30 million Americans, according to some estimates. The first seven are serotonin reuptake inhibitors, and their sales in 2003 exceeded those of any other drug class except the group of painkillers that includes codeine. An estimated 7% of the Americans taking the medications are children. Drug use is tracked by the number of prescriptions written. A total of 2.7 million antidepressant prescriptions were dispensed for children younger than 12 and 8.1 million were written for adolescents in 2002, according to the FDA, although some individuals received more than one prescription a year.
      In studying reports from 28 clinical trials, most of them unpublished and thus not open to public inspection, Mosholder concluded the data showed a "statistically significant" risk of serious suicidal events among children taking the drugs. And he stressed that what he acknowledged were limitations in the data he was analyzing would not change his conclusion. "Finding a statistical association despite these limitations makes the finding difficult to dismiss," he wrote in one of the documents, which was authenticated by government officials familiar with the document. FDA officials would not comment directly on the documents.
      Dr. Robert Temple, associate director for medical policy at the FDA's center for drug evaluation, said Mosholder "thought those data were persuasive just as they were." But his superiors believed that it was "premature" to come to the conclusion that the drugs were linked to suicide, he said. Temple and other senior FDA officials think that some of the data from the drug companies were flawed because they were based on the firms' own decisions about what constituted serious suicide-related events. For instance, there were several cases of teenagers who cut themselves but were not planning to kill themselves. Still, those cases were counted as serious suicide-related events by the drug companies; senior FDA officials decided they should not have been counted. The FDA is having suicide experts at Columbia University reexamine the data. "We would be doing something bad if we made them look like they are more dangerous than they are, just as we would be doing something bad to make them look much less dangerous than they are," Temple said. "It's important to do this right." Although drug trials have yet to show efficacy for most of the drugs in children, many doctors and patients think that they help depressed kids, FDA officials said.

Expert's Results Differ
Mosholder was assigned in June to head up the FDA's assessment of a possible association between Paxil and suicidal behavior in children, but his mandate was broadened to include other antidepressants. By January he had come up with conclusions that did not jibe with the FDA's official position, according to internal FDA e-mails and interviews with FDA officials other than Mosholder. The FDA's official public position was that there was not adequate data to support a link between antidepressants and possible suicide.
      At first, FDA officials had planned to have Mosholder tell the advisory panel about his conclusions. One of the internal documents was a trial question-and-answer session, rehearsing what Mosholder would tell the committee. In italic type, Mosholder was asked questions about his analyses and coached on how he should handle them. Mosholder's answers, summarizing his findings, appeared in normal type.
      Mosholder wrote that trials of eight antidepressant drugs, involving 4,100 pediatric patients, showed 108 suicide-related events -- 74 on drugs and 34 on placebo. About a quarter of the events could be classified as serious; and most of the suicide-related events were among children suffering major depressive disorder, not from the other diseases treated with the medications, such as obsessive-compulsive disorder. In these seriously depressed patients, there was one serious suicide-related event per five patient years on the drug, compared with one per 10 patient years on the drug for placebos. Patient years are a statistical measure of the frequency of drug side effects. Mosholder also wrote that the risk was most evident for paroxetine, or Paxil, and venlafaxin, or Effexor. His findings also suggested that patients should not quickly stop taking the drugs. About a quarter of the suicide-related events on paroxetine occurred within four days of discontinuing the drug, he wrote.
      In italics, Mosholder was advised not to give any recommendations to the panel and to acknowledge the limitations of his analyses "relative to the definitive analyses being prepared." Later, senior officials decided Mosholder should not appear before the advisory committee, and it was not told of his work During the panel session, FDA officials explained that the Columbia University experts would analyze the data from the drug company trials, and their results would be published this summer.
      One of the reasons that some senators and representatives decided to investigate the FDA's approach to regulating antidepressants was that the British government -- faced with the same information -- took a much more protective action, warning doctors not to prescribe any of the drugs to children except Prozac, or fluoxetine, according to congressional staffers. Mosholder wrote that his conclusion "essentially mirrors the conclusions" of the Medicines and Healthcare products Regulatory Agency, the FDA's British counterpart.
      Glenmullen said that given Mosholder's findings, the FDA should have given a stronger warning to Americans about the possible risks of using the drugs. "For the FDA to issue an ambiguous warning when they had unambiguous data like this is an outrage," Glenmullen said.