Chapter 4. The Chemistry of Behavior: Neurotransmitters and Neuropharmacology
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Published by drrubidium Out-of-control libido or drug habit? Take Nervine. Nervous, excitable, wakeful, or restless? Take Nervine. Over-the-counter Nervine wasn't a wonder drug, just a cocktail of the oldest class of sedatives - inorganic bromides. Nervine contained the most commonly used bromides - sodium bromide (NaBr), potassium bromide (KBr), and ammonium bromide (NH4Br). These particular bromides were once so popular that only aspirin sold better. The use of bromides to treat "nerves" was so prevalent that 'bromide' entered the lexicon of common speech. Instead of "calm down", people were instructed to "take a bromide". Instead of calling someone a 'bore', the term 'bromide' was a used to denote "a commonplace or tiresome person". Bromides may owe their sedative effect to a family connection. The element bromine is in the same chemical family as the element chlorine – the halogens. Being a chemical family, chlorine and bromine have similar properties. Both form single, negatively charged ions (monovalent anions) via oxidation-reduction reactions - chloride (Cl-) and bromide (Br-). Chloride is found in nearly all of our cells, having its own set cell membrane-crossing highways (chlorine channel). The regulated flow of chloride (as hydrated chloride) across neuron membranes is key to communication between neurons. Being family and all, bromide (as hydrated bromide) can travel along chloride's highways. But hydrated bromide is a teeny bit smaller than hydrated chloride, allowing hydrated bromide to get into cells faster than hydrated chloride. A flood of anions, such as bromide or chloride, into a neuron makes it more negative than it would be at rest, a state called 'hyperpolarization'. It's hard for other neutrons to stimulate - talk to - hyperpolarized neurons. Less neuron stimulation can translate to a feeling of calm. Thirty-Seven Copyright © 2012
Keyword: Drug Abuse
Link ID: 17535 - Posted: 11.26.2012
Smoking "rots" the brain by damaging memory, learning and reasoning, according to researchers at King's College London. A study of 8,800 people over 50 showed high blood pressure and being overweight also seemed to affect the brain, but to a lesser extent. Scientists involved said people needed to be aware that lifestyles could damage the mind as well as the body. Their study was published in the journal Age and Ageing. Researchers at King's were investigating links between the likelihood of a heart attack or stroke and the state of the brain. Data about the health and lifestyle of a group of over-50s was collected and brain tests, such as making participants learn new words or name as many animals as they could in a minute, were also performed. They were all tested again after four and then eight years. Decline The results showed that the overall risk of a heart attack or stroke was "significantly associated with cognitive decline" with those at the highest risk showing the greatest decline. It also said there was a "consistent association" between smoking and lower scores in the tests. BBC © 2012
By BENEDICT CAREY Hundreds of Iraq and Afghanistan veterans with post-traumatic stress have recently contacted a husband-and-wife team who work out of their home in suburban South Carolina to seek help. Many are desperate, pleading for treatment and willing to travel to get it. The soldiers have no interest in traditional talking cures or prescription drugs that have given them little relief. They are lining up to try an alternative: MDMA, better known as Ecstasy, a party drug that surfaced in the 1980s and ’90s that can induce pulses of euphoria and a radiating affection. Government regulators criminalized the drug in 1985, placing it on a list of prohibited substances that includes heroin and LSD. But in recent years, regulators have licensed a small number of labs to produce MDMA for research purposes. “I feel survivor’s guilt, both for coming back from Iraq alive and now for having had a chance to do this therapy,” said Anthony, a 25-year-old living near Charleston, S.C., who asked that his last name not be used because of the stigma of taking the drug. “I’m a different person because of it.” In a paper posted online Tuesday by the Journal of Psychopharmacology, Michael and Ann Mithoefer, the husband-and-wife team offering the treatment — which combines psychotherapy with a dose of MDMA — write that they found 15 of 21 people who recovered from severe post-traumatic stress in the therapy in the early 2000s reported minor to virtually no symptoms today. Many said they have received other kinds of therapy since then, but not with MDMA. The Mithoefers — he is a psychiatrist and she is a nurse — collaborated on the study with researchers at the Medical University of South Carolina and the nonprofit Multidisciplinary Association for Psychedelic Studies. © 2012 The New York Times Company
by Sara Reardon , Debora MacKenzie and Jessica Griggs TWO states in the US are now more cannabis-friendly than many parts of Europe. Thanks to ballot initiatives passed by Colorado and Washington last week, people there now have legal access to as much recreational marijuana as they can grow, sell or smoke. This is still illegal under US federal law, but if the states are left alone, the legalisation could launch a living experiment into how people behave when drug laws are relaxed, and into the public-health implications and the effect on the drug cartels. "The Feds now have to decide whether to make that experiment impossible," says Mark Kleiman, a professor of public policy at the University of California, Los Angeles. The Obama administration has yet to give its response to the votes, but a statement from the US Drug Enforcement Agency, which treats marijuana as an illegal drug, said: "The department's enforcement of the Controlled Substances Act remains unchanged." Robert Mikos of Vanderbilt Law School in Nashville, Tennessee, says that federal agencies have the authority to arrest anyone possessing marijuana, but they cannot stop the states from passing the laws, or make the states enforce federal law. Still, the federal government could make life very difficult for the new industry, Mikos says, by seizing growers' assets or prohibiting banks from opening accounts for people committing federal crimes. But even if the US government does crack down, Mikos says, it is not going to make much of a difference. "It will put a dent in the industry, but it will also affect the shape of it." Small businesses will learn how to fly under the radar, he says, and state regulators will have to craft their new laws around federal law. © Copyright Reed Business Information Ltd.
Keyword: Drug Abuse
Link ID: 17505 - Posted: 11.19.2012
Seniors who take common medications to treat insomnia, anxiety, itching or allergies may have symptoms of forgetfulness or trouble concentrating, a new review concludes. About 90 per cent of people aged 65 and older take at least one prescription medication and almost half take five or more, studies suggest. About 90 per cent of people aged 65 and older take at least one prescription medication, U.S. research suggests.About 90 per cent of people aged 65 and older take at least one prescription medication, U.S. research suggests. (iStock) As people increasingly report memory and attention problems and seek testing for early dementia, researchers in Montreal wanted to see how medications can induce such symptoms. Dr. Cara Tannenbaum, research chair at the Montreal Geriatric University Institute and her co-authors in Montreal, Calgary, Australia and the U.S. reviewed 162 studies on medications most likely to affect memory, creating what's called an amnesia effect, or affect brain functions like attention and concentration that are called non-amnestic. "There is a consistent body of evidence suggesting that drug-induced mild cognitive impairment can occur with episodic use of medications for insomnia, anxiety, [itching] or allergy symptoms," the study's authors concluded in the journal Drugs & Aging. "Combined amnestic and non-amnestic deficits occur with the use of benzodiazepine agents and may partially underlie older adults' frequent complaints of forgetfulness or difficulty concentrating." © CBC 2012
By Hannah Krakauer, Last week, the Food and Drug Administration released incident reports describing several deaths that have occurred following the consumption of Monster Energy drinks. Much of the concern over energy-drink consumption centers on the high caffeine content of such beverages. How did these deaths come to light? Anais Fournier, 14, of Hagerstown, Md., died suddenly last December from a heart arrhythmia that led to cardiac arrest. She had apparently drunk two Monster Energy drinks over two days. In mid-October, Fournier’s mother, Wendy Crossland, filed a lawsuit against Monster Beverage, based in Corona, Calif., claiming that the company did not make clear the risks that come with drinking the beverage. As part of a Freedom of Information request by Crossland, the FDA released details of the other four cases, plus one nonfatal heart attack, all of which are alleged to be associated with drinking Monster Energy. The company maintains that its drinks are safe. How much caffeine is in energy drinks such as Monster Energy? Actually, not a huge amount. A 24-ounce can of Monster Energy contains 240 milligrams of caffeine. A typical eight-ounce cup of brewed coffee contains 90 to 200 milligrams of caffeine. © 1996-2012 The Washington Post
Keyword: Drug Abuse
Link ID: 17448 - Posted: 11.03.2012
Kerry Grens Fewer than five percent of patients prescribed narcotics to treat chronic pain become addicted to the drugs, according to a new analysis of past research. The finding suggests that concerns about the risk of becoming addicted to prescription painkillers might be "overblown," said addiction specialist Dr. Michael Fleming at Northwestern University's Feinberg School of Medicine. "If you're a person that doesn't have a history of addiction and doesn't have any major psychiatric problems, narcotics are relatively safe as long as your doctor doesn't give you too much and uses the right medication," Fleming, who was not involved in the new study, told Reuters Health. Some recent research has concluded the same thing, but another expert remained skeptical about the new report because many of the studies it included were not considered the best quality research, and they varied widely in their results. Advertise | AdChoices "I think the jury's still out" on how worrisome prescription opioid addiction is, said Joseph Boscarino of the Geisinger Clinic in Danville, Pennsylvania, who studies pain and addiction. Opioid painkillers, which include oxycodone, fentanyl and morphine, have only recently become available for patients with chronic pain, said Boscarino, who was not part of the new study. © 2012 NBCNews.com
By Gary Stix Nicotine enhances the ability to focus and remember. The alkaloid acts in a similar manner to the brain’s own signaling molecule, acetylcholine. It interacts with eponymous receptors on the surface of nerve cells to regulate signaling in the brain. The role of the nicotinic-acetylcholine receptors throughout the central nervous system is so wide-ranging that new discoveries about the molecule continue apace. A recent study published in Nature Neuroscience found that one type of nicotinic receptor acts as a key element in a cell that appears to perform a critical function in regulating memory. A team of researchers—led by one group from Uppsala University in Sweden and another from Rio Grande do Norte in Brazil—found that a type of nicotinic receptor on a cell called oriens lacunosum-moleculare (OLM-alpha 2) seems to be involved in turning on a critical circuit in the hippocampus, a brain structure involved with memory formation. “This cell has a significant influence on the incoming information to the hippocampus,” says Klas Kullander from Uppsala University. When this circuit is switched on, visual, auditory or other inputs to the hippocampus are targeted for additional processing of the incoming information, perhaps a means of flagging its importance so that it can be directed to the cerebral cortex for long-term storage of memory. The on-state of this circuit “prioritizes more intense local processing of the information,” Kullander says. “It lets the hippocampus dwell on the information longer.” © 2012 Scientific American
Keyword: Learning & Memory
Link ID: 17443 - Posted: 11.03.2012
By Scicurious Treating alcoholism is incredibly difficult on many levels. One of the most difficult areas to deal with is social interaction, how people with alcoholism can interact with others. Alcoholics can have many problems with social exclusion. This is partially due to the severe stigma that accompanies alcoholism, but it’s also due to the difficulties that being an alcoholic can produce on social interaction. Regardless, being an alcoholic can result in ostracism and a breaking down of social support networks, and that can make recovery, especially in times of stress, that much more difficult. But of course, it’s not just the act of being socially ostracized or excluded, it also matters how the person being excluded responds. And there are some indications that alcoholics have a larger response to social exclusion than controls. But do they? And if so, why? So the authors of this study wanted to look at how people with alcoholism respond to things like social rejection compared to controls. They took 22 recovering alcoholics (abstinent, all male, all inpatient treatment and in the 3rd week of detox), and 22 controls, and put them in an fMRI scanner to look at changes in blood oxygenation in the brian. By determining where more or less oxygenated blood is going, fMRI gives an idea of where more or less activity may be taking place. © 2012 Scientific American
Smoking cigarettes throughout adulthood reduces life expectancy by about 11 years in women but quitting avoids much of the extra risk, a new large study shows. The Million Women Study in the UK recruited 1.3 million British women who were born in the early 1940s to look at the hazards of smoking and the benefits of stopping at various ages. Women in North America took up smoking decades later than men. Women in North America took up smoking decades later than men. (Jonathan Alcorn/Reuters) In most of Europe, Canada and the U.S., the popularity of smoking among young women reached its peak in the 1960s, decades later than for men. Among women in the study who smoked cigarettes through their adult lives, the mortality rate was three times that of women who never smoked or who stopped well before middle age, Sir Richard Peto of the University of Oxford and his co-authors said in Saturday's issue of the journal Lancet. "Stopping before 40 years of age, and preferably well before, avoids more than 90 per cent of this excess mortality; stopping before 30 years of age avoids more than 97 per cent of it," the study's authors concluded. "This does not, however, mean that it is safe to smoke until 40 years and then stop, for women who do so have throughout the next few decades a mortality rate 1.2 times that of never-smokers." Study participants were recruited from 1996 to 2001. They filled in questionnaires about the lifestyle, medical and social factors and were resurveyed by mail three and eight years later. © CBC 2012
Keyword: Drug Abuse
Link ID: 17426 - Posted: 10.27.2012
By Maggie Fox and Linda Carroll Does this sound like you? Two cups of coffee in the morning, a coffee break at 11 or so, another cup in the afternoon and a cup after dinner? That might be enough to interfere with sleep or even give some people the jitters, but it’s nowhere near an overdose. It may also be nothing compared to what some teenagers are consuming to deal with schoolwork or job pressures. James Stone, a 19-year-old from Wallingford, Conn., died in 2006 after he took nearly two dozen NoDoz tablets. Each tablet has about 200 mg of caffeine – about twice that found in a cup of coffee. But while it would be near impossible to down 48 cups of coffee in a few hours, it’s relatively easy to pop a handful of small tablets. Now the question is whether guzzling energy drinks might be as dangerous as popping No-Doz. The Food and Drug Administration is investigating reports that five people died and one survived a heart attack after consuming energy drinks. It is not yet clear whether the drinks actually caused – or even contributed to - those adverse events, said FDA spokeswoman Shelly Burgess. “So far there’s been no causal link,” Burgess said. “There could have been other products involved. We don’t know that yet and that’s why we’re taking this seriously and looking into it.” © 2012 NBCNews.com
Keyword: Drug Abuse
Link ID: 17412 - Posted: 10.24.2012
by Sara Reardon We talk to ourselves all day, whether it's convincing ourselves to get out of bed, or avoid that second piece of cake. But this internal voice uses a lot of brainpower. People who have to concentrate on resisting an addiction appear to sacrifice this ability in order to conserve brainpower for other tasks. The average person can juggle about four mental tasks at any time, says Monica Faulkner of Johns Hopkins University in Baltimore. How much you can multitask is related to working memory. With the assumption that recovering addicts must think constantly about their addiction, Faulkner and her colleagues wondered whether this comes at the cost of using up one of those four "slots", possibly impairing their overall working memory. Faulkner and Cherie Marvel, also of Johns Hopkins, recruited six people who had never used drugs and six recovering from a heroin addiction who were taking methadone to help. They showed the volunteers an image, either of a word, a Chinese character, or a pattern. They then waited six seconds, and showed the volunteers a second image. During those six seconds, the researchers recorded the volunteers' brain activity using functional magnetic resonance imaging (fMRI). The volunteers' task was to press a button if the second image matched the first. The people recovering from addiction took a few hundred milliseconds longer than the controls to determine whether they had seen the images previously. But the more interesting result came from the pattern of activity in their brains throughout the 6 second window. © Copyright Reed Business Information Ltd.
by Sara Reardon, New Orleans, Louisiana Does beer make you shlur your wordsh? You're not alone: drunk zebra finches (Taeniopygia guttata) sing songs that are blurrier and more disordered than those of their sober counterparts. What's more, binge drinking may permanently impair juvenile finches' ability to learn new songs – which could have implications for our understanding of the effect of heavy drinking on adolescents. Having a unique and interesting song is important for zebra finches to mate, and each male develops his own signature tune as he matures, says Christopher Olson of Oregon Health and Science University in Portland. Because zebra finch song is so well studied, Olson and colleagues decided to find out how alcohol would affect it. First, they had to find out whether finches are even interested in alcohol. When they gave a group of adult finches 6 per cent ethanol in their water bottles, the birds drank enough of it that their blood alcohol content sometimes reached 0.8 per cent: the legal limit for drivers in many places. The birds were also happy to sing while drunk. Using audio analysis software, the researchers determined the degree of "white noise", or disorganised sounds, in their songs. The drunk birds' songs were significantly more broken and disorganised. "It's their husky bar voice," says Olson. © Copyright Reed Business Information Ltd.
By NICHOLAS BAKALAR A new study suggests that prenatal exposure to mercury is associated with symptoms of attention deficit hyperactivity disorder, but the greater a mother’s consumption of fish — a source of mercury — the less likely her child is to suffer these symptoms. The apparently paradoxical findings, published online last week in Archives of Pediatrics & Adolescent Medicine, come from an analysis of 607 children born between 1993 and 1998. The researchers reviewed data on the amounts of mercury in the mothers’ hair, comparing them against dietary records. At ages 7 to 10, the children underwent neuropsychological examinations. After controlling for fish consumption and many other factors, the scientists found an association between several A.D.H.D.-related behaviors and levels of mercury above one microgram per gram in the maternal hair samples. At the same time, they found that after adjusting for mercury levels, mothers who ate more than two servings of fish per week — more than the 12 ounces that government guidelines suggest — were less likely to have children with A.D.H.D.-related behaviors. “All fish has some mercury in it, but there are very different levels,” said the lead author, Sharon K. Sagiv, an assistant professor at Boston University. The findings may seem contradictory, she added, but “they highlight an important public health issue: Eating fish is good for you, but eating fish that is high in mercury is not.” Copyright 2012 The New York Times Company
Cort Pedersen at the University of North Carolina at Chapel Hill and his team gave 11 alcohol-dependent volunteers two daily doses of an oxytocin nasal spray or a placebo, during the first three days of a detox programme. The volunteers also received lorazepam - a detox drug - when their withdrawal symptoms reached a specific level. The oxytocin group had fewer alcohol cravings and milder withdrawal symptoms than the placebo group, and used just one-fifth of the lorazepam (Alcoholism: Clinical and Experimental Research, doi.org/jgp). "Four [oxytocin] volunteers didn't need any lorazepam at all," says Pedersen. This is good news because lorazepam is highly addictive. While it reduces anxiety and seizures during alcohol withdrawal, users can experience insomnia and cravings when they come off the drug. Although it is unclear how oxytocin - famed for its role in social bondingMovie Camera - helps to aid withdrawal, it has no known side effects. Pedersen hopes that alcoholics who take the hormone will therefore be less likely to experience the unpleasant symptoms that can lead to relapse. © Copyright Reed Business Information Ltd.
By NORIMITSU ONISHI LOS ANGELES — One year after federal law enforcement officials began cracking down on California’s medical marijuana industry with a series of high-profile arrests around the state, they finally moved into Los Angeles last month, giving 71 dispensaries until Tuesday to shut down. At the same time, because of a well-organized push by a new coalition of medical marijuana supporters, the City Council last week repealed a ban on the dispensaries that it had passed only a couple of months earlier. Despite years of trying fruitlessly to regulate medical marijuana, California again finds itself in a marijuana-laced chaos over a booming and divisive industry. Nobody even knows how many medical marijuana dispensaries are in Los Angeles. Estimates range from 500 to more than 1,000. The only certainty, supporters and opponents agree, is that they far outnumber Starbucks. “That’s the ongoing, ‘Alice in Wonderland’ circus of L.A.,” said Michael Larsen, president of the Neighborhood Council in Eagle Rock, a middle-class community that has 15 dispensaries within a one-and-a-half-mile radius of the main commercial area, many of them near houses. “People here are desperate, and there’s nothing they can do.” Though the neighborhood’s dispensaries were among those ordered to close by Tuesday, many are still operating. As he looked at a young man who bounded out of the Together for Change dispensary on Thursday morning, Mr. Larsen said, “I’m going to go out on a limb, but that’s not a cancer patient.” In the biggest push against medical marijuana since California legalized it in 1996, the federal authorities have shut at least 600 dispensaries statewide since last October. California’s four United States attorneys said the dispensaries violated not only federal law, which considers all possession and distribution of marijuana to be illegal, but state law, which requires operators to be nonprofit primary caregivers to their patients and to distribute marijuana strictly for medical purposes. © 2012 The New York Times Company
Keyword: Drug Abuse
Link ID: 17343 - Posted: 10.08.2012
By Ashutosh Jogalekar In a previous post I described the benefits and enduring value of Small Science. I emphasized the fact that in the current economy and funding environment, Small Science is likely to be consistent while Big Science happens in fits and starts. And I talked about how crowdsourcing and crowdfunding could bring great value to both Big and Small Science. Now I want to describe a crowd funded Small Science project that could prove very valuable in understanding the root causes of one of the most pernicious scourges of our time – methamphetamine addiction. Ethan Perlstein at Princeton and David Sulzer at Columbia are interested in dissecting the different ways in which meth acts in and on the brain and they have taken the bold step of pitching this as a crowdfunding project. Their project and others like it could not only help us develop new treatments for meth addition but they could address a more general and key question; how do psychotropic drugs work? It turns out that in spite of the legions of psychiatrists prescribing a record number of antidepressants and other medications every year, we still don’t have a good idea how these compounds work. The same lack of understanding permeates our efforts in tackling the addiction epidemic. From a chemical standpoint the simplicity of psychotropic drugs like meth and PCP is breathtaking. The fact that a few carbon, hydrogen, oxygen and nitrogen atoms arranged in and around a simple ring can cause such profound behavioral changes in human beings continues to beguile and fascinate us. Sadly, our knowledge of the mechanism of action of these molecules as well as legal psychotropic drugs has reached a kind of roadblock. © 2012 Scientific American
Keyword: Drug Abuse
Link ID: 17339 - Posted: 10.06.2012
By LISA SANDERS, M.D. On Thursday, we challenged Well readers to try their hand at solving the case of a comatose young woman dropped off at the emergency room by her friends after attending a concert the previous night. More than 350 people wrote in, and more than 90 of you were able to figure it out. The Correct Diagnosis Is … … Ecstasy-induced hyponatremia. Over the past 20 years there have been many reports of young people, mostly young women, who have had seizures or become unconscious after taking the illegal drug Ecstasy, also known as MDMA. The cause is a dangerously low level of sodium in the bloodstream. The brain is exquisitely sensitive to the exact right balance of sodium and water, and when they are out of whack, nausea, confusion and seizures can follow. It’s a rare but dangerous side effect of the drug. Nearly one in five patients reported to have this complication died. Others had permanent brain damage. When this complication was first observed, it was thought to be because of an overconsumption of water. The drug was used widely at concerts or “raves,” and attendees were told to drink lots of water to replace what was sweated out in the crowded, hot concert and dance floors. Further research revealed that the drug actually alters the way the brain and the kidney work so that the body holds on to water and dumps sodium. This change is exaggerated by the presence of estrogen, so women are far more likely to be affected than men. Why the drug can have this effect on any given individual is not well understood, but it is clear that it is not because of an overdose or a contaminant. It appears to be a response to the drug itself. Copyright 2012 The New York Times Company
Keyword: Drug Abuse
Link ID: 17338 - Posted: 10.06.2012
By Katherine Harmon A bite from the black mamba snake (Dendroaspis polylepis) can kill an adult human within 20 minutes. But mixed in with that toxic venom is a new natural class of compound that could be used to help develop new painkillers. Named “mambalgins,” these peptides block acute and inflammatory pain in mice as well as morphine does, according to a new study. Researchers, led by Sylvie Diochot, of the Institute of Molecular and Cellular Pharmacology at Nice University, Sophia Antipolis in France, purified the peptides from the venom and profiled the compounds’ structure. They then were able to test the mambalgins in strains of mice with various genetic tweaks to their pain pathways. Diochot and her colleagues determined that the mambalgins work by blocking an as-yet untargeted set of neurological ion channels associated with pain signals. The findings were published online October 3 in Nature (Scientific American is part of Nature Publishing Group). As a bonus, mambalgins did not have the risky side effect of respiratory depression that morphine does. And the mice developed less tolerance to them over time than is typical with morphine. Experimenting with the newfound compounds should also help researchers learn more about the mechanisms that drive pain. As the researchers noted in their paper, “It is essential to understand pain better to develop new analgesics. The black mamba peptides discovered here have the potential to address both of these aims.” © 2012 Scientific American,
By PAUL CHRISTOPHER, M.D. “I’m addicted to painkillers,” J., a thickset construction worker, told me on a recent afternoon in the emergency room, his wife at his side. Two years before, after months of pain, stiffness and swelling in his hands and neck, his primary physician had diagnosed rheumatoid arthritis and had prescribed three medications: two to slow the disease and one, oxycodone, for pain. Bolstered by the painkiller, J. had felt more limber and energetic than he had in years. “I could finally keep up with the other guys,” he told me. He worked harder, and his pain worsened. His primary physician increased the oxycodone dose. Soon, J. was looking forward more to the buzz than to the relief the pills brought. He went to see two other physicians who, unaware that he was double-dipping, prescribed similar medications. When a co-worker offered to sell him painkillers directly, J.’s use spiraled out of control. By the time I saw him, he was taking dozens of pills a day, often crushing and snorting them to speed the onset of his high. With remarkable candor, he described how the drugs had marred every facet of his life — from days of missed work to increasing debt, deteriorating health and marital strain. But when I listed the treatment options that might help, J. shook his head, looked from me to his wife, and got up. “I’m all set,” he said, holding up his hands. Then he walked out of the room. Despair fell on his wife’s face. “Please,” she said, grabbing my arm, “you can’t let him leave.” Copyright 2012 The New York Times Company