Quality & Practice

ASAM Weekly Editorial Comment

William Haning, MD, DFASAM, DFAPA 

Editor-in-Chief

Bill Haning is a Professor of Psychiatry at the John A. Burns School of Medicine, University of Hawaii, who serves as the Director, Medical Doctorate Programs for the school; and as Director, Addiction Psychiatry/Addiction Medicine. A director of the American Society of Addiction Medicine (Region 8), he also serves as Chair of the Examination Committee for Addiction Psychiatry, American Board of Psychiatry and Neurology. He is the current Chair, ASAM Publications Council.

Question for the editor? Email pubs@ASAM.org

  • April 18, 2017

    From the NY Times of October 19, 1894:

    “Alcoholism in the Army.

    WASHINGTON, Oct. 19., 1894.

    Alcoholism is on the increase in the army, according to Dr. R. Smith, Surgeon at Governors Island" who reports that several thousand days' labor was lost on this account by troops in the Department of the East this year. Alcoholism comprises a large percentage of the disabilities of the soldier. Fort Porter, N.Y, and Newport Barracks. Ky., give the greatest proportion of disability from effects of alcohol, a trifle more than 100 cases per thousand of mean strength. The  Surgeon makes a suggestion which may be taken up by the War Department.

    He says: "It ...certainly would  be naught but justice were there a difference between the pay and allowance of those suffering from the effects of alcohol during the time they are unable to perform their duty in consequence of such causes and the pay of the soldier who has lost no time from disease or who has lost time only for causes tor which he is not responsible through his own self-indulgence and misconduct.”           

    This commentary from 123 years ago emphasizes the enduring difficulty of segregating personal responsibility from compulsion. It may never be resolved, for the reason that there is an element of accountability in both the progress of addiction as well as in recovery from it. While it is consoling to our patients to understand that not all of the consequences of addiction, of specifically alcoholism in this example, are the result of misconduct, a diagnosis of addiction is not exculpatory of all accountability. With examples such as malaria and famine-associated nutritional deficits apart, the most prevalent illnesses, whether obesity devolving into diabetes, heart disease, or skin cancer tend to begin with neglect or a bad decision. There is little defense in behaving otherwise. In fact, it may be paradoxically empowering to understand one's own role in illness propagation. Those ill may come to understand that they preserve some elements of authority, most notably in seeking help once aware of the illness.

    Editor-in-Chief: William Haning, MD, DFAPA, DFASAM

    http://www.asam.org/quality-practice/asam-weekly/archives

  • April 11, 2017

    In a note to Dr. Kelly Clark dated 05 April 2017, Dr. Stephen Martin correctly noted an important oversight in the 04 April number of ASAMW, regarding the citation of a JAM debate on the use of benzodiazepines in patients with substance use disorders. He pointed out that the abstract and link referred to only one position in a debate series consisting of three parts: “Yes,” “No,” and an Editorial resolution (thesis, antithesis, synthesis - Hegel).

    Dr. Martin is absolutely right. This was an editorial error; I apologize. I ask that the readership disregard the original link, and instead take note of all three, below.

    Dr. Richard Saitz’s editorial resolution:  http://journals.lww.com/journaladdictionmedicine/Citation/2017/04000/Should_Benzodiazepines_Be_Used_to_Treat_Anxiety_in.1.aspx

    Dr. Robert L. DuPont (“No”): http://journals.lww.com/journaladdictionmedicine/Abstract/2017/04000/_Should_Patients_With_Substance_Use_Disorders_Be.2.aspx

    Dr. Tae Woo Park  (“Yes”):  http://journals.lww.com/journaladdictionmedicine/Abstract/2017/04000/Debate___Are_Benzodiazepines_Appropriate.3.aspx

    Editor-in-Chief: William Haning, MD, DFAPA, DFASAM

    http://www.asam.org/quality-practice/asam-weekly/archives

  • April 4, 2017

    At the moment many of you are reading this, the American Society of Addiction Medicine is meeting in New Orleans. One demonstration of the magnitude of the field and of its geometric increase is the density of the agenda, and the necessity for overlapping events. Independent of the Board of Directors meetings and a number of pre-meeting meetings (…), on Tuesday and Wednesday, there are now four days of academic sessions with three, count them three, overlapping full-day courses on Thursday. This has necessitated pushing the annual business meeting into the last morning, late-night caucuses, and more. We have a surfeit of educational riches. We are blessed. [Program:  http://www.asam.org/docs/default-source/education-docs/final-program-2017-web.pdf?sfvrsn=8 ]

    It is just as well. For an organization whose membership includes many in recovery, meeting sites such as New Orleans and Las Vegas, with their reputations as drinking cultures, provide interesting but challenging laboratories to explore. Here are three useful links:

    AA New Orleans:  http://www.aaneworleans.org/

    NA New Orleans:  http://www.noana.org/

    Al-Anon Family Groups New Orleans:  http://www.neworleansafg.org/

     

    Editor-in-Chief: William Haning, MD, DFAPA, DFASAM

    http://www.asam.org/quality-practice/asam-weekly/archives

  • March 28, 2017

    We include several items this week bearing on alcohol. 

    As a profession, we have episodically advocated the drinking of alcohol as medicinal.  The concept of alcohol as a healthful tonic, as an invigorating potion of virtuous spirits, is historic; and the caricature of physicians as snake-oil salesmen, standing on the backboard of a wagon, provides our most iconic characterization of the physician-as-quack.

    The 22 March issue of Time magazine carries an overview article by Alice Park [http://time.com/4709302/alcohol-heart-disease-risk/ ] which again raises the “healthfulness” of alcohol consumption. Citing a British Medical Journal article [ http://www.bmj.com/content/356/bmj.j909  ] by Steven Bell and colleagues, a retrospective review of health records, the Time article opts to emphasize the apparent correlation between heart health and modest alcohol consumption, below the problem-drinking (NIAAA) level. This is a recurrent sampling error of medical literature conclusions of which I was recently reminded by Dr. Stephen Jurd (U.Syd), and which requires a response. The cited study focused on cardiovascular disease apart from other forms of cardiac disease (e.g., myocardiopathy, myocarditis, conduction disorders); and without consideration of all other forms of morbidity (e.g., liver disease, encephalopathy, carcinoma). Time’s interpretation may also demonstrate a Type II statistical error, in that the comparison population of non-drinkers will include those who cannot or do not drink, because of alcoholic aggravation of other illnesses; adverse fmily histories; hospitalization or institutionalization where alcohol is unavailable; or high-risk occupational assignments precluding alcohol consumption, among other examples. Thus the population of drinkers will appear healthier than the non-drinkers, but the contrast will have nothing to do with the impact of alcohol. The study is useful as an epidemiological survey, and Time deserves credit for embedding the full-text article, but it does not pretend to be a controlled trial of randomized, matched populations. Failure to demonstrate significant injury from a given dosage of a substance or toxin in one narrow area, is not the same as indicating harmlessness to other organs, or even to the same organ in a different sense (e.g., direct toxic effect on heart muscle). And it is certainly not the same as saying that consumption of alcohol improves health. This is not a case for abstention from alcohol; but it is a request for honesty in recognizing the limits to any conclusions. As the authors of the BMJ study themselves recommend, “… a more nuanced approach to the role of alcohol in prevention of cardiovascular disease is necessary.”

    Editor-in-Chief: William Haning, MD, DFAPA, DFASAM

    http://www.asam.org/quality-practice/asam-weekly/archives