Quality & Practice

ASAM Weekly Editorial Comment

William Haning, MD, DFASAM, DFAPA 

Editor-in-Chief

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

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  • May 30, 2017

    In a month that witnessed spectacular oscillations between government parties on the matter of universal health coverage, culminating in this week's combat between a Kansas Congressional candidate and a member of the Fourth Estate – hopefully, reporter  Ben Jacobs had satisfactory health insurance coverage  –  there has been relatively little mention of the systems that work well. In her comments to the graduating medical school class of the University of Hawai`i, two weeks ago by the time of this printing, Vice Admiral Raquel Bono, Director of the Defense Health Affairs Agency, identified significant challenges to the profession of medicine which bear particularly upon our field of addiction medicine. Most of these challenges are familiar to us: new sources of epidemics, increasing demands upon the individual physician’s performance, and implicitly, stressors of daily labor that cause many doctors to question their impact. Dr. Bono oversees one of the two largest single-payer healthcare providers in the country, the other being the Department of Veterans Affairs.  …I will personally attest to one of the greatest joys of working in such a system being the lack of concern that providing a particular therapy or medication, or ordering a given test or image, or arranging a plan for substance use disorder treatment will bankrupt the family or impede its children's educations. Justification of decisions certainly is always required in such a system, but the ultimate arbiter of those decisions is a physician. And, interestingly, the system proves generally to be both fair and economical.   

    Included in her remarks on 14 May was this passage, which I note as an encouragement to members of our specialty: “Even the most senior leaders bump up against the limits of their authority. But while that formal authority will always be constrained, your ability to influence others is potentially limitless. If you can take the time and make the effort to learn to understand the world through the eyes of others, to see the viewpoint of those around you, and to bring them along rather than order them around - then you will exercise the best and most effective kind of leadership."

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

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

  • May 23, 2017

    On one weekend, 8 days past, Honolulu had present the two most senior uniformed Federal health officials, and at two separate events. The 19th Surgeon General of the United States, Vice Admiral (USPHS) Vivek Murthy, spoke at the University’s two commencement ceremonies; and Vice Admiral Raquel Bono, USN,  head of the Defense Health Affairs Directorate, spoke at the convocation of the John A. Burns School of Medicine. Both presented topics that are of particular interest to our community in addiction medicine. I expect to review these comments in the next ASAM Weekly, but one exchange deserves commentary. At a reception, Dr. Murthy held a short colloquium with reception attendees. At it, he spoke of the many populations in medical need, and of his own wish to see participant power bases from those populations created that will help improve their respective health statuses. I suggested that his activities, following departure from the role of Surgeon General, might well include personally building those advocacy groups, and I openly ventured a guess that he might find that a form of employment with enlightened foundations. He smilingly responded that this might in fact be a good job. I then further ventured that one population particularly needy of his attention would be the addicted prison inmates, in this country and ultimately elsewhere. I gave some loose statistics more for the benefit of fellow attendees than for Dr. Murthy, who knows the terrain better than I; and suggested that if there is one population that serves as a repository for the transmission of addiction in this country, and who also provides the most extraordinary opportunity for intervention and treatment in an enclosed setting, it is those 2 million who are imprisoned. Again, smilingly - and convincingly -  he said he would include the population in his list.

    It was a reminder that even with our current difficulties that include assaults on the Affordable Care Act and the potential for assaults on Medicare and Medicaid, there are strong-minded and even brilliant allies at high levels who know the pivot points at which to effect change. While I should like to see such folks engaged as members in the American Society of Addiction Medicine, that attitude is impelled more by a wish to take advantage of their imaginations and knowledge base, than by any wish to proselytize them. They do not require proselytizing. 

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

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

  • May 16, 2017

    1. Please reserve some of your attention for the British Medical Journal report below, centering on lowered mortality associated with opioid substitution treatment for opioid use disorders. The literature is replete with validation of opioid agonist therapies, particularly with methadone or buprenorphine, so this article will come as no surprise to those already in the field. However, it has particular topical moment in the context of the new Health and Human Services’ Director’s view, that such therapy is not productive. While that view is held by a number of people in positions of responsibility, it reflects an unfortunate lack of understanding of the dynamics of treatment and the nature of the illness. I know that there are many of us who would be receptive to providing the information or training needed to avert misguided interruption of access to care with these agents. Highly effective pharmacological approaches to addiction, they provide powerful improvements in mood and impulse management.
    2. The Chicago Tribune piece on "gray death" has of course been taken up by a number of news agencies and media. It is important to note that the substance being referred to is not actually a unique chemical preparation or even a single opioid. It is, as stated, a combination of pretty much whatever the dealer had on hand, heroin, fentanyl, carfentanyl, etc., and not in any particular proportion. The best analogy that I can summon up is of a pot-au-feu, a stew simmering on the back burner of the stove to which ingredients may be added without strict regard for type or for volume. There is no recipe; or if there is, it is very Julia Child in nature: a bit of this, a lot of that, and maybe some of the other. The problem is of course no different from that experienced whenever heroin is being cut: the potency is not reliable and can cause serious misjudgment in terms of safe dosing for the user. The risk is multiplied, however, by the number of substances being employed, and exacerbated terrifically by the astronomical potency of substances such as carfentanyl. For the sake of intervention, this translates as a need to use much higher doses of an opioid antagonist in reversal efforts , or for lengthier periods of respiratory support.

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

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

  • May 9, 2017

    The CDC’s MMWR article below (https://www.cdc.gov/mmwr/volumes/66/wr/mm6603a2.htm)  serves as a mnemonic for several topics.

    1. The unique importance of the Morbidity and Mortality Weekly Report as a monitor of novel, invasive health threats. The obvious historic example of this is its description of the original cohort of AIDS cases, almost 4 decades ago, which surely would have propagated further without the epidemiological alertness provided by the CDC. In this time of Federal fiscal threat, it is important to emphasize the Center’s role in protecting the public.
    2. Despite the public’s tendency to fixate on the all-or-none aspects of opiate overdose, there are intermediate points of injury between complete recovery, and apnea with death. Brain hypoxia can create differential injury according to tissue susceptibility.
    3. While not specifically mentioned, this stimulates reconsideration of the antique diagnosis of "wet brain," an untidy syndrome of dementia in alcohol use disorder with no single area of injury; but tending to most reliably affect, again, the hippocampus.

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

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