Quality & Practice

ASAM Weekly Editorial Comment

  • February 21, 2017

    The guidelines on noninvasive treatments for low back pain in the Annals of Internal Medicine, below, are provided as a full-text article and represent the conclusions of the American College of Physicians. The first of three recommendations carries the strongest evidence support, focusing on an expectant philosophy and employing managements that exclude opioids. Interestingly, skeletal muscle relaxants are included among the pharmacologic recommendations, despite the controversial utility of these agents of which several may pose risk of habituation; the weight of support is low, however. The second recommendation, focusing on chronic low back pain, includes a greater number yet of management strategies that allopathic physicians would normally see as belonging in the realm of complementary and integrative medicine. The third recommendation emphasizes reservations regarding opioids. There is a brief reference to radicular pain but as noted in the title, the article and its recommendations are not intended to discuss surgical management. Readers should go to the discussions of specific medications and their respective evidentiary weights at the midpoint of the article, as these provide serious cautions. One example is extracted, for benzodiazepines: “Benzodiazepines: Low-quality evidence showed no difference between diazepam and placebo for function at 1 week through 1 year and analgesic use, return to work, or likelihood of surgery through 1 year of follow-up in patients with acute or subacute radicular pain (60). Diazepam resulted in a lower likelihood of pain improvement at 1 week compared with placebo.”

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

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

  • February 14, 2017

    Our offerings this week may seem a bit leaner than usual. I had put on hold some content about whose origins I was uncertain. Pending a more careful review of that choice, I suspect that I was being overly sensitive. But it puts me in mind of several unique qualities of the American Society of Addiction Medicine, one of which is that many in its large population of investigators, physicians, therapists, administrators and even students are themselves in recovery from substance use disorders. In the matter of commercial influence, the membership has reason to be sensitive. The experience of addiction has commonly distorted a normal understanding of boundaries, and it makes us cautious. In LeClair Bissell’s 1987 text, "Ethics for Addiction Professionals," she includes an entire chapter on exploitation. It begins with, "The chemically dependent patient is vulnerable to exploitation in a variety of ways. In early recovery there is confusion and impaired judgment directly resulting from alcohol or other drug use." A number of us would submit that the experience of addiction is sufficiently formative that boundaries with risk of financial influence must forever remain risky, mine-strewn, demilitarized zones. Dynamically, this may explain why a great deal of the organization’s governing board meetings involve active and enthusiastic discussions regarding financial contributions and conflicts of interest; and this is, of course, a very good thing.

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

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

  • February 6, 2017

    This continues a sequential review by sections of the National Academies Press, The Health Effects of Cannabis and Cannabinoids: The Current

    State of Evidence and Recommendations for Research, 440 pp., http://www.nap.edu/24625 , cited last week and the week prior: Part 3, chapters 5-14, somewhat euphemistically titled "Other Health Effects," addresses many of the reservations that those in the addiction field will experience in the presence of a developing strong advocacy for open use of cannabis. Again, the paper is not a policy document, but rather an attempt to organize and present factual material relating to the substance, cannabis, which has so enthralled our culture for over a century. An outcome of reviewing the paper should be to inform national and regional policy decisions regarding the substance’s use. The adverse effects are catalogued by system, and range from absence of effect to severe injury. The list is extensive and the discussion is comprehensive; a limited sample of some findings follows (cancer, and injury), extracted directly from the paper:

    Chapter 5 Conclusions—Cancer

    There is moderate evidence of no statistical association between cannabis use and:

    • Incidence of lung cancer (cannabis smoking) (5-1)

    • Incidence of head and neck cancers (5-2)

    There is limited evidence of a statistical association between cannabis smoking and:

    • Non-seminoma-type testicular germ cell tumors (current, frequent, or chronic cannabis

    smoking) (5-3)

    There is no or insufficient evidence to support or refute a statistical association between

    cannabis use and:

    • Incidence of esophageal cancer (cannabis smoking) (5-4)

    • Incidence of prostate cancer, cervical cancer, malignant gliomas, non-Hodgkin

    lymphoma, penile cancer, anal cancer, Kaposi’s sarcoma, or bladder cancer (5-5)

    • Subsequent risk of developing acute myeloid leukemia/acute non-lymphoblastic

    leukemia, acute lymphoblastic leukemia, rhabdomyosarcoma, astrocytoma, or

    neuroblastoma in offspring (parental cannabis use) (5-6)

    Chapter 9 Conclusions—Injury and Death

    There is substantial evidence of a statistical association between cannabis use and:

    • Increased risk of motor vehicle crashes (9-3)

    There is moderate evidence of a statistical association between cannabis use and:

    • Increased risk of overdose injuries, including respiratory distress, among pediatric

    populations in U.S. states where cannabis is legal (9-4b)

    There is no or insufficient evidence to support or refute a statistical association between cannabis use and:

    • All-cause mortality (self-reported cannabis use) (9-1)

    • Occupational accidents or injuries (general, non-medical cannabis use) (9-2)

    • Death due to cannabis overdose (9-4a)

    …Other chapters focus on the perinatal, immune, cardiovascular, and pulmonary effects, among others.

    Next week, ASAMW will extract the findings on behavioral and substance use disorder-associated consequences, probably the region of greatest concern for our reading population.

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

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

  • January 31, 2017

    This begins a sequential review by sections of the National Academies Press, The Health Effects of Cannabis and Cannabinoids: The Current

    State of Evidence and Recommendations for Research, 440 pp., http://www.nap.edu/24625 , cited last week:  The preface and first two chapters provide a background to the discussion of cannabis-as-medicine.  They are readable and include a summary, bulletized, of the weighted support for therapeutic uses of cannabis.  The text is down-loadable at no cost, as a PDF.  Review of this text does not constitute an endorsement of the use of cannabinoids as medication, by ASAM;  it is our duty to provide current, well-supported literature bearing on the discipline of addiction medicine.   Some of the conclusions do not vary from those stated by Sir William Osler, in Principles and Practice of Medicine, 1892.  Consequently, given the inevitable controversy that will arise surrounding the report’s conclusions, readers are advised to at least scan the methodology, as a reassurance of validity.  There are many findings of negative outcomes of cannabis use, by system (respiratory, immunologic, psychologic, etc.).  Initially, an extract of the weighted, positive findings is provided here; parenthetical numbers refer to chapters:

    There is conclusive or substantial evidence that cannabis or cannabinoids are effective:

    • For the treatment of chronic pain in adults (cannabis) (4-1)

    • As anti-emetics in the treatment of chemotherapy-induced nausea and vomiting (oral

    cannabinoids) (4-3)

    • For improving patient-reported multiple sclerosis spasticity symptoms (oral

    cannabinoids) (4-7a)

    There is moderate evidence that cannabis or cannabinoids are effective for:

    • Improving short-term sleep outcomes in individuals with sleep disturbance associated

    with obstructive sleep apnea syndrome, fibromyalgia, chronic pain, and multiple sclerosis

    (cannabinoids, primarily nabiximols) (4-19)

    There is limited evidence that cannabis or cannabinoids are effective for:

    • Increasing appetite and decreasing weight loss associated with HIV/AIDS (cannabis and

    oral cannabinoids) (4-4a)

    • Improving clinician-measured multiple sclerosis spasticity symptoms (oral cannabinoids)

    (4-7a)

    • Improving symptoms of Tourette syndrome (THC capsules) (4-8)

    • Improving anxiety symptoms, as assessed by a public speaking test, in individuals with

    social anxiety disorders (cannabidiol) (4-17)

    Improving symptoms of posttraumatic stress disorder (nabilone; one single, small fair quality trial) (4-20)

    We will continue this review in subsequent issues of ASAM Weekly.

    For further stimulation this week, please see the JSAT citation below, Comparison of 12-step groups to mutual help alternatives for AUD in a large, national study.


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

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

  • January 24, 2017

    Commentary this week is limited an encouragement to readers to download the National Academies' report on medical use of cannabis.  A free version of the $87 book is currently available at the site cited (http://nationalacademies.org/hmd/reports/2017/health-effects-of-cannabis-and-cannabinoids.aspx) as a free pre-publication PDF; a time limitation is implied but not stated.  We anticipate highlighting several conclusions and recommendations in the course of the next issues of ASAMW.

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

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

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