Thinking Beyond Dry January

Have you given up booze for the month? If so, you’re not alone. An estimated one in five Americans are participating in “dry January,” the health kick-turned-social media phenomenon that urges people to forgo alcohol for the month. If you’re participating in dry January and seeing benefits, you might be curious about long-term sobriety. Getting sober — even for the short term — has many health benefits. Studies have found that people who participate in dry January lose weight, save money, sleep better and have more energy. All of those benefits can lead to you wanting to give alcohol (or other substances) less of your time, money and health during the year ahead. In fact, research has also shown that people who start the year sober drink less over the course of the year. “The brilliant thing about Dry January is that it’s not really about January,” Dr. Richard Piper, CEO of Alcohol Change UK, told Inverse in 2019. “Being alcohol-free for 31 days shows us that we don’t need alcohol to have fun, to relax, to socialize.”Here are a few common experiences during dry January, and how they can inform your relationship with alcohol and other mind-altering substances in the year and decade ahead. You Cut Back, and Felt GreatThis is a common experience for dry January participants. They realize that they don’t need alcohol to feel good, and that in fact they often feel better when they haven’t been drinking. Waking up on weekend mornings with a clear head, or going to bed without a rumbling stomach from drinking too much can be addicting in and of itself. If you find that you’re feeling better without the booze, take a critical look at your drinking habits. If drinking doesn’t ultimately make you feel better over all, why are you doing it? Often, we drink in social situations without really considering why we’re imbibing. As you move away from dry January, become more mindful about when you really want a drink, and when you’ll be just fine with a mocktail. You Participated, but Struggled Some people who participate in dry January are surprised at how difficult it is for them to cut out booze for 31 days. If you participated, but struggled to go without drinking for a whole month, it might be a sign that you use drinking as a coping mechanism. Sometimes, you think you’re in control of your drinking, until your patterns are challenged. If you found it very difficult to be sober, or looked forward to the end of the month with relief, you should ask yourself some tough questions about your relationship with alcohol. What need does booze fill in your life? Do you feel like you’re in control of your drinking, or has the balance shifted and your drinking is controlling your behavior? Don’t be afraid to reach out to qualified professionals who can help you sort through these questions.You Couldn’t Stay Dry, or Didn’t Participate Some people start January with the best of intentions, but end up drinking before the 31st because staying sober is too hard. Others opt not to participate in the first place because the idea of a sober month seems too challenging. This can be a sign that you’re not in control of your drinking any more, and it’s time to make more drastic changes, like talking to treatment professionals. If you find yourself in this camp, it’s important not to be embarrassed. Alcohol use disorder and troubling drinking patterns are very common in our country. The important thing to remember is that alcohol use disorder is a progressive disease. If you catch it early and get the help that you need, it’s much easier to build your life around a healthier relationship with alcohol. However, if you leave it untreated you’re likely to find that you’re drinking more and more over time, and that you have less control over your drinking. Dry January may seem like a fun and lighthearted challenge, but it can also be a powerful tool for evaluating your relationship with alcohol, and reclaiming your power over drinking.Asana Recovery offers residential and outpatient treatment in Costa Mesa, California. Learn more by calling 949-438-4504.

5 Life Skills You’ll Need in Recovery and Where to Learn Them

It’s often said that people with substance use disorder stop maturing at the age they were when they started using. If you were addicted to drugs or alcohol throughout your teens or young adulthood, you probably missed on out on learning essential life skills. That can make early recovery difficult. Not only are you adjusting to your new, sober life, but you’re also making up for lost time in learning life skills that are important for success. The good news is that most recovery programs can help you through this gap, and your sober community can help you learn these essential life skills. From conflict resolution to writing a resume and managing your finances, here are the life skills that everyone should learn in early recovery, and where you can find support for learning them. 1. How To Resolve ConflictEveryone who has relationships with other people experiences conflict. Whether it’s in your romantic life, among friends or at work, you’re bound get into disagreements now and then. When you find yourself at odds with someone, remember the communication techniques you’ve learned in recovery. Don’t attack or take things personally. Just focus on the issue at hand and working toward a common understanding.2. How To Write A RésuméMany people look for a job in early recovery, so having a resume on hand to highlight your skills is important. Many treatment centers and transitional housing programs can connect you with resources that will teach you how to write a great resume. State job programs can also help on this front.If you’re concerned about gaps in your resume, start with a bulleted section that highlights key skills. That way, you can show the skills and accomplishments that make you stand out, even if they’re not your most recent endeavors. Once you have a great resume on hand, remember that it’s important to tweak it to fit the desired skills of specific jobs that you’re applying to.3. How To Manage Time and Keep Yourself AccountableDuring treatment and transitional periods, you have a lot of structure built into your day. As you get more freedom, it’s important to learn to manage your time well, and to hold yourself accountable for this. Being on time — whether to work or for a meeting — shows that you respect the people you’re meeting with. During the early days of recovery consider making a weekly schedule. Make sure that there is time in it for the activities that help you stay sober, like meetings or yoga. Keeping yourself on schedule will help you establish new routines in sobriety.4. How To Manage Your MoneyMoney is a huge source of stress for many people. Knowing how to manage your money well can help keep stress at bay. When it comes to financial health, start with the basics: open a bank account and check your credit. From there, you can work with people that you trust to build a financial future. This might include paying past-due balances from active addiction, or saving for your own home.5. How To Create Healthy BoundariesOne of the most important life skills in recovery is knowing how to set and stick to your boundaries. There are likely certain people and places which you need to distance yourself from. You need to decide what your boundaries will be, communicate them to the people involved, and stick to the stated consequences if people violate your boundaries. Doing this can be difficult, but your recovery team is there to help, since this is critical for protecting your new, sober life.Learn more about Oceanside Malibu at http://oceansidemalibu.com/. Reach Oceanside Malibu by phone at (866) 738-6550. Find Oceanside Malibu on Facebook.

FDA Keeps Brand-Name Drugs on a Fast Path to Market ― Despite Manufacturing Concerns

After unanimously voting to recommend a miraculous hepatitis C drug for approval in 2013, a panel of experts advising the Food and Drug Administration gushed about what they’d accomplished.“I voted ‘yes’ because, quite simply, this is a game changer,” National Institutes of Health hepatologist Dr. Marc Ghany said of Sovaldi, Gilead Science’s new pill designed to cure most cases of hepatitis C within 12 weeks.Dr. Lawrence Friedman, a professor at Harvard Medical School, called it his “favorite vote” as an FDA reviewer, according to the transcript.What the panelists didn’t know was that the FDA’s drug quality inspectors had recommended against approval.They issued a scathing 15-item disciplinary report after finding multiple violations at Gilead’s main U.S. drug testing laboratory, down the road from its headquarters in Foster City, Calif. Their findings criticized aspects of the quality control process from start to finish: Samples were improperly stored and catalogued; failures were not adequately reviewed; and results were vulnerable to tampering that could hide problems.Gilead Foster City doesn’t manufacture drugs. Its job is to test samples from drug batches to ensure the pills don’t crumble or contain mold, glass or bacteria, or have too little of an active antiviral ingredient.Recent news reports have focused public attention on poor quality control and contamination in the manufacturing of cheap generic drugs, particularly those made overseas. But even some of the newest, most expensive brand-name medicines have been plagued by quality and safety concerns during production, a Kaiser Health News analysis shows.More disturbing, even when FDA inspectors flagged the potential danger and raised red flags internally, those problems were resolved with the agency in secret ― without a follow-up inspection ― and the drugs were approved for sale.Erin Fox, who purchases medicines for University of Utah Health hospitals, said she was shocked to hear from KHN about manufacturing problems uncovered by authorities at the facilities that make brand-name products. “Either you’re following the rules or you’re not following the rules,” Fox said. “Maybe it’s just as bad for branded drugs.”The pressure to get innovative drugs like Sovaldi into use is considerable, both because they offer new treatments for desperate patients and because the medicines are highly profitable.Against that backdrop, the FDA has repeatedly found a way to approve brand-name drugs despite safety concerns at manufacturing facilities that had prompted inspectors to push to reject those drugs’ approval, an ongoing KHN investigation shows. This happened in 2018 with drugs for cancer, migraines, HIV and a rare disease, and 10 other times in recent years, federal records show. In such cases, how these issues were discussed, negotiated and ultimately resolved is not public record.For example, inspectors found that facilities making immunotherapies and migraine treatments didn’t follow up when drug products showed evidence of bacteria, glass or other contaminants. At a Chinese plant making the new HIV drug Trogarzo, employees dismissed “black residue” found to be “non-dissolvable metal oxides,” assuming it “did not pose a significant risk,” federal records show.Without a follow-up inspection to confirm drugmakers corrected the problems inspectors found, these medicines eventually were approved for sale, and at list prices as high as $189,000 a month for an average patient, according to health data firm Connecture. The cancer drug Lutathera was initially rejected over manufacturing problems at three plants but was approved a year later without a fresh inspection and was priced at $57,000 per vial.John Avellanet, a consultant on FDA compliance, said data integrity problems, like those at Gilead’s lab in Foster City, should have sparked further investigation, because they raise the possibility of “deeper issues.”Dr. Janet Woodcock, the director of the FDA’s Center for Drug Evaluation and Research, said an inspector’s recommendation to withhold approval can be “dealt with” without a follow-up. Woodcock said the agency can’t comment on specifics, and companies are reluctant to discuss them because the details of the resolution are protected as a corporate trade secret.“That doesn’t mean that there’s anything wrong with the drug,” Woodcock said.Dinesh Thakur, a former drug-quality employee turned whistleblower, called the secrecy a “red flag.” A follow-up inspection is critical, he said: “I’ve seen many times paper commitments are made but never followed through.”What worries Fox is that a faulty drug could get through and nobody would know.“In general, very few people suspect that their medicine is the problem or their medicine is not working,” Fox said. “Unless you see black shavings or something horrible in the product itself, the drug is almost the last thing that would be suspect.”The Market BeckonsIf the FDA finds problems at preapproval inspections for generics, the agency is likely to deny approval and delay the drug’s launch until the next year’s review cycle, according to industry and agency experts.In fact, just 12% of generics were approved the first time their sponsors submitted applications from 2015 through 2017.The calculus appears different for heralded new therapies like Sovaldi. In 2018, 95% of novel drugs ― the newest of the new ― were approved on the first try, the FDA said.Woodcock said the agency has “the same standards for all drugs,” but she emphasized that many of the manufacturing issues “are somewhat subjective.”For new brand-name drugs, she said, the FDA “will work very closely with the company to … bring the manufacturing up to snuff.”The manufacturer submits written responses and commits to resolve quality concerns, but the details are kept confidential.An estimated 2.4 million Americans have hepatitis C and, before Sovaldi, treatment came with miserable side effects and a strong chance it wouldn’t work. Sovaldi promised up to a 90% cure rate, though it came with an eye-popping $84,000 price tag for a 12-week course, putting it out of reach for most patients and health care systems.But corporate pressure to get such therapies into the marketplace is also considerable.Pharmaceutical firms pay hefty fees for FDA review and lobby the agency to speed products to market. For Gilead, time lost is money.“If approval of sofosbuvir were delayed, our anticipated revenues and our stock price would be adversely affected,” Gilead wrote in an SEC document filed Oct. 31, 2013, using the generic name for Sovaldi.Since its debut in 2013, Sovaldi has been widely criticized for its price but recognized as a medical breakthrough. Gilead has never recalled it.However, hundreds of patients who have taken the drug have voluntarily reported cancer or other complications to the FDA’s “adverse event” reporting database, including concerns that the treatment doesn’t always work. One in 5 Sovaldi patients and health care professionals who reported serious problems to federal regulators said the drug didn’t cure the patients’ hepatitis C.“The FDA approved these products after a rigorous inspection process, and we are confident in the quality/compliance of these products,” Gilead spokeswoman Sonia Choi said.Problems at Foster CityGilead’s Foster City facility has been cited for an array of problems over the years. In 2012, FDA inspectors said the facility had failed to properly review how the HIV drugs Truvada and Atripla became contaminated with “blue glass” particles; some of that tainted batch was distributed. The company “made no attempt to recover” the contaminated drugs, according to FDA inspection records.Gilead had just filed its application for Sovaldi’s approval when FDA inspectors arrived at Foster City for an unrelated inspection in April 2013. Inspectors slapped the facility with nine violations in what’s called a 483 document and said that the reliability of the site’s methods for testing things like purity were unproven and that its records were incomplete and disorganized, according to FDA inspection documents.As a result, the FDA initially rejected two HIV drugs, Vitekta and Tybost. Gilead had to resubmit those applications, and it would take 18 months before the FDA approved them in late 2014.On Sept. 19, 2013, FDA officials met to discuss Sovaldi with Woodcock, agency records show. Meeting minutes show inspectors recommended hitting Gilead Foster City with a formal warning letter based on the April inspection. (A warning letter is a disciplinary action from the FDA that typically includes a threat to withhold new approvals or place a foreign facility on import alert and refuse to accept its products for sale in the U.S.)At the same meeting, FDA inspectors said their recommendation to approve Sovaldi would be “based on” removing an unnamed drug ingredient manufacturer from the application and “a determination that Gilead Foster City has an acceptable cGMP [current good manufacturing practices] status.”Records show the FDA didn’t issue a warning letter or otherwise delay the approval process when Foster City failed its inspection.Instead, the Sovaldi preapproval inspection started four days later and lasted two weeks. At the end, inspectors issued Foster City another 483, this time with 15 violations, formally outlining problems and requiring a written plan to fix them. Inspectors said they couldn’t recommend Sovaldi’s approval.FDA officials gave Gilead two options during an Oct. 29 teleconference: Remove Foster City, a “major testing site” for Sovaldi, from the application, and use a third-party contractor instead; or use Foster City but hire another firm to monitor the site and sign off on its testing work.Gilead was optimistic. “Based on recent communications with the FDA, we do not expect these [inspection] observations to delay approval of sofosbuvir,” the company said in its Oct. 31 SEC filing.Gilead chose to replace the Foster City plant with a contract testing site, federal records show. By December, Sovaldi was approved for distribution, and the company soon announced its $1,000-per-pill price tag.Not Just GenericsRecent media reports, and the ongoing recall of the widely used blood pressure medicine valsartan, have led consumers ― and members of Congress ― to question whether generics are manufactured safely. Valsartan pills made in China and India were found to contain cancer-causing impurities.Branded-drug quality, in large part, has been spared from congressional scrutiny. But many factories ― overseas and in the U.S. ― make branded and generic drugs.In January 2018, FDA inspectors hit a Korean manufacturing plant that makes Ajovy, a migraine drug, with a warning letter. With the problems still unresolved in April, an agency reviewer recommended withholding approval. When they returned in July, inspectors wanted to give the plant the worst possible classification: “Official Actions Indicated.” Among other problems, inspectors found that glass vials sometimes broke during the manufacturing process and that the facility lacked protocols to prevent the particles from getting into drug products. The FDA’s Office of Manufacturing Quality eventually downgraded the inspection to just “Voluntary Actions Indicated.”The drug was approved in September 2018 and priced at $690 a month. FDA records indicate no further disciplinary action was taken. Teva, the maker of Ajovy, did not respond to requests for comment.Similarly, when FDA inspectors visited a contract manufacturing facility in Indiana used to make Revcovi, which treats an autoimmune disease, they noted that a redacted drug lot had failed a sterility test because the vials tested positive for a bacterium called Delftia acidovorans, which can be detrimental even in people with healthy immune systems, studies show. But the drug-filling machine stayed in use after the contaminant was discovered, the FDA determined. Inspectors recommended withholding approval.The drug was approved in October 2018 even after another inspection turned up problems, with a list price of $95,000 to $189,000 per month for an average patient, according to health care data firm Connecture.Revcovi’s manufacturer, Leadiant Biosciences, said through an outside public relations firm that its contract manufacturer’s written responses to the FDA observations were considered “adequate” by two FDA offices, adding, “We do not have any more information to share with you at this time as pharmaceutical manufacturing processes are confidential.”Problems with drugs can take years to discover ― and then only after patients are injured. So, many health researchers say, more caution is warranted.“They’re doing so few of these [FDA] inspections pre-market,” said Diana Zuckerman, president of the nonprofit National Center for Health Research. “The least they can do is listen to the ones they’re doing.”This story was originally published at Kaiser Health News on November 5, 2019

What Happens After Treatment?

In recovery circles, there is a lot of focus on treatment. Admitting you have a drug or alcohol problem and being willing to seek treatment is a massive step on the journey toward health. Finding the right treatment center that can meet your individual needs can help you create a solid foundation for recovery. Still, the 30, 60 or even 90 days that you spend in treatment are just a drop in the bucket compared to the rest of your life. To really succeed in sobriety, you need to focus on recovery after treatment. Whether you’ve recently finished treatment or are floundering a bit in early recovery, having a plan for recovery after treatment can help you get on the right track. Here’s what you can do to protect your sobriety after treatment ends. Have Realistic ExpectationsIt would be wonderful if people could go to treatment for a set amount of time and emerge entirely cured from their substance use disorder. Unfortunately, that’s not realistic. The past traumas, underlying mental health issues and other factors that contributed to your substance abuse are still with you, even in recovery. The key difference is that you’re now able to deal with them in healthier ways. You can talk to professionals, go to a meeting, meditate or exercise when you’re overwhelmed, rather than using. Still, you have to accept that sometimes you’re not going to feel great. Life can still be challenging even in recovery, so be prepared for there to be bumps in the road, no matter how transformational your treatment experience was. Utilize Step-down Programs and Transitional HousingMany people who go through treatment had their lives interrupted by their addiction. You might have experienced job loss, homelessness or credit challenges. Some people never learned to cope with the challenges of adult life without turning to drugs and alcohol. No matter what, reentering the “real world” after treatment can be daunting. That’s where step-down programs and transitional housing can help. If you went to an inpatient treatment program, it can be shocking to go from a structured environment to being on your own. To ease that transition, “step down” through treatment options, including outpatient and evening programs. Consider living in transitional housing, where you can pursue a job or education while still having some structure and accountability. Grow Your Sober CommunityAfter you leave treatment, you might feel a bit lonely. Many of the people that you spent time with during active addiction aren’t safe to be around now that you’re building a sober life. Your friends who didn’t experience addiction might still be hurt by your past actions, or cautious in reestablishing their relationship with you. Your new sober community can help fill the gaps. Attend meetings, go to alumni events at your treatment center, and make friends with others at your sober living. Although putting yourself out there can be scary, the benefits of having sober friends invested in your success are well worth it. Focus On The Long TermWhen you’re in treatment, your attention is on the next 30 days. However, to stay sober over a lifetime you have to focus on the big picture, one day at a time. You might experience days where you’re coping with cravings. You’ll likely have frustrations that your life isn’t coming together as quickly as you would like. By staying focused on your long-term goal of surviving and thriving in recovery, you can better handle the ups and downs of early recovery. Staying sober is a lifelong commitment. During early recovery, you can set the foundation for that, by building your community, establishing healthy habits, and learning which practices are most helpful for you. You’ll learn to recognize triggers and how to avoid them. And you will realize the importance of reaching out for help. Over time, all of this will strengthen your sobriety and help you live the life that you want live, without drugs or alcohol. Learn more about Oceanside Malibu at http://oceansidemalibu.com/. Reach Oceanside Malibu by phone at (866) 738-6550. Find Oceanside Malibu on Facebook.

A Kinder, Better Way: How CRAFT Uses Love and Kindness to Heal Families with Addiction

About ten years ago, I got one of those letters. It was painful to read it but once I had a drink, my pain turned into indignation. I folded the letter multiple times till it ended up a tiny square, which I shoved into a shoebox where it lives till this day, next to old birthday cards and love notes from exes. I’m talking about my first Intervention Letter. If you’ve never gotten one of these, then you were probably not destroying your family’s life successfully enough! I’m kidding, of course, and not everyone gets an Intervention Letter; some of us also get a serious talking-to; most of us get ultimatums and threats; and all of us get tears. This is what it’s like to have a family while high or drunk. Not fun. But it’s even less fun for the families—they are some of the most tortured, miserable, angry, confused people entangled in their misery by love. It’s no wonder that resentment is ever-present, fuelling many misguided attempts to help circumvent addiction. Why misguided? Because those attempts rarely get anyone better. And a person going to a rehab to please their loved ones has less of a chance of staying clean than a person going on her own account. On top of it, the families are still often left without any solid tactics in place on how to keep their loved one sober, how to prevent relapses, and how not to fall back into the muck of co-dependency. There are programs designed to help families but many of them advocate “tough love” and aren’t terribly effective. So Intervention Letters and ultimatums are common. Instead of Ultimatums and Threats, CompassionFortunately, there might be a better way—specifically the CRAFT way. According to one definition, “Community Reinforcement and Family Training (CRAFT) teaches family and friends effective strategies for helping their loved one to change and for feeling better themselves. CRAFT works to affect the loved one’s behavior by changing the way the family interacts with him or her.” At first look, CRAFT’s techniques might appear contra-intuitive as a lot of its teachings seem to advocate dismissing the addictive behavior—complaining, arguments and demands are discouraged. In fact, on the cover of the popular book on CRAFT, Get Your Loved One Sober, the tagline reads “Alternatives to Nagging, Pleading, and Threatening.” Instead of tough love, CRAFT advocates gentle love—and that approach seems to be working.According to one trial by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), CRAFT was more effective than Al-Anon and Johnson Institute Intervention. CRAFT had a 64 percent success rate of getting the person with addiction into treatment compared to 30 percent for Johnston Institute and 10 percent for Al-Anon. Johnson Institute is a model that’s based on confrontation that is supposed to motivate the person with addiction to enter treatment. Al-Anon, similar to CRAFT, teaches detachment with love, but it is also a 12-step-based program which includes the sometimes-problematic concept of Higher Power and advocates a certain kind of passivity, which might not be conductive to strengthening the very fragile fabric of families dealing with active addiction. In contrast, CRAFT focuses on attending to your own needs along with steering the problem user toward treatment, which often happens organically as the patterns of interaction change. CRAFT’s mission is to help reduce the loved one’s alcohol and drug use, whether or not the loved one has engaged in treatment yet. CRAFT discourages enabling, encourages problem solving, employs reward systems and aims to empower the beaten-down, frustrated family members. CRAFT doesn’t approve of breaking the family apart and its goal is to not only keep it all intact but also get everyone better. A family member who’s part of CRAFT is taught to change her/ his reactions—from negative to positive—in response to the triggers from the person with addiction. For example, a husband coming home late after a night of drinking with his buddies again won’t get a lecture for being late for dinner, as he usually does in that situation, because the wife will have been instructed to take care of her own needs, and she will have eaten the dinner on her own. Observing and AdaptingAs part of CRAFT, the family members are asked to observe and monitor the addictive behavior of their loved one—this means noting what situations might cause the person to reach for another drink, what creates conflict, and observing any patterns in behavior. With time, as these patterns become obvious, the family member changes the approach—from aggressive to more passive and compassionate—and in that more loving way, upsets the predictable trajectory of maladaptive interactions with the addicted person. Instead of yelling at someone and accusing her of being a liar, the family member might say, “I know you haven’t been going to work all this time and I am hurt that you’re lying to me. Let’s talk about it in the morning after you sleep it off.” A calm, reasonable way of dealing with the situation will most likely elicit a reaction that’s not combative. Eventually those kinds of interactions will become a norm and change will occur.It’s not exactly “kill them with kindness” but it’s a similar principle. When you expect Intervention Letters—like I did—and you’re stuck in a hamster wheel of constant conflict, getting something completely opposite might just shock you into action. Receiving praise for sticking to commitments—even something as small as coming home on time—or staying sober for a string of days, is more effective than having those subtle changes ignored or taken for granted. No, we don’t need to applaud every nice thing a person with addiction does but in the beginning, perhaps it makes sense to do so. People who are just starting to get sober are very much like babies—deregulated emotions, lack of impulse control—and praise goes a longer way than punishment does. Punishment tends to prolong trauma where praise leaves the person wanting to earn it again, which leads to repeating the desirable action. A Better Alternative to Tough LoveMy family has always taken the “tough love” route and my addiction did contribute to me eventually separating from my husband. I imagine if we were a part of CRAFT program, things could’ve gone differently. I lived through ultimatums and anger and once I was kicked out of my house. I’ve often felt alone and ashamed and angry with myself for disappointing everyone. I thought I was worthless and my loved ones’ attitude confirmed that. But I don’t think they knew any better. So many of us with addiction still live in an episode of Intervention; we have never been shown a kinder, better way. 

The Brain, the Criminal and the Courts

8.30.2019On March 30, 1981, 25-year-old John W. Hinckley Jr. shot President Ronald Reagan and three other people. The following year, he went on trial for his crimes.Defense attorneys argued that Hinckley was insane, and they pointed to a trove of evidence to back their claim. Their client had a history of behavioral problems. He was obsessed with the actress Jodie Foster, and devised a plan to assassinate a president to impress her. He hounded Jimmy Carter. Then he targeted Reagan.In a controversial courtroom twist, Hinckley’s defense team also introduced scientific evidence: a computerized axial tomography (CAT) scan that suggested their client had a “shrunken,” or atrophied, brain. Initially, the judge didn’t want to allow it. The scan didn’t prove that Hinckley had schizophrenia, experts said — but this sort of brain atrophy was more common among schizophrenics than among the general population.It helped convince the jury to find Hinckley not responsible by reason of insanity.Nearly 40 years later, the neuroscience that influenced Hinckley’s trial has advanced by leaps and bounds — particularly because of improvements in magnetic resonance imaging (MRI) and the invention of functional magnetic resonance imaging (fMRI), which lets scientists look at blood flows and oxygenation in the brain without hurting it. Today neuroscientists can see what happens in the brain when a subject recognizes a loved one, experiences failure, or feels pain.Despite this explosion in neuroscience knowledge, and notwithstanding Hinckley’s successful defense, “neurolaw” hasn’t had a tremendous impact on the courts — yet. But it is coming. Attorneys working civil cases introduce brain imaging ever more routinely to argue that a client has or has not been injured. Criminal attorneys, too, sometimes argue that a brain condition mitigates a client’s responsibility. Lawyers and judges are participating in continuing education programs to learn about brain anatomy and what MRIs and EEGs and all those other brain tests actually show.Most of these lawyers and judges want to know such things as whether brain imaging could establish a defendant’s mental age, supply more dependable lie-detection tests or reveal conclusively when someone is experiencing pain and when they are malingering (which would help resolve personal injury cases). Neuroscience researchers aren’t there yet, but they are working hard to unearth correlations that might help — looking to see which parts of the brain engage in a host of situations.Progress has been incremental but steady. Though neuroscience in the courts remains rare, “we’re seeing way more of it in the courts than we used to,” says Judge Morris B. Hoffman, of Colorado’s 2nd Judicial District Court. “And I think that’s going to continue.”A Mounting Count of CasesCriminal law has looked to the human mind and mental states since the seventeenth century, says legal scholar Deborah Denno of Fordham University School of Law. In earlier centuries, courts blamed aberrant behavior on “the devil” — and only later, starting in the early twentieth century, did they begin recognizing cognitive deficits and psychological diagnoses made through Freudian analysis and other approaches.Neuroscience represents a tantalizing next step: evidence directly concerned with the physical state of the brain and its quantifiable functions.There is no systematic count of all the cases, civil and criminal, in which neuroscientific evidence such as brain scans has been introduced. It’s almost certainly most common in civil cases, says Kent Kiehl, a neuroscientist at the University of New Mexico and a principal investigator at the nonprofit Mind Research Network, which focuses on applying neuroimaging to the study of mental illness. In civil proceedings, says Kiehl, who frequently consults with attorneys to help them understand neuroimaging science, MRIs are common if there’s a question of brain injury, and a significant judgment at stake.In criminal courts, MRIs are most often used to assess brain injury or trauma in capital cases (eligible for the death penalty) “to ensure that there’s not something obviously neurologically wrong, which could alter the trajectory of the case,” Kiehl says. If a murder defendant’s brain scan reveals a tumor in the frontal lobe, for instance, or evidence of frontotemporal dementia, that could inject just enough doubt to make it hard for a court to arrive at a guilty verdict (as brain atrophy did during Hinckley’s trial). But these tests are expensive.Some scholars have tried to quantify how often neuroscience has been used in criminal cases. A 2015 analysis by Denno identified 800 neuroscience-involved criminal cases over a 20-year period. It also found increases in the use of brain evidence year over year, as did a 2016 study by Nita Farahany, a legal scholar and ethicist at Duke University.Farahany’s latest count, detailed in an article about neurolaw she coauthored in the Annual Review of Criminology, found more than 2,800 recorded legal opinions between 2005 and 2015 where criminal defendants in the US had used neuroscience — everything from medical records to neuropsychological testing to brain scans — as part of their defense. About 20 percent of defendants who presented neuroscientific evidence got some favorable outcome, be it a more generous deadline to file paperwork, a new hearing or a reversal.But even the best studies like these include only reported cases, which represent “a tiny, tiny fraction” of trials, says Owen Jones, a scholar of law and biological sciences at Vanderbilt University. (Jones also directs the MacArthur Foundation Research Network on Law and Neuroscience, which partners neuroscientists and legal scholars to do neurolaw research and help the legal system navigate the science.) Most cases, he says, result in plea agreements or settlements and never make it to trial, and there’s no feasible way to track how neuroscience is used in those instances.The Science of States of MindEven as some lawyers are already introducing neuroscience into legal proceedings, researchers are trying to help the legal system separate the wheat from the chaff, through brain-scanning experiments and legal analysis. These help to identify where and how neuroscience can and can’t be helpful. The work is incremental, but is steadily marching ahead.One MacArthur network team at Stanford, led by neuroscientist Anthony Wagner, has looked at ways to use machine learning (a form of artificial intelligence) to analyze fMRI scans to identify when someone is looking at photos they recognize as being from their own lives. Test subjects were placed in a scanner and shown a series of pictures, some collected from cameras they had been wearing around their own necks, others collected from cameras worn by others.Tracking changes in oxygenation to follow patterns in blood flow — a proxy for where neurons are firing more frequently — the team’s machine-learning algorithms correctly identified whether subjects were viewing images from their own lives, or someone else’s, more than 90 percent of the time.“It’s a proof of concept, at this stage, but in theory it’s a biomarker of recognition,” Jones says. “You could imagine that could have a lot of different legal implications” — such as one day helping to assess the accuracy and reliability of eyewitness memory.Other researchers are using fMRI to try to identify differences in the brain between a knowing state of mind and a reckless state of mind, important legal concepts that can have powerful effects on the severity of criminal sentences.To explore the question, Gideon Yaffe of the Yale Law School, neuroscientist Read Montague of Virginia Tech and colleagues used fMRI to brain-scan study participants as they considered whether to carry a suitcase through a checkpoint. All were told — with varying degrees of certainty — that the case might contain contraband. Those informed that there was 100 percent certainty that they were carrying contraband were deemed to be in a knowing state of mind; those given a lower level of certainty were classified as being in the law’s definition of a reckless state of mind. Using machine-learning algorithms to read fMRI scans, the scientists could reliably distinguish between the two states.Neuroscientists also hope to better understand the biological correlates of recidivism — Kiehl, for instance, has analyzed thousands of fMRI and structural MRI scans of inmates in high-security prisons in the US in order to tell whether the brains of people who committed or were arrested for new crimes look different than the brains of people who weren’t. Getting a sense of an offender’s likelihood of committing a new crime in the future is crucial to successful rehabilitation of prisoners, he says.Others are studying the concept of mental age. A team led by Yale and Weill Cornell Medical College neuroscientist B.J. Casey used fMRI to look at whether, in differing circumstances, young adults’ brains function more like minors’ brains or more like those of older adults — and discovered that it often depended on emotional state. Greater insight into the brain’s maturation process could have relevance for juvenile justice reform, neurolaw scholars say, and for how we treat young adults, who are in a transitional period.The Jury Is Still OutIt remains to be seen if all this research will yield actionable results. In 2018, Hoffman, who has been a leader in neurolaw research, wrote a paper discussing potential breakthroughs and dividing them into three categories: near term, long term and “never happening.” He predicted that neuroscientists are likely to improve existing tools for chronic pain detection in the near future, and in the next 10 to 50 years he believes they’ll reliably be able to detect memories and lies, and to determine brain maturity.But brain science will never gain a full understanding of addiction, he suggested, or lead courts to abandon notions of responsibility or free will (a prospect that gives many philosophers and legal scholars pause).Many realize that no matter how good neuroscientists get at teasing out the links between brain biology and human behavior, applying neuroscientific evidence to the law will always be tricky. One concern is that brain studies ordered after the fact may not shed light on a defendant’s motivations and behavior at the time a crime was committed — which is what matters in court. Another concern is that studies of how an average brain works do not always provide reliable information on how a specific individual’s brain works.“The most important question is whether the evidence is legally relevant. That is, does it help answer a precise legal question?” says Stephen J. Morse, a scholar of law and psychiatry at the University of Pennsylvania. He is in the camp who believe that neuroscience will never revolutionize the law, because “actions speak louder than images,” and that in a legal setting, “if there is a disjunct between what the neuroscience shows and what the behavior shows, you’ve got to believe the behavior.” He worries about the prospect of “neurohype,” and attorneys who overstate the scientific evidence.Some say that neuroscience won’t change the fundamental problems the law concerns itself with — “the giant questions that we’ve been asking each other for 2,000 years,” as Hoffman puts it — questions about the nature of human responsibility, or the purpose of punishment.But in day-to-day courtroom life, such big-picture, philosophical worries might not matter, Kiehl says.“If there are two or three papers that support that the evidence has a sound scientific basis, published in good journals, by reputable academics, then lawyers are going to want to use it.”10.1146/knowable-082919-1 Eryn Brown is a freelance writer and editor whose work has appeared in the Los Angeles Times, the New York Times, Nature, and other publications. Reach her at erynbrown.writer@gmail.com. This article originally appeared in Knowable Magazine, an independent journalistic endeavor from Annual Reviews. Sign up for the newsletter.

Podcast Review: Seasons of Sobriety

The first time I met Howard M. was in June of 2012, at a recovery retreat. Just eight months sober and sequestered among dozens of men with far more experience in recovery, I was over my head and out of my comfort zone. I had, apparently, come to a weekend-long gathering of fellow alcoholics only to feel alone and alienated.Before one of the first breakout sessions, I fixed my eyes to my phone for fear of fixing them elsewhere. Over my shoulder, an authoritative voice pierced my self-preserving silence.“Recovery isn’t on your phone.”I hated Howard for five minutes, and have loved him ever since.Howard is refreshingly albeit sometimes blisteringly direct. He is unwavering and disciplined, perhaps too rigid for some but a role model to many more. Howard is an endearing endurance test; I learn something valuable from him--if sometimes semi-begrudgingly--whenever we’re together.Like me, in addition to being an alcoholic, Howard is a (slowly) recovering curmudgeon. One privilege of knowing him is seeing his inner eyeroll; he can’t help but notice when a meeting goes off on a well-intentioned tangent. In those moments his calm countenance undoubtedly belies a silent psychic scream--one begging the banter to return to progress-inspiring experience, strength, and hope.He sat in plenty of speaker meetings looking forward to a message of hope and recovery, but would often hear of new and old ways of getting high or drunk.Howard has taken this desire to stay on-message into his latest project. And irony of ironies, this little slice of recovery can indeed be found on your phone.“Seasons of Sobriety” is Howard M.’s resoundingly successful effort to focus and streamline the modern-day AA speaker meeting. It is an audible manifestation of the host himself, born of an undesirable trait noticed, analyzed and righted in fastidious fashion.I work with media for a living and, in an online landscape increasingly crowded with amateurs, rarely does a novice nail a broadcast vehicle from the get-go. But that’s exactly what Seasons of Sobriety accomplishes, through a combination of its host’s intelligence, meticulousness, and big-heartedness.As host, Howard is both in control and in the background. He is part guide, part guardrail – yielding his guests the wheel while keeping the conversation from veering off course. The podcast is interested in recovery rather than addiction, calm rather than chaos, and, above all, what we do with the most valuable gift ever received: freedom from drugs and alcohol. Howard, like anyone with decades of recovery, finds himself strategizing the long game. Per its homepage, the podcast is a deep dive into “what it takes to persevere through fears, resentment, sadness and joy.”Howard M. is a man who has pushed through the plateaus of long-term recovery and committed to perpetual progress. His series of succinctly guided speaker meetings exemplifies and amplifies this dedication to growth, literally speaking volumes about the lifelong journey that is recovery from our shared disease.Check out Seasons of Sobriety.