Quality & Practice

ASAM Weekly Editorial Comment

ASAM Weekly Editorial Comments

  • January 17, 2017

    ASAM members will note with interest the bulletin  below, indicating a new partnership that will extend the range of training in buprenorphine prescribing to physician assistants and nurse practitioners. At the time of publication, this is the extent of the information provided. One editorial concern is that the action be seen as a positive and appropriate role for ASAM, but not be seen as an overemphasis on one medication modality. There are many more arrows in the quiver; they all deserve training for their use while not necessarily requiring federal or state regulation of their prescription. We anticipate further explication in ASAMW.

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

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

  • January 10, 2017

    This week’s link to a U.S. News and World Report report of CDC data comments on the upward trend of poisoning by cocaine places it nominally in the “2nd place” position for unintended, drug-using deaths.

    Although not included in the comparisons, ethyl alcohol deserves a moment’s consideration in context. Also from the CDC:

    “Excessive alcohol use led to approximately 88,000 deaths and 2.5 million years of potential life lost (YPLL) each year in the United States from 2006 – 2010, shortening the lives of those who died by an average of 30 years.1,2 Further, excessive drinking was responsible for 1 in 10 deaths among working-age adults aged 20-64 years. The economic costs of excessive alcohol consumption in 2010 were estimated at $249 billion, or $2.05 a drink.” [ https://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm ] 

    While the death rate from the respective drugs is not a competition, this disparity in focus underlines a conceptual issue that is long a topic among those in addiction medicine, the matter of whether addiction per se, unto itself, is an illness. The characterizations of substance use disorders by substance has phenomenological justification, but it doesn’t do much toward a unified-field theory. It is important to have such a theory if we are to avoid the situation described in the Wall Street Journal article on the VA and opioid analgesic prescriptive consequences. There should be no doubt about the good intentions of the physicians in the VA system, and their dilemma is evident: if they overmedicate, the patients are at risk for development of a SUD (or an addiction); if they do not prescribe, they are subject to criticism at all levels for failing to meet the needs of the vets.  A shared, research-supported notion of the nature of and constituents of addiction qua addiction is a prerequisite to coherent and productive SUD treatment policy.

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

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

  • January 3, 2017

    Alva Noe, a University of California philosopher, discusses the recent Surgeon General’s report on addiction in the link below, a NPR op-ed piece. In taking issue with the characterization of addiction as a "… brain disease,"  he emphasizes - I believe correctly - that multiple other factors determine the development of addiction beyond those which are biologically-centered. He goes on to say, “This doesn't make the slogan that 'addiction is a disease of the brain' false, exactly. But it does show it to be a bit misleading.” Unfortunately what follows seems to be an unnecessary dichotomization, using the example of diabetes.

    …”Bad diet and low levels of exercise trigger type 2 diabetes in those prone to the disease. In a similar way, drug abuse causes addiction. But diabetes comes down, finally, to a difficulty managing glucose levels in the blood. You can't say that addiction boils down to something straightforwardly physiological in the same sort of way.”  

    This is unfortunately a false syllogism. Because it is not true that diabetes is simply a disruption in glucose metabolism or a failure on the part of the pancreas to perform its assigned duties. For those who have dealt with people with diabetes, there are clear changes in personality and in behavior, the most familiar of which is difficulty with adherence to treatment regimens. These accompany the more measurable elements of that illness. The similarities between diabetes and addiction are much greater than Dr. Noe might appreciate, greater interestingly than their differences.

    Dr. Noe questions whether emphasizing the brain as a site of the disease of addiction risks “…suggesting that they [those with addiction-WFH] are solely bystanders unjustly afflicted by mechanisms in their brains.” Ultimately addiction is a brain disease, but is also much more, and for those of us tasked with bringing medical students to the frontiers of understanding, the analogy is an important one to preserve. The part that may be missing for those reading Dr. Volkow for the first time is the enormous distance that medicine had to come, in accepting the notion that addiction is at least a brain disease. Just as, again, diabetes is at least a disorder of glucose metabolism. NIDA Directors from before Alan Leshner in 1998 and up to the present, Nora Volkow, have been tireless in raising understanding of addiction as more than a moral failing.

    A part of me wants to appreciate and to thank Dr. Noe for showing sensitivity to the complexity of addiction as an illness. I am hoping that my remarks won't seem churlish, so much as they are an effort to remind us that the chronic, progressive, relapsing disorders, whether tuberculosis or diabetes or multiple sclerosis or schizophrenia or addiction, have these common qualities: a biological component; and consequences that are physical, behavioral, social…and spiritual.

    (Please accept our wishes from ASAMW for a joyous and prosperous and healthy new year.)

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

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

  • December 27, 2016

    This is a note targeting healthcare providers, and is in the context of the holidays. In William L. White’s 1996 text, Pathways from the Culture of Addiction to the Culture of Recovery: A Travel Guide for Addiction Professionals (2nd Ed.), he convincingly describes a culture that in some respects seems not a culture, at least not as it is commonly understood: the addict (person with an addiction) who uses in isolation. It is certainly a culture in the sense of both shared patterns of behavior and common origins of that behavior. It just isn't particularly tribal. The notion clearly characterizes what goes on for doctors, nurses, and their like who experience this disease. A recent example of this is seen in Oliver Sacks’s end-of-life autobiography, On the Move, in which this extraordinary author and neurologist (The Man Who Mistook His Wife for a Hat) candidly discloses his obsessive drug use behaviors in early adulthood. It wasn't party behavior, except in so far as it was a party of one: the seat at the counter, the table for one; or perhaps a clinical case study rather than a clinical trial. As physicians we commonly make our decisions privately and in isolation, all too aware that we alone are responsible for the outcome. So, our decision-making process seems to inform our drinking and using behavior, for those among us with addiction. 

    It is less likely that the behavior of our affected peers is going to emerge in the setting of a party of many, a crowd or social activity. It will more likely be manifest in the recesses of the night, behind the locked office door or in the battened bathroom stall. 

    As the holidays are a mnemonic for past emotional turmoil, they serve in turn as a mnemonic for intoxication. So now, in this season – yes, while we all have too much else to do -  our colleagues, our shy, smart, and evasive colleagues deserve uncommon attention. The hand that is held cannot reach for a drink.

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

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