Quality & Practice

ASAM Weekly Editorial Comment

  • March 21, 2017

    The link titled, “Ultra-Low-Dose Buprenorphine as a Time-Limited Treatment for Severe Suicidal Ideation: A Randomized Controlled Trial,” below, by Yoram Yovell et al., is a May, 2016 article that cautiously suggests a role for opioid agonists in management of suicidality in conjunction with mood disorders. It brings into focus at least one other consideration, beyond the role of the endogenous opioid system in maintaining mood balance. The use of buprenorphine is not exclusively within the province of the addiction specialist, despite its being principally deployed in the management of opioid use disorders. The brain’s functions exist in a complex ecological balance. To view any one pharmaceutical as serving just one disorder ignores the effect on psychological equilibrium that any one disorder may have, in inducing or altering the course of another. In the Yovell study, investigators were careful both to use a dose of buprenorphine at the lower level of that used for analgesia, and 20-fold below that used to initiate opioid substitution therapy for opioid use disorder. They looked for and found no indication of opioid withdrawal in the subjects (57 active arm of 88 total), a level of caution that was well-justified by this country’s tendency to employ dependence-inducing pharmaceuticals in the management of any number of disorders (insomnia, ADHD, pain). But given the inductive effect of any degree of opioid use on the development of opioid use disorder, the modifier, “Ultra-Low Dose” should be taken in context; it is not the same as “benign,” “homeopathic,” or “harmless.” To be fair to the authors, neither do they suggest any conclusion of harmlessness. But a much longer-term, if not larger study population, should be the next step.

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


  • March 14, 2017

    Last week celebrated International Women’s Day. My mother was fond of reminding me that there is only a Mother’s Day, but a National Pickle Week. In that vein, April will see Confederate History Month, Autism Awareness Month, Financial Literacy Month, Jazz Appreciation Month, and Mathematics Awareness Month. Attention to half the world’s population is drawn by three articles, this week: “Are women increasingly at risk of addiction?" from The Washington Post, an assembly of opinions and studies that include the National Household Survey of 2015; Pregnant Women and Substance Use, from Jacob Health; and State Expands Residential Substance-use Treatment for Women, from Business West. 

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


  • March 7, 2017

    ASAMW has previously included a link to and brief discussion of the Centers For Disease  Control (CDC) Guideline for Prescribing Opioids for Chronic Pain from 2016.  52 pages long, it included a short summary of recommendations that was a model of concision, 12 points that emphasized restraint and careful monitoring. Dr. Lori Karan directed my attention to the just-released Department of Defense – Veterans Administration Clinical Practice Guideline for Opioid Therapy for Chronic Pain; it is 198 pages, of which much is reference material and careful documentation of the process by which the recommendations were developed. Particularly valuable are four modules, algorithms that describe the management approach to four separate clinical problems: general appropriateness for opioid therapy, treatment with opioid therapy, tapering or discontinuation of opioid therapy, and management of patients currently on opioid therapy. It is nonetheless a daunting document, and I have only just finished reading it side-by-side with the CDC guidelines. Four notes warrant presentation:

    1. Both documents provide explicit, quantitative, recommended limits to daily opioid dosage.
    2. Neither document proposes that there is no place for long-term opioid therapy, in some patients. Said differently, both documents allow for the possibility that there is a population of patients for whom some long-term opioid therapy is appropriate; however there is a clear and insistent de-emphasis of the place for long-term opioid therapy, throughout both documents.
    3. The two documents are mutually concordant. This is a miracle of interagency cooperation.
    4. In making recommended upper limits to opioid prescribing dosage, neither document proposes that the actual opioid dose is indicative of an opioid use disorder. This is consistent with the philosophic trend that has been employed in developing criteria for all substance use disorders from DSM-III forward. That is, the frequency or the amount of the substance used is not the issue in determining a usage disorder (dependence); the consequences of the usage are the issue in determining a disorder.

    Recapitulating the links:

    CDC Guidelines (2016): https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm, (PDF format of guidelines - https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6501e1.pdf)

    DoD/VA Guidelines (2017): http://www.healthquality.va.gov/guidelines/Pain/cot/ 

    (PDF of full guidelines - http://www.healthquality.va.gov/guidelines/Pain/cot/VADoDOTCPG021517clean.pdf)


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


  • February 28, 2017

    Please recognize the addition of Dr. Nick Athanasiou as an Assistant Editor with ASAMW, working with Dr. Karen Miotto at UCLA where he is the Associate Program Director in Addiction Psychiatry.

    His involvement is an indication of the increasing engagement of training programs in the production of enduring materials for education. In this past week's American College of Psychiatrists conference in Scottsdale, Arizona, one of the best-attended interest groups centered on the future of medical student and residency education. It was evident from this session, as well as from selection of the NNCI as the annual awardee for curricula (www.nncionline.org ), that there is generalized and increasing interest in shared educational materials, whether in general psychiatry or the field of addiction. I sensed consensus around the notion that regulation of curricula is by no means the same as collaboration in pursuit of optimal curricula. The former can be pernicious; the latter could be evolutionary.

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


William Haning, MD, DFASAM, DFAPA 


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