Quality & Science

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 directs neuroscience education for the medical students and is the Program Director, Addiction Psychiatry/Addiction Medicine. A Director of the American Society of Addiction Medicine, he also serves as Chair of the Examination Committee for Addiction Psychiatry, American Board of Psychiatry and Neurology. He is the current Chair of ASAM’s Publications Council.

Question for the editor? Email pubs@ASAM.org

  • Recovery Month | 9.11.2018

    September 11, 2018

    Staff Specialist Jasmine Rennie proposed a comment about Recovery Month, which for this year has as its theme, Join the Voices for Recovery: Invest in Health, Home, Purpose, and Community.   The event is featured on the main ASAM.org site, as well as directly at: https://www.recoverymonth.gov/ .  A more comprehensive discussion of the recovery movement may be found within the site at https://recoverymonth.gov/about, from which much of this is drawn.   Be forewarned that the history and the initiatives are government-centric, and so much of the grassroots – and older  - “recovery movement” is not addressed, whether AA, Oxford Groups, Temperance Movement, etc.   For a more comprehensive depiction of the history of addiction treatment, please sample William L. White’s website  [http://www.williamwhitepapers.com/ ], or his now-classic text, Slaying the Dragon.

    Beginning in 1989 as Treatment Works! Month, Recovery Month began by focusing on substance use treatment professionals. In 1998, it became National Alcohol and Drug Addiction Recovery Month, coming to include the stories and accomplishments of those themselves in recovery. In 2011 it was retitled National Recovery Month (aka Recovery Month), effectively acknowledging all mental/behavioral health disorders; and philosophically allying recovery paths of all stripes, a parity different from that for reimbursement but equally important.

    At the 20 year mark, the project published a timeline describing the chronology of treatment events, with these excerpted milestones emphasized, among others.  They are inserted verbatim.

    “1988 The Office of National Drug Control Policy (ONDCP) was established.
    1989 Warning labels were added on alcoholic beverages.
    1989 The first drug court was established.
    1990 The Americans with Disabilities Act was passed.
    1990 The Robert Wood Johnson Foundation’s Fighting Back program funded 15 communities in 11 states to combat alcohol and illicit drug-related programs.
    1990 Addiction medicine became a specialty, and a representative of the field was admitted to the AMA House of Delegates as a voting member.
    1992 The Substance Abuse and Mental Health Services Administration (SAMHSA) was established by Congress, which also created the Center for Substance Abuse Treatment (CSAT), Center for Mental Health Services (CMHS), and Center for Substance Abuse Prevention (CSAP). The National Institute on Drug Abuse (NIDA) became part of the National Institutes of Health.
    1994 The Violent Crime Control and Law Enforcement Act was signed by President Clinton and included the Drunk Driving Child Protection Act of 1994.
    1994 The first Administrator of SAMHSA was appointed by President Clinton.
    1996 In the political sphere, the Health Insurance Portability and Accountability Act (HIPAA) passed, which increased the confidentiality of patient records related to alcohol and drug abuse.
    1996 The Federal Crime Bill provided start-up funding to drug courts.
    1998 The United States Congress created the National Youth Anti-Drug Media Campaign to prevent and reduce youth drug use. The Campaign is the nation’s largest anti-drug media campaign and is generally thought to be the single largest source of drug-prevention messaging directed to teens.

    1998 SAMHSA/CSAT began Recovery Community Support Programs (RCSPs).
    1999 The Supreme Court decided in the Olmstead decision that states cannot require people with disabilities to remain inappropriately institutionalized so they can receive health care services.
    2000 The Drug Addiction Treatment Act of 2000 (DATA) was passed.
    2000 Demand Treatment!, a project funded primarily by the Robert Wood Johnson Foundation, was launched. The project was a national initiative to expand access to quality alcohol and drug treatment.
    2000 The House of Representatives issued a Concurrent Resolution supporting the goals of Recovery Month.
    2001 Oversight and regulation of methadone programs was transferred to SAMHSA from the FDA.
    2002 The Indian Alcohol and Substance Abuse Program (IASAP) was developed by the U.S. Bureau of Justice Assistance to assist tribal jurisdictions in improving their criminal justice systems and reducing substance abuse.
    2002 The Recovery Community Support Programs changed its name to the Recovery Community Services Program (RCSP).
    2003 President Bush’s New Freedom Commission on Mental Health convened and published a report.
    2004 SAMHSA/CSAT’s Access to Recovery grant program was founded.
    2004 SAMHSA/CSAT began the Screening, Brief Intervention, and Referral to Treatment (SBIRT) grant program. In addition, SAMHSA launched the State Incentive Grant Program to build prevention capacity at the state and community levels.
    2005 The National All Schedules Prescription Electronic Reporting Act was signed by President Bush.
    2008 The first-ever recovery/wellness rooms were introduced at national political conventions.
    2008 The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act passed in Congress and was signed by President Bush. It provided equal coverage of mental health and addiction treatment compared with traditional medical coverage.
    2009 SAMHSA is delegated the authority to administer grants to states to implement prescription drug monitoring programs.”

    While not yet updated for the intervening nine years, the timeline would certainly have later included such steps as 1) the approval of addiction medicine as a specialty (2017-2018), by both the American Board of Medical Specialties (ABMS) and the American College of Graduate Medical Education (ACGME); and 2) the founding of Faces & Voices of Recovery (2001).  The latter may have as much or more symbolic value than any of the foregoing exactly because it acquiesces in the recovering population’s status as a stakeholder in treatment availability and effectiveness. 

    - W. Haning, MD

  • Safe Injection Sites (SIS) | 9.4.2018

    September 4th, 2018

    U.S. Deputy Attorney General Rod Rosenstein’s guest editorial for 27 August (New York Times) is linked below.  It is an important perspective to read. Mr. Rosenstein argues for the abandonment of a trend in urban centers of establishing safe sites for conducting injection drug use (Safe Injection Sites, or SISs). He maintains that more of a penal approach to drug distribution is needed, stating that there is evidence that currently reactive Federal drug policy is achieving significant improvements in diminishing drug use. The editorial’s strongest basis for opposing SISs appears to be that the facilities do not show a justifying rate of recovery from substance use disorders.This will predictably yield a wave of opposing commentary, centered on what seems to be a missed point:  the principal purpose of the SISs is not to treat addiction. It is to reduce collateral damage. There is an obligation, founded in humanity, to diminish harm in any population. The SISs have been repeatedly demonstrated not so much to encourage drug use, which will occur regardless the venue, as to encourage medically safe use.  They are deployed in communities with limited resources as a means of controlling the spread of HIV, hepatitides A/B/C (sic), and blood-borne infections resulting in severe heart, lung, renal, hepatic and joint disease; and with the hope of rapid intervention in the event of overdose. The other aim is that in conserving health, the opportunity to enter recovery is lengthened. Any effectiveness of suppressing endemic drug use through prosecution, particularly of distributors who are themselves addicted, needs another, larger forum.

    There was no shortage of controversial opinionizing, this past week.  Again in the New York Times, 31 August 2018 (Opinion, https://www.nytimes.com/2018/08/31/opinion/addiction-recovery-survivors.html ), Maia Szalavitz employs a series of testimonials to support the contention that, as titled, “Addiction Doesn’t Always Last a Lifetime.” The vignettes of peoples’ lives and their respective recoveries are at turns gritty, poignant, and lovingly hopeful; and give insight to the cultures of addiction.  But the fundamental premise provided at the outset is that “…almost all of those who once met criteria for prescription opioid-use disorder achieved remission during their lifetimes — and half of those recovered within five years. “The comment is drawn from a 2013 article in the Journal of Psychiatric Research, based on the NESARC survey and linked within the piece (https://www.ncbi.nlm.nih.gov/pubmed/22985744 ); but there is perhaps insufficient emphasis on the article’s study question, which was of prescription drug use.This risks setting a flash fire of reactive indignation and anger, when in fact the fundamental point that the author seems to want to make – that there are many routes to recovery - is a good one. 

    - W Haning, MD

  • August 28th, 2018

    EDITORIAL COMMENT:  Contagion

     

    This promised comment on contagion follows on the August 21 editorial comments, about market forces in the distribution of drugs. 
    If we consider drug distribution within a public health framework as an example of contagion, then we are bound to see some important similarities between the spreads of substance use and of infectious disease.  These may be useful.   For example, contrasting the characteristics of influenza against those of highly-popular euphorigenics (sic), such as methamphetamine, parallels are immediately discerned:
     
    Infection characteristics (e.g., influenza)
    • Contagious (human-to-human, animal-human, etc.)
    • Parasite cannot too swiftly incubate or kill the host (or contagion may be interrupted, as with Ebola, Marburg, Lassa)
    • Ease of infection assures prevalence (determinants are susceptibility of the population, and route of transmission; thus Hansen’s disease is limited in both impact and spread yet can persist in a population for generations)
    • Geographic spread follows lines of commerce (as well as lines of migration and invasion; typhus, cholera in war)
    • The most dramatic effects may be acute (abrupt disability or death); however, the greatereconomic effect may be seen with contagions that result in chronic or recurrent disease (e.g., tuberculosis, malaria, hookworm [anemia])
     
    Drug characteristics (e.g., methamphetamine)
    • Contagious (users beget users)
    • “Performance drug” precedes disability or lethality
    • Inhalation/injection induces rapid dependence
    • Market forces and lines of commerce determine distribution (e.g., Hawai`i sits astride trade routes from Korea and the Philippines, less so South America; thus methamphetamine use in Hawai`i has long overshadowed cocaine use)
    • The most dramatic effects are those which capture the public’s attention, and are acute (e.g., motor vehicle collisions, death by opioid overdose, amphetamine psychosis); however, as in infectious disease contagion, the greater economic and social integrityimpacts are allied with chronic disease (e.g., debility/disease from tobacco use, disability from chronic intoxication or work injuries, diversion of economic resources, imprisonment and disenfranchisement of up to 2% of the working population).
     
    Examining those similarities allows us to seek interventions that both consider market forces,and which overlap with an understanding of contagion. An evident example would be aggressive substance use disorder (SUD) treatment intervention during and after incarceration.  Making SUD treatment the primary focus of imprisonment, probation, and parole 1) increases return-to-work rate on release, yielding improved productivity and social/family integrity; (2) makes use of an otherwise unproductive interval, generally measured in years; 3) reduces contagion between inmates; 4) markedly reduces drug (primarily opioid) overdose and death rates on discharge.  Where there is a reservoir of illness, it offers the least expensive and most direct interventional target.   I suspect many among you have wanted to be Dr. William Gorgas, pouring kerosene on Anopheles-breeding stagnant pools, and draining swamps* in Panama; or John Snow unscrewing the handle of the Broad Street pump.  Our penal system is our reservoir.
     
    *[No, I mean really. Really draining swamps.]
     
    - W. Haning, MD
  • August 21st, 2018

    Market Forces

    This week's piece from Science Daily addresses the utility of increasing alcohol taxes as a means of reducing the consumption of beverage alcohol, and its consequences. It is not a novel concept, but it is good to see research at the level of prevention which buttresses previous experience. Whether in the extreme example of (U.S.) national Prohibition, or in the lesser examples of individual state excise taxes, the principle has been demonstrated.This international study by Dr. Dan Chisholm & colleagues in The Journal of Studies on Alcohol and Drugs in July (https://www.jsad.com/doi/full/10.15288/jsad.2018.79.514) examined the impact of making alcoholic beverages more expensive.

    It demonstrates as well a mundane quality of drugs and alcohol distribution, that it follows market forces. It is a principle that has been most impressively demonstrated by the impact of increased taxes on pulmonary disease and smoking rates, as the taxation rate has come to far exceed the actual product costs. [In 1970 in Laos, a packet of 20 Lem Thong cigarettes – generically closest to unfiltered Camels - cost 5 cents U.S.  Camels themselves were about 30 cents. It seemed then that no one did not smoke.] In so doing, it becomes completely believable that other drug consumption would be affected by taxation. 

    A casual examination of market forces in the distribution and use of ethyl alcohol, for example, discloses the following characteristics:

    • Advertising:
      • Mass - multimedia, relatively unrestricted
      • Role-modeling and induction – peers who drink provide uncompensated endorsement of its pleasures and benefits
      • Induction (parents)
    • Association with benefits:
      • Amaretto gets you sex
      • Beer makes you a Guy; “Miller Time”
      • Wine demonstrates your culture & sensitivity
    • “The responsible drug” (“drink, but drink responsibly,” where, in fact, the whole point of drinking is to momentarily loosen the bonds of responsibility and abolish cares.)
    • Tradition of use: Guaranteed base (est. 10-15 percent of U.S. drinkers buy 60 percent of production)
    • Availability:
      • Easy to manufacture
      • Bulky, but uncomplicated and legal to transport (Grecian urns have evolved into wine-boxes)
    • Difficulties:
      • Too many competitors
      • Taxation cuts into profit margin
    • Exponents:
      • Availability and access advocated by a majority of the public

     Models examining commercial properties of drugs may aid in designing further interventions. The same should also be true of using a public health model, contagion.  A comment in this vein will follow in the 28 August ASAM Weekly.

    - W. Haning, MD                                   

     

  • August 14th , 2018

    Metaphors 

    A recent article by Zsuzsa Kalo and Associates in the International Journal of Mental Health and Addiction* examines the experience of using cannabinoids expressed metaphorically.  They note, “Metaphors are increasingly used to better understand drug user experiences and as medium to inform and guide clinical responses. Participants describe their drug-related experiences and a myriad of metaphors are recognizable in their depictions.”  This is phenomenological research, carefully auditing the experience of the drug user. Metaphors relating to substance use have long surrounded us, but as physicians we tend to concentrate on how the description of drug use fits into diagnostic criteria. While this effort to rationally conceptualize an illness has merit in the practical task of healing, it sometimes does not take note of the experiential gulf between therapist and drug user. Perhaps none of my patients have sustained their drug use for no apparent reason.  An understanding of the perceived benefits or merits of a drug experience is central to motivational interviewing.

    Examples of the use of metaphor in describing drug or alcohol use are dispersed throughout literature, lay and medical.  Ann and Alexander Shulgin in their famous 2000 text, ”PiHKAL (sic)”, (phenethylamines I have known and loved), describe both the synthesis of 1000 pages worth of investigational psychoactive chemicals and the subjective experiences of taking them.  In one example,”#41”, 2C-T-4, “…Very rational, benign, and good-humored. The insight and calm common to the 2C-T’s are present with less of the push of body energy which makes 2C-T difficult for some people. There are no particular visuals, but then I tend to screen them out consistently, except in cases of mescaline and LSD and psilocybin, so I can’t judge what others would experience in the visual area. The eyes-closed imagery is very good without being compelling. The decline is as gradual and gentle as the onset. I am fully capable of making phone calls and other normal stuff. Music is marvelous, and the body feels comfortable throughout.”

    In an earlier example, Thomas DeQuincey’s Confessions of an English Opium-Eater (1821)  provides descriptions both of the pleasurable aspects and the adverse consequences of using opium.  At one point, he discusses the respective qualities of alcohol and opioids.

    But the main distinction lies in this, that whereas wine disorders the mental

    faculties, opium, on the contrary (if taken in a proper manner),

    introduces amongst them the most exquisite order, legislation, and

    harmony.  Wine robs a man of his self-possession; opium greatly

    invigorates it.  Wine unsettles and clouds the judgement, and gives a

    preternatural brightness and a vivid exaltation to the contempts and the

    admirations, the loves and the hatreds of the drinker; opium, on the

    contrary, communicates serenity and equipoise to all the faculties,

    active or passive, and with respect to the temper and moral feelings in

    general it gives simply that sort of vital warmth which is approved by

    the judgment, and which would probably always accompany a bodily

    constitution of primeval or antediluvian health.

     

    I anticipate that an argument against eliciting these descriptions will be that it induces euphoric recall. Balance in accessing such a history is certainly needed, just as it is in taking a history from someone with PTSD. But an unwillingness to explore the individual’s experience of drug usage risks a misunderstanding of that person’s motivations, and may miss an opportunity to connect with the patient.  If psychotherapy truly is an important component of addiction treatment, then more support for phenomenological research is warranted.

    *Zsuzsa Kaló, Szilvia Kassa, József Rácz, Marie Claire Van Hout, 

    Synthetic Cannabinoids (SCs) in Metaphors: a Metaphorical Analysis of User Experiences of Synthetic Cannabinoids in Two Countries, International Journal of Mental Health and Addiction

    https://doi.org/10.1007/s11469-018-9970-0

     

    - W. Haning, MD

  • August 8th , 2018

    International Doctors in Alcoholics Anonymous

    International Doctors in Alcoholics Anonymous (IDAA) held its 69th annual meeting this past week, in Reno, NV.  [ https://www.idaa.org/ ] It thus pre-dates ASAM.

    With a membership approaching 10,000, the organization provides an annual general international meeting, guidance in the formation of local meetings, and a number of online chat groups.  Its membership is heterogeneous, and its foci are the addictions: substance use disorders, process addictions, codependency – the broader concept of “alcoholism” most often practiced in physicians’ recovery groups. Regardless of the founding title, its professional membership criteria are inclusive. Taken verbatim from the website, membership is available to “…any alcoholic or drug dependent ‘doctor’ whose degree is in the field of health care. Members Include DDS's, DVM's, PhD's [& Psy.D’s – wfh3] in psychology, nursing, social work, and the health sciences.” To this list more recently have been added physician assistants, nurse practitioners, certified registered nurse anesthetists, and members of Alanon.  IDAA’s meetings are particularly famous for inclusion of child and adolescent offspring in a separate, highly organized and powerfully productive program that is professionally-facilitated.  Meeting attendance is aided by a generous scholarship program.

     

    As a good many of the articles that we review include discussions of professional, particularly physician burnout, this endorsement of a non-commercial organization developed to meet the needs of healthcare professionals should not require justification.  The Vision/Mission Statements of IDAA follow:

    - Vision:  IDAA envisions recovery for all health care professionals and their families impacted by addictive disorders.

    - Mission: The mission of IDAA is to carry the message of recovery to health care professionals and their families.

     

    - W. Haning, MD

  • July 31st, 2018

    Subtopics - hepatic mortality, confidentiality in addiction health records, early discharges from treatment, epidemiologic correlations, cannabis contaminant, doctors with addictions, cocaine testimonial

    • The British Medical Journal article on increased alcoholic hepatic mortality reads well against a JAMA article drawn from 70 years of Australian statistics (below), citing the correlation between alcohol/tobacco consumption and declining cancer deaths.  The teasers raised by the former article are of course what factors would contribute to increased consumption of alcohol, or to increased toxicity of the alcohol being consumed.
    • A discussion of proposed Title 42 US Code changes reflects the need for balance between privacy and effective communications in providing addiction treatment.  At the same time, the prevailing climate of commercial and even governmental intrusion into privacy is likely to make the Congressional discussion adversarial.
    • A review of early discharges from treatment is itself another discussion of balance. There is a theory that intervention during a crisis, such as an emergency room visit (e.g., SBIRT), provides a powerful impetus towards effective treatment; but it is countered by concern that too premature or forceful a referral may lead to early discharge against medical advice.
    • Brodifacoum, a vitamin K antagonist, has been identified as the contaminant responsible for hemorrhage in users of synthetic cannabinoids. The next question to be answered is, how did it get there? One mundane hypothesis is that it may have been used to control pests in the production of the plant material generally used as a vehicle for synthetic cannabinoids; or even in cannabis agriculture  subsequently augmented with synthetic agents. User blogs have cited the poisonings as another argument for legalized, regulated cannabis production.
    • A long-standing tenet of substance use disorders as they affect our colleagues has been that doctors develop addiction at the same rate as the general population; but they differ from the general population in their choice of substances.
    • A celebrity’s discussion of her cocaine use and recovery is cogent in light of the increasing attention being paid to sources of burnout among physicians.

    This week, International Doctors in Alcoholics Anonymous (IDAA, https://www.idaa.org/ ) - which happily includes the spectrum of healthcare providers and  their families, and the full range of substances and processes of addiction – meets in Reno, Nevada. It's not too late to go; as we are accustomed to hearing from recovering patients and friends, you are only ever truly late for your first meeting.

     

    - W. Haning, MD

  • July 24th, 2018

    Voting/opioids

    A recent JAMA Network piece (below) hypothesized and then demonstrated a correlation between regional voting patterns and chronic opioid use, in 2016.  Unsurprisingly, the study is already coming under fire both with accusations of selection bias and as a politicization of demographic research; as any mention of voting affiliation in the present national political climate is bound to provoke reaction. One critic’s contention has been that the impoverished and less-educated voters were those using opioids chronically; when, in fact, it could be that this was exactly the population that did not vote, as elections are unlikely to hold a high priority for those who are busy using drugs, and that the balloting results reflect instead those voters who were best able and motivated to get to the polls.   Another’s is that the voting pattern reflected dissatisfaction with an environment that was threatened by the high level of drug usage.  None of these contentions is easily supported or refuted on the available evidence.  Where the authors deserve special applause, it is for venturing into deep water. Ultimately the difficulty faced in examining these results is whether the data are interpreted politically or epidemiologically.  As it includes a discussion of a similar study in 2012, a reading of the full text is strongly encouraged.  

    - W. Haning, MD

  • July 17th, 2018

    Culpability and illness

    Yesterday released was an opinion by the Massachusetts Supreme Judicial Court relating to a probationer who was incarcerated, consequent upon violating her terms of probation by usage of fentanyl.  The case served as a ground for contention between experts in the fields of addiction and criminal justice.  The embedded link is from WBUR, Boston Public Radio, and when read against of the background of the actual opinion, Commonwealth vs. Julie A. Eldred [provided separately, Dr. K. Freedman], reasonably construes the essentials of the case. The prosecution contended that by illicitly taking a drug, and thus violating her probation, she defied a directive and warranted incarceration. Initially refusing inpatient SUD treatment when the violation came to light, she then accepted the opportunity after 10 days of imprisonment. 

    Read Judges Can Require Drug 'Users' On Probation To Remain Drug-Free, Court Rules (WBUR)

    The argument against imprisonment was that an individual's relapse to use represented a worsening of the illness, that the worsening was beyond the control of the sufferer, and that a punitive response was inappropriate. However, the case placed at risk the foundation for the current system of contingency management-based drug courts, most of which operate on an assumption of rapid adverse consequences to achieve compliance with therapeutic objectives. The premise is that an effective drug or DWI court requires both arms of operant conditioning: reward and punishment.  The opinion of the court in this matter reflects an understanding of the behaviors associated with addiction, even while superficially constituting punishment of an illness state. The confounding attributes of addiction as we all see it in our patients is a combination of both volition and susceptibility.  Employment of event-triggered consequences aims to reduce the factor of volition.  The common analogy of addiction using diabetes mellitus would suggest that the person with diabetes should not be punished for allowing her blood glucose or hemoglobin A1c to go out of bounds; but the analogy fails when examining the consequences, which, while wasteful and injurious, are not criminal. …Mine is hardly the last or wisest word in this matter, and I am confident that others will find bases for further dispute. But what I believe can be said is that the element of accountability in addiction appears to have been fairly and thoroughly examined.

     

    - W. Haning, MD

  • July 10th, 2018

    In the Mu and CB receptor cross-hairs.

    Dr. Mark Gold, well-known, and author of a blog deserving the strongest endorsement (“Research You Can Use), referred an article from Lancet by Gabrielle Campbell and associates, Volume 3, No. 7, e341–e350, July 2018:  Effect of cannabis use in people with chronic non-cancer pain prescribed opioids: findings from a 4-year prospective cohort study: [open-access].  The study enrolled 1514 participants with noncancer pain, of whom 295 employed cannabis for analgesia. It was conducted by a group that includes recognizable names in the field from Australia and the United Kingdom.  One sentence from the Findings section serves as a synopsis:  “We found no evidence of a temporal relationship between cannabis use and pain severity or pain interference, and no evidence that cannabis use reduced prescribed opioid use or increased rates of opioid discontinuation.”   While not designed to address individual cannabinoids, the study ought to serve as a brake on any riotous enthusiasm for providing cannabis per se as an analgesic.

     

    - W. Haning, MD

  • July 3rd, 2018

    Doctor-as teacher
     

    I sit in the smaller of two offices, more of a cubicle, really, with a view of the dealer preparation parking lot for a Chevrolet outlet. My task, as I suspect is true for many of you, is frenetically getting through the stack of items that have a July 1 deadline. The calendar is a menacing spirit. I would curse Pope Gregory, but I imagine that his intention was good: to impose order. Unfortunately, imposition of order is the core principle of imprisonment.

    Episodically, I participate in a teaching exercise at my high school.  One such was yesterday.  The invitation comes from the science department head, Daniel Gaudiano; the students are 16 to 17 years old, and they have voluntarily enrolled in a summer program to examine the tenets of science.  The course blends several pedagogical techniques, one of which is problem-based or case-based learning, increasingly the medical education standard in this country.  40 students, in groups of five, have identified eight topics; each cluster of five students accepts one of the topics, creates an avatar - in this case, an emblematic patient for one of the eight disorders under discussion - and then explores what the illness means to that fictional person, and the community resources for managing it. I get invited because at least one of these 2-1/2 hour sessions is on "Addiction." Some years ago, it was pretty much all about Substance Use Disorders. But in yesterday's session, exactly half of the presentations were on what we have come to name “process addictions,” compulsive and destructive behaviors that have much in common, either phenomenologically or neurophysiologically, with substance use disorders.   Questions posed to me after the session suggest that several of the students are startlingly close to understanding the unified-field nature of these disorders.

    The kids are shining-bright. Although some are shy and hesitant, all present individually-researched learning issues from within their respective cases, standing up before the most critical of all audiences, their peers. Some are bold, some fearless, some retiring; all are well-informed and tolerate intrusive questions from their facilitator, me. By the conclusion of the 2-1/2 hours, I am exhausted; they, as we might expect, are energetic, focused less on their appetite for knowledge than on their appetite for food, and not in the least in need of a nap. Their questions to me, at the conclusion of each of the eight cases, are carefully crafted and challenging. It is a reminder to me that old people do not hold the corner on knowledge; most of the time, they hold only a corner on old knowledge.

    - W. Haning, MD

  • June 26, 2018

    Crime and Punishment, minus crime.
     

    The segregation of children from their parents as a Federal response to illegal immigration has generated an extraordinary public reaction. Several national professional associations have been among the respondents; indignation and even anger are expected responses to any maltreatment of children.  The pertinence of this to the field of addictions has obvious examples.  Children are of course especially vulnerable to exploitation as a result of being defense-deficient, both psychologically and physically, when compared to adults. The upshot is that they may be used as mules for carrying drugs, or be inducted into addiction in conjunction with servitude, domestic, industrial, or sexual. Two links to the popular press follow, which interestingly make reference to Great Britain's recent enactment of a statute that includes the possibility of life imprisonment for child slavery. Slavery is, if course, imprisonment or restraint in service to the wishes of the enslavers, and does not require that the persons so enslaved be compelled to physical work.  It can be sufficient to use them as hostages in obtaining demands placed on others: 

    Drug mules:  https://www.reuters.com/article/us-britain-slavery-drugtrafficking-child/uk-targets-gangs-who-use-child-drug-mules-with-tough-anti-slavery-laws-idUSKBN1DS2K3

    Drug mules 2:  https://www.reuters.com/article/us-britain-slavery/from-child-drug-mules-to-migrant-smuggling-reports-of-slavery-soar-in-britain-idUSKBN1H21G7

     

    As those involved in the identification and treatment of addiction, we are equally if not more familiar with the nexus between childhood trauma and subsequent drug and alcohol use. Isolation and segregation are simply specific types of neglect, neglect that emerges later in self-soothing through the use of drugs.  The astonishing thing is how many children evolve healthily in spite of childhood neglect and trauma, a demonstration of human resilience; but we recognize how effectively that resilience is sabotaged if drugs or alcohol are introduced.  Two examples of pertinent literature follow, on childhood experiences contributing to later drug use: 

    1. Lamya Khoury et al.,  Substance use, childhood traumatic experience, and Posttraumatic Stress Disorder in an urban civilian population in 2010, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3051362/
    2. Hannah Carliner & associates in the Journal of Child and Adolescent Psychiatry, in a study drawn from the National Comorbidity Survey:  https://www.jaacap.org/article/S0890-8567(16)30212-X/pdf

     

    Our clinical response to addiction is clear; what is sometimes more difficult is identifying prophylactic public health interventions.  Yet here is one: the abolition of isolation and segregation of children from their parents is an obvious intervention.  So we circle back to that word, "indignation," because I find it difficult to write these words - evinced by my regression to a stilted style - without growing angry over the thousands who will be damaged and at explicit risk for addiction.

     

    - W. Haning, MD

  • June 19, 2018

    Comorbidities and recovery
     
    This upcoming weekend marks the 48th annual celebration of Gay Pride.  June also marks the 57th anniversary of the MMWR issue identifying a cohort of gay men with Pneumocystis carinii pneumonia, later marked as the beginning of awareness of the AIDS epidemic .  As understanding of the vectors of HIV developed, it became apparent that the retrovirus could be communicated by injection drug use. That of course was not the only role that drug use had to play in propagation of the epidemic; disinhibition associated with any source of intoxication, as well as erotic enhancement from stimulants, were zones of crossover between the study and management of both infectious disease and addiction.  It is this example of disciplinary crossover that best demonstrates the need for the field of addiction medicine, akin to but not identical with addiction psychiatry.
     
    In 1990 I met an émigré poet and essayist from Singapore, who ultimately left Hawaii to settle in, and die in San Francisco.  Justin Chin was 46 years old when killed by an AIDS-related CVA in 2015, a fact unknown to me until recently.  I ought to know better than to think the consequences of the plague done.  Yet I continue to be stunned with each of these later deaths; as though some historical era, neatly bounded by Randy Shilts at one end and the advent of HAART at the other, had passed.  It has not, any more than the millennia of endemic, occasionally epidemic addictions have.  In his poem “Grave,” Justin Chin wrote:
     
    I used to have this theory about how
    much life a human body could hold.
    It all had to do with the number
    of heartbeats. Each human is assigned a number
    determined by an unknown power cascading
    over the dark waters of the unformed Earth.
    For some, it was a magnificently high number,
    seen only in Richie Rich comics, and for others,
    it was frightfully low, like twenty-six.
    No bargaining, no coupons,
    no White Flower Day sale, no specials. Once
    you hit your number, you croak.
     
    Justin’s number was 1,692,432,000 heartbeats.

     
  • June 12, 2018

    Literature Sampling and Fellowships

    I do not do this sufficiently often.  I wish to acknowledge the heavy-lifting regularly provided by my fellow editor, Dr. Nick Athanasiou.

    …This week’s pieces touch on the following topics, in order:

    - Suicide rates and substance use correlations

    - Interventional proposals to avert opioid deaths

    - Quantitative authoritative opioid poisoning mortality data

    -  Impact of naltrexone on comorbid alcohol use disorder and HIV disease in inmates

    -  Standardization and immediacy of SUD care requirements in emergency medicine settings

    - Written assistance from ASAM in assuring provider network recognition as an addiction specialist

    - A sample anti-stigma scheme

    Those program directors creating new addiction medicine training programs will have already discovered that the Residency Review Committees (Ad Psy & Ad Med) expect some consistency across the respective specialties in curricular content. Some of this is also a matter of form, with Journal Clubs employed to increase interaction between fellows and faculty while meeting both Core Competencies of Medical Knowledge (MK) and Interpersonal and Communication Skills (IC). Residents collaborate with each other and ideally across programs in identifying suitable topics for in-depth analysis, and then open them up to discussion. The editors have had good outcomes using the ASAM Weekly as a means of helping meet those competencies and their associated Milestones, and providing at least one hour of the expected weekly didactics for residents or fellows.  My point - and, to paraphrase Ellen Degeneres, I do have one – is to remind Program Directors of this one shortcut to establishing a Journal Club when working with a limited number of fellows, and often only one.

    (While today’s is a considerable breadth of reading, even for those of you already employing the Weekly in your fellowship programs’ journal clubs, I will add one item while it is still available in full-text, open access online.   It identifies additional needs for effective implementation of SBIRT in police custody settings:  Addison M et al., Alcohol Screening and Brief Intervention in Police Custody Suites: Pilot Cluster Randomised Controlled Trial (AcCePT)  

    - W. Haning, MD

  • June 5, 2018

    Accountability

     

    Dostoevsky's original title for "Crime and Punishment" was "The Drunkards," intended to be a fictionalized discussion of the disorganization of a family under the influence of alcohol.  Most in my generation will recall reading the novel for high school Advanced Placement English or in college, and possibly recall sympathizing with the protagonist, Raskolnikov. His character is painted in highly sympathetic terms that appealed well to adolescents or young adults, even at the same time that his anguish and guilt were not easy for us all to understand. The task became easier when we had decades of experience with addiction, direct or through our patients. 

     

    In the 29 May New York Times editorial, "If Addiction Is a Disease, Why Is Relapsing a Crime?**[link below]", the author cites a case before the Massachusetts Supreme Judicial Court regarding the incarceration of an addict who resumed drug use.  If I re-state the previous phrase as, "…the imprisonment of a patient with substance use disorder because of worsening condition and relapse," the action appears imbecilic.  This is not bowdlerization or sweetening of language; it is an important re-framing. Our patients do not do stupid things because they are intrinsically evil, but without question they do stupid things; alcohol and drugs are solvents of good judgment.  The public servants who would care for them and for the community are similarly conflicted; that ambivalence is reflected in the title given to a prison in which almost 2/3 of the inmates were voluntary, the Lexington Federal Medical Center.  The argument for treating people with addiction differently from other types of patients comes from a model based on epidemic control [see below, You’re Not a Drug Dealer? Here’s Why the Police Might Disagree]: the notion is that the carriers of illness must be isolated from the rest of the population.  But prisons are rarely good treatment centers or hospitals, and release into the community of an untreated person still carrying the illness makes no sense.  Batya Swift Yasgur in the 29 May Psychiatry Advisor, “Court-Mandated Substance Abuse Treatment: Exploring the Ethics and Efficacy* [link below],” provides a thoughtful review of the efficacy of mandated treatment, noting particularly the many and sometimes conflicting meanings  of “treatment.

     

    A cynical juxtaposition occurs when next reading the article from New York, “Purdue Pharma Knew Its Opioids Were Widely Abused by Late ’90s [below]”.  The piece describes an example of institutional antisocial behavior with severe national consequences, that went largely unpunished.  Just as with the person who relapses, so we have certainly seen recurrence of these behaviors by some manufacturers despite being confronted. But unlike the case with the person who relapses, the issue is one of greed rather than illness. Here is an instance where the public weal would be better served by application of consequences to self-interested bad behavior; rather than as in the case of the person with addiction, with applying penalties as a substitute for treating sickness.

     

    - W. Haning, MD

     

    *Yasgur BS, [ https://www.psychiatryadvisor.com/addiction/is-court-mandated-substance-abuse-treatment-ethical-effective/article/768718/?utm_source=newsletter&utm_medium=email&utm_campaign=pa-update-dmd-20180531&dl=0&DCMP=EMC-pa-update-dmd-20180531&cpn=Psych_MD%2cpsych_all%2clytics_urologicaldisorders&hmSubId=&hmEmail=F6Bw4na-mnwkVjqoRE9t5HkTAXc2eBD_0&NID=1679527691&spMailingID=19653041&spUserID=MzQ0NTg0Njg2NzA5S0&spJobID=1261830382&spReportId=MTI2MTgzMDM4MgS2]

     

    ** NYT Editorial 29 May 2018, https://www.nytimes.com/2018/05/29/opinion/addiction-relapse-prosecutions.html?smprod=nytcore-ipad&smid=nytcore-ipad-share

  • May 22, 2018

    Memorial Day; Postgraduate Training Support; Quiz References

    1. This is being written in the week before Memorial Day, but should arrive while the event is still fresh in memory.  Dr. Jonathan Shay, in Achilles in Vietnam: Combat Trauma and the Undoing of Character, writes: “Mind-altering substances of all sorts seem to have been the main shrines to which American soldiers brought their grief. [JS provides an illustration from the account of a veteran writing of the days immediately after the death of a special comrade in arms, and who was subsequently alcoholic: -wfh] ‘And I cried and I cried and I cried. They started giving me I don't know what kind of pills. They gave me some pills. And I had to write down what happened, because there was nobody to be identified. He would have been missing in action. So I wrote the letters.’”  While we are encouraged to characterize the illnesses we treat using diagnostic criteria, it is necessary to consider them in context; in this instance, in the context of war. No illness is suffered in isolation.  To those readers who have served, and who treat those who have served, please accept our respects this week.
    1. Presently before Congress are two companion bills relating to postgraduate training support from the federal government for fellowships in addiction medicine and addiction psychiatry. The bills are financially substantial, coming at a time when future support of all postgraduate medical education funded through CMS is uncertain. Readers with involvement in academic training centers are encouraged to read these bills.  The following is a précis provided by the American Association of Medical Colleges:   The Opioid Workforce Act of 2018 (H.R.5818, S. 2843)
    • Introduced May 15, 2018 by Representatives Joseph Crowley (D-NY) and Ryan Costello (R-PA) and Senators Bill Nelson (D-Fla.) and Dean Heller (R-Nev.)
    • Increases, by 1,000, the number of Medicare supported direct graduate medical education (DGME) and indirect medical education (IME) slots available to hospitals that have or are in the process of establishing approved residency programs in addiction medicine, addiction psychiatry, or pain management.

     

    1. Some readers may not have seen the correction of an omission to the short quiz, providing an explication of the "correct" answers; I was delighted at how many people asked for justifications. The citations are reiterated here for convenience.  This is one of the benefits of an electronic versus a paper medium:

    - Question 1.C [Lofexidine differs from clonidine principally in its regulatory designation; use of clonidine for opioid withdrawal has been common for 4 decades but without FDA designation.  Alpha-2 adrenergic agonists are not recommended for alcohol or sedative-hypnotic withdrawal, as they mask autonomic dysregulation without improving safety.  Hypotension, orthostatic and occasionally resting, is a common side effect. Lofexidine is a prescribed but not Controlled agent. -wfh]

    - Question 2.A [See Miron JA, Zwiebel J, Alcohol Consumption During Prohibition, NBER, April 1991,http://www.nber.org/papers/w3675 ].  While Prohibition was initially very effective in reducing consumption, morbidity, and mortality from alcohol, by its conclusion alcohol consumption had slowly risen to pre-Prohibition levels.  The trend continued following Prohibition’s repeal.  An excellent general resource, entertaining and poignant, is Daniel Okrent’s "Last Call: the Rise and Fall of Prohibition," published in 2011.  – wfh]

    W. Haning, MD

  • May 22, 2018

    Readership self-audit

    These (2) questions relate to the items abstracted in this issue.  Sorry, no CME credits, as yet; virtue must be its own reward.
    1)    Which of the following is true of lofexidine (below, US Food and Drug Administration)?
    a.    Lofexidine is a unique pharmaceutical, unrelated to any presently available.
    b.    Alpha-2 adrenergic agonists improve safety of withdrawal symptom management in all substance use disorders.
    c.    Unlike clonidine with similar phamacodynamics, lofexidine has been FDA-approved for the specific indication of opioid withdrawal.
    d.    Hypertension is a common side effect. 
    e.    Lofexidine is a “scheduled” (controlled) medication, suitable for long-term opioid use disorder management.

    2)    If the analogy of American alcohol consumption during and following the era of Prohibition holds true for termination of the sports betting restrictions, which of the following will be the most likely consequence? (See “Sports Betting Ruling…” below)

    a.    Prevalence of gambling will increase.
    b.    Prevalence of gambling will remain at its present level.
    c.    Prevalence of gambling will diminish.
    d.    Alcohol use nationally will diminish as drinkers shift compulsive behavior onto gambling.
    e.    Americans will self-regulate their expenditures and demonstrate responsible gambling. 

     
    On Associations and Causations:
    In 1935, Mauna Loa, a volcanic neighbor of the one that is presently erupting (Kilauea), sent lava down towards the city of Hilo on the island of Hawai`i, the “Big Island”. The Army Air Corps bombed the channels or rifts through which the lava was flowing and two days later the lava stopped, cooling and forming a large dam without running into the town. Over the ensuing 83 years, the argument remains alive as to whether the bombing had an effect, or was mere coincidence.
    Most doubt that it had much effect on the lava flow. It had, however, a notable effect on the morale of the territorial inhabitants of the time, who were accustomed more to being exploited than supported by the continental United States. Somebody was doing what they could do.

     

    Answers

    1)    C 
    2)    A 

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

     

    Citations:

    1. [Lofexidine differs from clonidine principally in its regulatory designation; use of clonidine for opioid withdrawal has been common for 4 decades but without FDA designation.  Alpha-2 adrenergic agonists are not recommended for alcohol or sedative-hypnotic withdrawal, as they mask autonomic dysregulation without improving safety.  Hypotension, orthostatic and occasionally resting, is a common side effect. Lofexidine is a prescribed but not Controlled agent. -wfh]
    2. [See Miron JA, Zwiebel J, Alcohol Consumption During Prohibition, NBER, April 1991,http://www.nber.org/papers/w3675 ].  While Prohibition was initially very effective in reducing consumption, morbidity, and mortality from alcohol, by its conclusion alcohol consumption had slowly risen to pre-Prohibition levels.  The trend continued following Prohibition’s repeal. – wfh]
     
  • May 15, 2018

    Duty

    *Attention is invited to the Journal of Addiction Medicine article, which is open access until 18 May. 

     

    This past weekend, I participated in several graduation events, with graduates of all stripes: Bachelors, Masters, PhD, MD. We do not have dental or osteopathic graduates here, our loss. But watching the oscillating and osculating crowds, mostly excited and happy families, mostly happy at the prospect of being off the financial hook for an education, led to an obvious reflection that in medicine, there really is no final graduation. Keynote speakers at two of these events included Dr. Arthur Kellermann, Dean of the Uniformed Services University of the Health Sciences, and Gen. Eric Shinseki, past Chair of the Joint Chiefs of Staff and past Secretary, Department of Veterans Affairs. Both had unique observations on the process unfolding before them, yet both also emphasized the need for the long view: taking care of oneself if one is to serve, or to care for others. 

     

    Ours is among those professions that obliges an oath, a compact between its members that sets ethical and practical expectations.  The one used most commonly remains the Oath of Hippocrates, a 3000 years-old ritual covenant between physicians and patients.  It is the distinction between a medical degree and any other, in that it entails a sworn commitment, similar to that made by police, officers of the military, and other public servants. There is to my knowledge no equivalent compact for those completing their PhD in Romance languages; even though facility in romance languages is a very good thing, and deserves promotion.  But, except for a casual appeal to the gods for long life, no mention is made in the Oath, of the obligation to take care of oneself in order to be able to run the marathon that is a medical career. This obligation is not gratuitous; if we remain ethically consistent with the advice we are giving our patients and opt not to be the targets of sarcasm, then we can’t afford to model poor health habits.  It’s a bummer, guys, but we have to be as good as our word.  And the only reason that I can be forgiven for such finger-wagging behavior in what is nominally an academic periodical, is that I know that much of the reading audience is in recovery. Just as we do not graduate from medicine, so those in recovery do not graduate from recovery.

     

    Please accept the good wishes of the Editorial Board and Staff for your children and loved ones graduating in this season.

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

  • May 8, 2018

    Final common pathways

    This week, the dominant theme in the addiction literature is opioids; so we concede to that topic primacy, for this issue.   As one Hilo, Hawaii resident reminded me, all volcanic eruptions, like hemorrhages and epidemics, do stop eventually;  in the matter of hemorrhages and epidemics, we do have some influence.

    A line of conversation has recently appeared, in a closed site populated by our colleagues in addiction noteworthy for the practicality of its content and the imaginativeness of its contributors (LMDs). That line relates to the role of inflammation in addiction, posited both as a contributor to the development of the illness and as an important area of study in how best to manage withdrawal, symptom relief, and recovery.  While literature on this topic is young, it is tantalizing; e.g., this brief comment from the University of Colorado, and one of several recently that include a discussion of inflammation in alcoholism:  https://www.colorado.edu/lab/bachtell/research/neuroinflammation-and-addiction; https://academic.oup.com/alcalc/article/52/2/172/2769517#58912744 [currently full-text]. Interestingly, the larger topic of the role of inflammation in behavioral health injury has been acknowledged for some decades. One example is Nancy Andreasen's seminal imaging work involving brain morphologic changes in conjunction with schizophrenia, in which the inflammatory cascade was proposed as a contributor; that contribution is increasingly widely accepted.  [PDF download and CLICK HERE].  While it is important to remember that inflammation is a mediator of change and not necessarily etiologic, inflammatory changes are increasingly supported as a valuable, shared area for investigation in those with addiction.

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

  • May 1, 2018

    Public Recovery

    A link below honors the singer Eminem for a sobriety accomplishment, 10 years of abstinence.  It will be for some a mixed message. Of two, the former and probably more important one is the value assigned to recovery by those in prominently public roles. But exactly because this then puts the celebrity in a position of representing, specifically, Alcoholics Anonymous, it runs afoul of a central premise of that program: anonymity. Many may feel troubled less by the appeal for recognition than by the risk pool that this puts him in. The literature of AA contains many cautions regarding what such a public claim can produce, most concerningly the risk to the individual. For clinicians, this represents the horns of a dilemma: we would like the recovering community to assert the values of hard work and of adherence to well-vetted principles as a component of overcoming a chronic, relapsing illness. The opposing horn is of course that it is generally undesirable to place any one person in such an ego-sensitive posture. If they then slip, it would seem, the fall is from a much greater height. Those practicing in the field have sufficient challenge dealing with the Abstinence Violation Effect, and the difficulty that it creates for those who have had a relapse and would then want to reenter the community of recovering people.

    The discussion surrounding this point goes as far back as the founding of Alcoholics Anonymous; there are arguments on both sides, for and against self-revelation in a public setting. One of the strongest counterarguments has been that no one person may take credit for his or her own recovery in the context of Alcoholics Anonymous. It is certainly possible to do so on the basis of relationship with a physician or other therapeutic agent, but a major presumption of membership in AA is that the individual cannot accomplish recovery alone; and thus has no business asserting personal responsibility for success.  It is among those advisory principles generally thought of as “spiritual”.

    Improvement in medical care requires attention to Systems-Based Practices, one of the six core competencies* of any residency training program, and of which this is one example – involvement of the subject patient population in the design of treatment approaches.  Including the link provides a reminder, which may not be needed, that unlike management of rheumatoid arthritis or diabetes mellitus there is an element of both shame and guilt that distorts both the individual and the public views of this illness, and which commonly prevents those who have sustained the illness from participating in any public policy discussions or solicitation programs. Note that even without such a proscription, the March of Dimes is extremely circumspect in its use of pictures of children in recovery from their crippling illnesses.  It has already been said here and elsewhere, that there deserve to be participatory advocacy organizations independent of programs of recovery such as AA or NA, enabling the person with addiction to have a louder voice. 

    *[ACGME Core Competencies: Practice-Based Learning and Improvement, Patient Care and Procedural Skills, Systems-Based Practice, Medical Knowledge, Interpersonal and Communication Skills, and Professionalism].

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

  • April 24, 2018

    History informing public health response, regarding opioids
     
    An editorial in this past Sunday’s  New York Times has already generated controversy, unfortunately dividing some physicians.  It proposes policy and funding changes that are suggested by, but not directly analogous to two separate historic circumstances: the evolution of the Harrison Act in 1914, and the Federal response to the AIDS epidemic in the 1980s. There are dangers to accepting the analogies, some of the most obvious being that the only drugs available for management of opioid use disorders in 1914 were the same drugs giving rise to the tide of addiction; and that we saw a remarkable investment of those living with HIV in the 1980s-1990s in controlling the epidemic and in regaining health.  This is understandable; those living in addiction are not as likely to accept the fact of addiction.  While nascent for those with addiction, there is as yet no popular equivalent to ACT UP as a patient empowerment group. 

    There are practical suggestions deriving from the editorial that most would agree with, among them the need to trammel pharmaceutical and equipment manufacturers who profit from the situation, and the need to facilitate access, including by the expanded training of physicians, to the available medication strategies. But what is being left out is the longer-term necessity to train those other than physicians who would provide psychosocial therapy, for this is addiction.  It is not solely misuse of a substance, bad judgment, a surrender to hedonism, an expression of poverty and forlorn hope, a fracture of relationships, physical injury and erasure of spirit, but it is all of those things. And to make inroads on addiction requires more than simply substitutive pharmacotherapy, and more than focus on one class of drugs.

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

     
  • April 17, 2018

    Resuscitation and naloxone initiation; the Surgeon-General’s support for naloxone use in opioid overdose 

    It is good to encourage lifesaving acts.  But a focus on medication administration - whether naloxone or flumazenil or magnesium or antiarrhythmic - can be a distraction from the fundamental task.  High-performance CPR is the correct initial response to an unresponsive, pulse-less  individual; and while it can be argued that naloxone, like D50W or chicken soup, can’t hurt, the fundamental concern must be preserving survival while arriving at a determination of cause.  There is every reason to encourage everyone to learn the ways that they can sustain their fellows, particularly as naloxone injection is useless in the absence of circulation and may be ineffective if circulation is not assisted.  Single rescuer high-performance CPR and AED training is commonly available for free, and is increasingly provided to families and schoolchildren with impressive outcomes. Read more on validation of single-operator hands-only CPR and on available training.

    CPR & First Aid Guides

    - Editor-in-Chief: William Haning, MD, DFAPA, DFASAM
  • April 10, 2018

    Prescribing limits

    Two weeks ago, Jan Hoffman in the New York Times reported on an impending CMS rule that proposed to tightly constrain prescribing of opioids. The article described patients’ and providers’ concerns regarding the limitations. Implicit in the rule change were three expected outcomes: 1) reduction in Medicare part D costs; 2) a reduction in the pool of opioids available for diversion; 3) improvement in adherence to best prescribing practices. Difficulties which immediately became evident upon review of the pertinent section within the 231 page proposal included the likelihood that benefits administrators would use the rule to impose onerous pre-authorization requirements upon prescribers: providers already burdened with managing chronic pain disorders. Further concerns included the experience of patients considering committing suicide, as well as those actually having done so, in the anticipation of abrupt medication withdrawal. While the rule limits appeared to conform to the CDC's 2016 guideline for opioid prescribing, they diverged in one salient respect: transformation of a recommendation to a Federal expectation.  In the course of reviewing the assumptions made by the proposed rule, we find studies arguing against the assumption that physician prescribing patterns for chronic pain provide the major source of opioids for misuse.  Recent congressional testimony by Dr. Debra Houry of the CDC indicates that prescriptive diversion is diminishing in importance as a source of overdose deaths. Dr. Stefan Kertesz, Professor and clinician at the University of Alabama and rightly well-recognized as a patient advocate, submitted a written opinion to CMS with over 220 signatories, including from within addiction medicine, in opposition to the proposed rule.  His arguments are lucid and compelling. As of this week, in response to commentary, CMS modified the proposed rule substantially. CMS’s response to advice and feedback warrants appreciative acknowledgment.

    Footnote: Both the intended rule, and the responsive commentary by professionals such as Kertesz and by patients, demonstrate the complexity confronted in any effort to control prescribing practices by fiat. This week, at the ASAM scientific conference, Oxford University Press will release the first edition of the American Society of Addiction Medicine Handbook on Pain and Addiction, the Society’s publication effort to address this complexity, and to supplement the conference’s annual course on pain and addiction.

  • April 3, 2018

    Cannabis

    One item this week addresses concerns with cannabis (Are There Risks from Second-Hand Marijuana Smoke, above).  Apart from examining the public health risks, it is an acknowledgment of a social phenomenon, the timeless search for entertainment and for euphoria. Another which I insert here is more about first-hand use, the false reassurance to physicians of the progressive decriminalization of cannabis: It describes a physician who effectively lost the privilege to practice predicated on his intermittent use of cannabis. Probably more the author's intent, it also discusses the ethics of having physicians evaluated by treatment centers who may then seek to provide treatment for that same physician. This is not a new topic, yet it remains an unresolved one.

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

  • March 27, 2018

    Nicotine, the Never-Ending Story of
    1. Dr. Joseph Blustein flagged this invitation for commentary from the Federal Register: it is in conjunction with an FDA rule proposal to reduce or eliminate marketing of higher-nicotine-content tobacco. The desired outcome would be a public health benefit, in which an imagined portion of the population with lower nicotine use disorder susceptibility would be at lower risk  of developing the disorder. Some of the arguments that have been proposed against this is that it does not reflect the pharmacokinetics of nicotine, that is, the willingness of those with nicotine dependence to simply smoke larger quantities of tobacco. However, in our favored role in shaping policy, addiction medicine specialists may wish to keep in mind that any impact on nicotine addiction induction in a nation of over 325 million is impressive. One analogical counterargument is that legal availability of only low-alcohol-concentration beer during the Prohibition era did not completely prevent people from going outside the boundaries of the law to obtain higher-potency beverages. But, from a public health standpoint, there is an attractive face to the analogy: overall consumption of alcohol was reduced, and overall morbidity and mortality from alcohol declined. The proposal provided in any case deserves our input.
    2. In a study provided for the American Association for Geriatric Psychiatry (AAGP) 2018 Annual Meeting (Abstract EI-14, presented March 16, 2018), authors from Vanderbilt University described an open label trial of nicotine patch for late-life depression.  Similar to a study done by McClernon and associates, published in Psychopharmacology in 2006, it examined 15 non-smoking subjects with major depressive disorder (MDD) who were provided nicotine patches. The open-label uncontrolled trial yielded an improvement in depressive symptoms; as one author noted, several of the participants wished to continue the nicotine patch upon conclusion of the study. It is not clear whether in this NIH-funded study the study subjects were informed of the risk of development of nicotine use disorder. The attitude of the authors as reported by the interviewer appeared to be one of satisfaction that an over-the-counter remedy might be employed for this indication, and they propose a larger-scale, controlled trial to follow. This seems seriously premature, with concerns over the ethics of the present study. By analogy, we certainly know from our patients that cocaine will relieve symptoms of depression, an observation that figures prominently in histories of addiction. Low-dosage methamphetamine has been employed episodically in initiating MDD recovery in the elderly, yet this also is not a textbook practice, and the absence of large-scale trials reflects the safety concerns.  Statements relating to informed consent and IRB review are needed elements of a clinical trial report.

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

  • March 13, 2018

    The link provided to a National Public Radio (NPR) story, below, concerns a much-echoed observation regarding the enhanced susceptibility to pain of those receiving opioids. Briefly, the observation is that with increasing doses of opioid analgesia, many patients will find their resting pain levels between doses to have increased, and even to have intensified concurrent with opioid administration. The phenomenon has been dubbed "opioid -induced hyperalgesia," or OIH, and is a variant on the notion of cephalgia (or cephalalgia) medicamentosa.  

    review published in Pain Physician in 2011 by Lee, Silverman et al. (NCBI) pertains. Independent of the importance of this concept for those attempting to manage pain is the likelihood that it may be confused with tolerance, or that nociception and tolerance are interwoven. Not all of those with opioid dependence have pain in the usual meaning of that word; and, similarly, not all pain patients will experience the diminished analgesic effect of opioids as actually increasing the intensity of the pain.  For the moment, this paradoxical effect serves as a sentinel of hazardous opioid prescribing, calling for a reduction or even discontinuation of the opioid.

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

  • March 20, 2018

    Emergency Medicine Physicians and Patients with Substance Use Disorder (SUD)

    Within medicine, those who practice in the emergency setting are those most often confronted with SUD as a crisis. Our training of physicians regarding patients with addiction is generally pretty aversive. The training process runs something like this:

    We make an initial, tentative commitment to entering medicine, based usually on some positive experience during adolescence. The experience may be as simple as the sense of satisfaction following an act of altruism, or praise from someone in the field. Time passes, and we take the MCAT in the midst of a college curriculum saturated with difficult, even arcane topics - physical chemistry, organic chemistry, developmental anatomy, and the like. We matriculate on the tail end of collegiate debt, faced with an additional unsecured mortgage of 1/4 million dollars for medical school.  Meanwhile, we watch our high school classmates go on to get an MBA, marry, and buy that first BMW. We do so without resentment, taking our meals from larcenous vending machines and our fitful sleep sprawled between upright chairs, content that we will be of use. All that we ask of the patient is that s/he 1) tell the truth; and 2) follow instructions. We are then confronted on our first emergency department clinical experience with the obstreperous, even rage full person with addiction, most commonly to alcohol, and are forced into a choice: this person, who 1) routinely lies and 2) will not follow instructions, must be a patient yet doesn’t behave as one. It is unsurprising that the young physician can only resolve this conflict with her projection by deciding that this is not really a patient, but just someone who is behaving badly. She will of course one day discover that these behaviors are not limited to those with addiction, but that invites a longer discussion.

    Overcoming the pejorative viewpoint is difficult but possible if there are resources at hand, agencies and people, with whom to share the burden of meeting this patient's needs. The problem, then, for the emergency medicine physician is not so much the complexity of the clinical issue as it is the awful loneliness of having to try and manage it at 1:00 AM. I believe that our response as addiction clinicians ought be one of availability, as well as of pursuing public policy initiatives that increase our numbers and properly distribute the burden of care.

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

  • March 6, 2018

    Welcome to new staff!

    Karie Evans joins our staff this week as the principal associate for content and publication.  She follows upon Erin Foxworthy. Karie was last with Johns Hopkins  Medicine where she managed newsletters, email marketing, and content publishing. She holds a Bachelor of Arts in Public Relations from American University. We are very grateful for this opportunity to work together, in service to the ASAMW readership.

    The lead article, originally from Trust for America’s Health (TFAH) but as promoted by USA Today, comes close to inferring an apocalypse on the basis of accelerated drug use and a hypothesis of increasing self-destructiveness by the American public.  I’m unsure that the latter premise is supportable.  As noted in previous citations, the degree of opioid use increase is not so dramatic as the lethality of the drugs being used, and the consequent mortality; and this in turn does not approach the magnitude of deaths and disability deriving from alcohol and tobacco use. 

    The need for intervention is certainly real and not to be disputed; but the banner of the USA Today article – “Americans are increasingly becoming more self-destructive in ‘nightmarish’ trend” - appears to be more a projection of the national morale, than an objective interpretation of the statistics.  The case can clearly be made for a broad range of governmental funding restitutions and initiatives in public health, and the TFAH provides a reasoned list of recommendations separately.  

     

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

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

  • February 27, 2018

    Further on SAMHSA best practices for medications to treat opioid use disorder.

    The Substance Abuse and Mental Health Services Administration (SAMHSA) publishes the Treatment Improvement Protocol (TIP) series to provide science-based best-practice guidance for the treatment of substance use disorders and mental illness.  The quality of these TIPs has generally been high, yet perhaps underutilized.  In a continued effort to address the opioid crisis, SAMHSA has published TIP 63, Medications for Opioid Use Disorders, which reviews the use of methadone, naltrexone, and buprenorphine as well as other strategies needed for the treatment of opioid use disorders (OUD).  The TIPs are freely downloadable from the SAMHSA site, https://store.samhsa.gov/home ;  TIP 63 may be directly accessed via: https://store.samhsa.gov/product/SMA18-5063FULLDOC .  A sample of the Expert Panelists, Scientific Reviewers, and Field Reviewers includes Drs. Shannon Miller, Kelly Clark, Sarah Church, David Fiellin, Andrew Saxon, Adam Gordon, and Yngvild Olsen.  The full list runs to 37 equally well-credentialed contributors; I am seeking only to give an example of the range of those involved in any of the TIPs. There are currently 35 publications (“products”) available for electronic download, on opioids, for clinicians; with another 21 products for the general public.  Elements of many may be found in the more-inclusive TIP 63.  By way of tantalizing, they include such titles as: 

    Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders -

    Quick Guide for Clinicians Based on TIP 54, SMA-13/4792.

    Behavioral Health Barometer, Volume 4 – a data set & analyses for CY 2016.

    SMA17-BAROUS-16

    Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants

    SMA18-5054

    Clinical Use of Extended-Release Injectable Naltrexone in the Treatment of Opioid Use Disorder: A Brief Guide

    SMA14-4892R

    …and products targeted to specific language groups, e.g.:

    The Facts about Buprenorphine for Treatment of Opioid Addiction (Cambodian/Khmer Version)

    SMA16-4442KHMER

    [N.B. - The Federal Government maintains many homes for its instructional texts and data collections.  SUD monographs may be found in disparate locations.  With progressively-improving cross-indexing, access to health care instruction and data sets have become less bewildering.  For example, a review of the CDC’s Publications page (https://www.cdc.gov/nchs/fastats/drug-use-illegal.htm ) adds other agencies’ links conveniently to its own list of demographic data sets.]   

    - N. Athanasiou, MD & W. Haning, MD, Editors

  • February 20, 2018

    Cannabis in the management of opioid use disorder

     

    [It is important here to reiterate that the Weekly’s editor is not a spokesperson for the Board of Directors of the American Society of Addiction Medicine but selects and discusses topics that may be of interest to the readers.] 

    At last count, 29 states have given permission for the use of cannabis in the management of a number of chronic and progressive syndromes. Many state legislatures have considered extending this authorization to the management of opioid use disorders (OUDs). Consistently, this has been in response to the perception that there are inadequate means of treatment.  The usual arguments that are offered include:

    1. Cannabis may or even should be used in the management of opioid use disorder, whether in the withdrawal phase or at other points on the timeline of recovery.
    2. Cannabis efficacy has been demonstrated in such treatment.
    3. Cannabis is implicitly safe for use in the management of substance use disorders.
    Contrary concerns are apparent:
    1. None of these arguments has been convincingly demonstrated.---
    2. The implicit moral purpose of these laws has been relief of suffering. While that purpose is commendable, its achievement must include procedures for validating both efficacy and safety.  The history of medicine is replete with examples of raw plants (slippery elm, cinchona bark, foxglove, papaver somniferum) which contain therapeutically useful substances (aspirin, quinine, digitalis, morphine) but which are themselves toxic and inconsistent in content.  A medication’s dynamics, effects, safe therapeutic range and route of delivery, and adverse effects must be known before it is used.  Otherwise it is unregulated research with an uninformed subject.
    3. By acknowledging substance use disorders, and specifically opioid use disorders, as chronic or debilitating diseases does not automatically qualify them for management withcannabis.  This is equally true of other chronic, disabling illnesses.  The indications for treatment with a pharmaceutical agent are efficacy and demonstrated safety.
      1. There is no body of evidence that compellingly supports the use of cannabis or its components in the management of opioid use disorders. The requirements of such research are: respect for persons; beneficence; and justice.  Admittedly, a great obstacle to the development of cannabinoid research has historically been the federal government itself, which in criminalizing use of cannabis has profoundly complicated access and use in humans.  In the absence of adequate studies supporting use this then would constitute uncontrolled and unregulated research in humans.
      2. Human subjects research must conform to The Common Rule, which addresses in detail the requirements for ethical research.  The Common Rule provides guidance for the federal Health Resources and Services Administration (HRSA) in its determination of safe research practices. 
      3. Perhaps the foremost concern is this:  Use of an unvalidated approach risks de-railing those seeking care from treatment with appropriate and validated medications, based on our experience with many other such substitutions (in oncology, in behavioral health, others).  Those with substance use disorders are particularly vulnerable to offers of a quick fix, particularly one with the possibility of euphoria.  For opioid use disorders, the medications with known effectiveness include methadone, buprenorphine, naltrexone.

      4. Research which determines both the safety and efficacy of the component chemicals within cannabis warrants support.

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

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

     
  • February 13, 2018

    Cannabis in the management of opioid use disorder

     

    [It is important here to reiterate that the Weekly’s editor is not a spokesperson for the Board of Directors of the American Society of Addiction Medicine but selects and discusses topics that may be of interest to the readers.] 

    At last count, 29 states have given permission for the use of cannabis in the management of a number of chronic and progressive syndromes. Many state legislatures have considered extending this authorization to the management of opioid use disorders (OUDs). Consistently, this has been in response to the perception that there are inadequate means of treatment.  The usual arguments that are offered include:

    1. Cannabis may or even should be used in the management of opioid use disorder, whether in the withdrawal phase or at other points on the timeline of recovery.
    2. Cannabis efficacy has been demonstrated in such treatment.
    3. Cannabis is implicitly safe for use in the management of substance use disorders.
    Contrary concerns are apparent:
    1. None of these arguments has been convincingly demonstrated.---
    2. The implicit moral purpose of these laws has been relief of suffering. While that purpose is commendable, its achievement must include procedures for validating both efficacy and safety.  The history of medicine is replete with examples of raw plants (slippery elm, cinchona bark, foxglove, papaver somniferum) which contain therapeutically useful substances (aspirin, quinine, digitalis, morphine) but which are themselves toxic and inconsistent in content.  A medication’s dynamics, effects, safe therapeutic range and route of delivery, and adverse effects must be known before it is used.  Otherwise it is unregulated research with an uninformed subject.
    3. By acknowledging substance use disorders, and specifically opioid use disorders, as chronic or debilitating diseases does not automatically qualify them for management withcannabis.  This is equally true of other chronic, disabling illnesses.  The indications for treatment with a pharmaceutical agent are efficacy and demonstrated safety.
      1. There is no body of evidence that compellingly supports the use of cannabis or its components in the management of opioid use disorders. The requirements of such research are: respect for persons; beneficence; and justice.  Admittedly, a great obstacle to the development of cannabinoid research has historically been the federal government itself, which in criminalizing use of cannabis has profoundly complicated access and use in humans.  In the absence of adequate studies supporting use this then would constitute uncontrolled and unregulated research in humans.
      2. Human subjects research must conform to The Common Rule, which addresses in detail the requirements for ethical research.  The Common Rule provides guidance for the federal Health Resources and Services Administration (HRSA) in its determination of safe research practices. 
      3. Perhaps the foremost concern is this:  Use of an unvalidated approach risks de-railing those seeking care from treatment with appropriate and validated medications, based on our experience with many other such substitutions (in oncology, in behavioral health, others).  Those with substance use disorders are particularly vulnerable to offers of a quick fix, particularly one with the possibility of euphoria.  For opioid use disorders, the medications with known effectiveness include methadone, buprenorphine, naltrexone.

      4. Research which determines both the safety and efficacy of the component chemicals within cannabis warrants support.

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

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

     
  • February 6, 2018

    Tobacco Lite

    While Native Meso-Americans have been credited with the cultivation and use of tobacco for over two millennia, the middle of the 16th century saw the European popularization of its use. Until this past century, those who have marketed it have been able to emphasize its supposedly beneficial attributes, whether stimulation or relaxation. It has probably helped the successful marketing of tobacco, whether inhaled or chewed, that the average lifespan of man through most of its history has been under 40 years of age. This would certainly have obfuscated, or even altogether prevented the appearance of any bad consequences amongst its users. Nonetheless, by the 19th century, offers to cure nicotine-dependent individuals of "tobacco-ism" had proliferated, with treatment centers such as the Healy Institute even requiring abstinence from tobacco use as a condition for treatment of alcoholism or opioid addiction. While pharmacotherapy may be somewhat more rational now, it certainly had strong advocates throughout the past two centuries. The economic return on tobacco distribution was enormous, even considering the profound populational morbidity, and it is easily understood why: the principal impact on the working population would not be seen until they had reached  the conclusion of their useful life spans. Consequently, most experimental manipulations of tobacco or nicotine-delivery systems have focused on comfort, rather than on safety. And while historical efforts to manage the irritation caused by combusted tobacco have ranged from long cigarette-holders and pipe stems, to filter mentholation, to the hookah or water-pipe, there is no current pretense that any one of these delivery systems reduces the smoke’s toxicity.

    This week's lead article from the lay press describes cigarette manufacturer Phillip Morris’s testimony to the Food and Drug Administration, seeking support for a device that heats but does not fully combust tobacco, ostensibly placing it in a risk category somewhere between the nicotine-vaporizing devices and ignitable, smoke-producing tobacco. In defense of the Food and Drug Administration, their task is to identify risks to public safety; and nicotine products are not regulated as drugs per se. The majority response of the panel investigating the request was soundly critical of the new device.

    The company's description of the product as reducing the risk of tobacco-related disease is an invitation to spectacular sarcasm. It begs a competition for analogies, which prove easy to find: reducing the number of bullets chambered in a revolver prior to a game of Russian roulette is one possibility. The most recent potential simile was the National Football League's creation of a graded scale for return to play based on the severity of a concussion. Perhaps no analogy serves quite so well as the FDA's own intention, noted in the article, of progressively lowering the nicotine content of cigarettes so as to produce a type of national "weaning;" a practice, which any dedicated cigarette-smoker will tell you, leads to buying more cigarettes in order to get the same fix. One possible consequence would seem to be a rise in the tobacco companies’ revenues.

    Transitions: This is the final week for Erin Foxworthy, ASAM’s Coordinator and Staff Editor assigned to the ASAM Weekly. It is not an overstatement that any applause for content development must go to her; worn as the phrase is, she has our heartfelt thanks. Erin happily is pursuing an ambition that she has prepared-for over many years, and for which I envy her. E malama pono.

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

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

  • January 30, 2018

    Mortality, Opioids & Tobacco

    In an editorial by Ilana Richman and Harlan Krumholz in the Journal of the American Medical Association (JAMA Online doi:10.1001/jama.2017.19739, https://jamanetwork.com/journals/jama/article-abstract/2668515?redirect=true), a case is made for renewed attention to tobacco control in the US, predicated on that devoted to the recent surge in opioid use -related deaths. A particularly telling statistic is provided: 33,000 deaths associated with opioids in 2015, gauged against an estimated 480,000 deaths annually associated with cigarette smoking. The authors note that 41,000 deaths were attributed to secondhand smoke exposure, thus exceeding the number of opioid-related deaths. As we have recently noted editorially, in writing of the prevailing morbidity and mortality associated with alcohol use, these comparisons are not intended to create - or aggravate - a competition for resources dedicated to respective substances of use. They are useful, however, in reminding us that a long-term view is important when making those allocation decisions.

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

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

  • January 23, 2018

    Cogency of Reviewed Articles

    This week’s editorial comment is largely forgone in order to emphasize the richness of the abstracts included:

    • The New York Times article on disparate access to methadone and buprenorphine treatments identifies an area of bias that may be unintentional but which has been remarked by practitioners for some time. The problem could be ameliorated even if not resolved by facilitating the addition of buprenorphine access to all existing MMTPs.
    • The Business West piece comparing the experiences of Veterans Administration beneficiaries with those of a non-veteran population underscores how veterans constitute a distinct culture; an observation iterated in multiple publications and texts, which invites tailored care.
    • The nicotine potency study in the Journal of Addiction Medicine has multiple implications for quality assurance, for recommendations made to our patients, and for regulation – the last requiring resources for enforcement. But most intriguingly, it reminds us that drug dealers don't necessarily have their clients best interests at heart.
    • The Alcoholism: Clinical and Experimental Research analysis by White and colleagues is remarkable at least for the magnitude of the increase in alcohol-related emergency department visits, 61% over eight years. This sort of observation needs inclusion in discussions of treatment resource allocations. It represents a level of injury to the public which may be less dramatic than seen with opioid-related deaths, but is at least as profound and probably more pervasive (MVA risks, family disorganization, long-term physical comorbidity, size of affected population).

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

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

  • January 16, 2018

    Opioid Policy from the Former Mayor of New York 

    In a Businessweek column yesterday, January 10, Michael R. Bloomberg provides “A Seven Step Plan for Ending the Opioid Crisis.”  https://www.bloomberg.com/view/articles/2018-01-10/a-seven-step-plan-for-ending-the-opioid-crisis

    This article, which has achieved rapid dissemination in our field, has a number of strong points and merits. It also has a number of misapprehensions that seem to derive from confusing policy objectives with good clinical practice. One example is the proposed cap of several days’ quantity placed on an initial opioid prescription, limiting larger quantities to “…doctors who complete specialized education in pain management.” This is misguided, and for more reasons than to assure adequate pain relief. Particularly for those patients who have pain from trauma, access to medical care is limited; and to complicate their recovery further by obliging repeated travel to hospitals or physicians’ offices, ends up affecting most those who can least afford to deal with it. The infirm, the parents of children, and of course the impoverished. It further strains existing resources. This becomes one of several unintended consequences which I am pretty sure Mr. Bloomberg would not want to cause, but is again a risk of confusing therapeutic intervention with public policy. We would all agree with an attitude of harm reduction or even prevention when considering the level of need for opioid pain medications, but even the most committed addictionist will concede that there are pains not solvable with acetaminophen, or even in a matter of a few days. Is it good advice? Sure. Is it bad doctrine? Absolutely. …A longer-term intervention is one that was commenced by the previous Surgeon-General, VADM Murthy, in 2016: the acceleration of training in analgesia and addiction management at the levels of medical schooling and residency.

    It is a valuable contribution when a person with such influence and such acknowledged executive skills addresses a problem that is taking lives. These recommendations deserve respectful consideration, and discussion, and the contributions of the many skilled physicians who have worked with the problem. Doctors of a certain age will recognize echoes of previous initiatives from across decades. But if there is one severe criticism that this plan most deserves, it is for its unilateral emphasis on opioids rather than on the greater problem of addiction, regardless of the substance.

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

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

  • January 9, 2018

    Resources

    Not all who read the ASAMW have access to libraries for full-text materials, e.g., those of the Journal of Addiction Medicine (JAM). A useful supplemental approach to literature review, particularly for notification of open-access articles, is to join the National Library of Medicine’s National Center for Biotechnology Information (NCBI [https://www.ncbi.nlm.nih.gov/]). NCBI provides selective alerts to newly-emerging studies at no cost. An example is McClure et al.’s JAM article, Concurrent Use of Opioids and Benzodiazepines: Evaluation of Prescription Drug Monitoring by a United States Laboratory, J Addict Med 2017 Nov; 11(6) 420-426 [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5680991/]. Examining  231,228 sets of test results from 144,535 patients, the authors identified a high correlation between opioid use and benzodiazepine use, among patients for whom one or the other was prescribed:  “…laboratory test results indicated concurrent use of opioids and benzodiazepines in over 25% of patients. In 52% of test results with evidence of concurrent use, 1 drug class was prescribed and the other was non-prescribed.” This appears to further underscore the utility of combining body-fluid drug testing and prescription drug monitoring programs (PDMP) in identifying risk among patients with opioid use disorder.

    Follow-up: Several readers correctly identified a deficiency in a review of a cannabis-related article from the 11 July 2017 ASAMW. This was addressed in a correction posted within the Editorial Comment of 02 January 2017, https://www.asam.org/resources/publications/asam-weekly/asam-weekly-editorial-comment, with our thanks. We hope always to show appreciation of criticism and commentaries.

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

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

  • January 2, 2018

    The year in review, ASAMW 2017 – ADDENDUM, see below*

    This issue is a collection of entries for 2017, a recap of those titles that the readership evidently found most interesting in their respective issues. Consequently, it is not representative of the categorical proportions of articles reviewed, in research, clinical practice, policy, or of lay interest. Erin Foxworthy writes, "There are twelve stories below. One from each month of the year, all from the most highly opened email of each month. The articles that were picked were the top clicked, and I was pleased to find that almost half of them were not the lead articles."

    * The July 11, 2017, item deserves cautionary amplification. The source, Fibromyalgia News Today, published in Dallas, Texas, is not a peer-reviewed publication, and the article itself cites no references other than testimony from the product’s developer. Its inclusion six months ago was intended to demonstrate to what we may look forward, as cannabis derivatives – in this instance, cannabidiol (CBD) – are marketed openly without formal quality control or regulation. ASAMW received a number of recent complaints and concerns that inclusion of the citation could be misinterpreted as an endorsement.These concerns are justified and I apologize to the readership for omitting appropriate caveats. 

    A more representative example of a critical review of such articles, particularly as they discuss cannabinoids, can be found in the 25 July 2017 issue. There, claims made for analgesic properties of cannabis were challenged on the basis of inadequate evidentiary support:

    “An entry below, beginning, ‘Cannabis as a Substitute for Opioid-Based Pain Medication:…’ demonstrates several distortions that can and do arise with the current enthusiasm for cannabis as a panacea. It is provided to reflect on the justifications needed for therapeutic recommendations. The journal is an online open access periodical, Cannabis and Cannabinoid Research, published by an enterprise that captures specialty niches, Mary Ann Liebert, Inc., Publishers. The article, and the accompanying polemical editorial which asserts “…that cannabis is a safe, non-addictive product,” suffer from the illusion of balanced scientific inquiry. Of the population surveyed, the response rate was all of 4.3%. Respondents were incentivized by an offer of a vaporizing device, suitable for a variety of chemicals and herbs, via lottery. There was no control population, either active (employing opioid analgesics) or inactive (those receiving neither cannabis nor opioids). The authors correctly identify other limitations, including risk of selection bias by having provided the title of the study to potential participants. Those whose patients have feet in both of two worlds, pain and addiction, have long been aware that there is no completely benign, or even “safe” analgesic. All human pharmacotherapy is a matter of balance; choices must be made between levels of risk and types of risk. The difficulty as we read it is that the authors’ zeal for the possibility of a lower-risk analgesic has outpaced the rigor of their research. There are articles which, however well intended, do not justify therapeutic conclusions.”

    Our active subscriber list exceeds 34,000 as of December, 2017.

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

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