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.

Question for the editor? Email pubs@ASAM.org

  • July 18, 2017

    Physicians in the field of addiction are generally even more sensitive than their peers to the matter of role-modeling, for patients. There is a generally-held belief that patients who actually have an investment in their health and well-being will seek a physician who looks like s/he knows what s/he is talking about. Last week's article in the New York Times, linked here [https://www.nytimes.com/2017/07/13/well/family/when-your-doctor-is-fitter-than-you-are.html?mwrsm=Email ] provides a countervailing view, captured in its subtext, “Doctors who advertise their fitness can seem judgmental of less-than-perfect patients and, rather than inspire them, can drive them away, research found.”   

    Two responses present themselves: one is that the New York Times article, as written, seems to be more of a treatise about successful advertising approaches, than a review of attitudes about fitness in this country. The recommendation to the physician to represent oneself as "all-inclusive", is indicative of the commercialized nature of medicine in this country, whereby we compete by pandering. Other examples include the pharmaceutical imprecation, "...ask your doctor whether (insert name of drug here) is right for you!"  A second response is that I have seen too many badly overweight, cigarette-smoking, under-exercised, fatigued and sleep-deprived, enthusiastically-carnivorous and bibulous doctors in my time; and have certainly demonstrated those behaviors myself. Few or none of them made an active choice to deteriorate, or to abandon former, healthy behaviors. The timeless problem as a faculty member is getting the students and residents to maintain their fitness and other healthy lifestyle choices, with the hope that such maintenance will endure for the marathon of a medical career; so this then becomes a question of, “To which population is the message is being delivered: our patients, or one another?”

    One's selection of a physician because of the physician's personal qualities has long included negative bias. LGBT patients have been necessarily circumspect in choosing a sympathetic physician, when realizing that generally 90% of the physician population identifies as heterosexual; and for the longest time was that, and both white and male. Pursue that thought through the variety of minority experiences, from being Native Hawaiian to simply being poor, and we begin to realize that all the article can tell us, probably not very usefully, is that people have personal preferences for picking a doctor that are unrelated to competence. That should not undermine our collective commitment to behaviors consistent with our therapeutic practices.

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

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

  • July 11, 2017

    Two items warrant your attention this week, and perhaps a third:

    1. As the FDA called for public commentary on its proposed “Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioids,” it was rewarded with a stout barrage of criticisms, some more temperate than others. The following link provided the response from ASAM by its President, Dr. Kelly Clark: [https://www.asam.org/docs/default-source/advocacy/letters-and-comments/asam-comments-on-fda-blueprint-for-prescriber-education-for-er_la-opioids-july-10-2017.pdf?sfvrsn=0]. Similarly, a call for commentary on the FDA’s “Training Health Care Providers on Pain Management and Safe Use of Opioid Analgesics—Exploring the Path Forward,” a mandatory prescribing education program, provoked the following recommendation from ASAM:[https://www.asam.org/docs/default-source/default-document-library/asam-comments-to-fda-re-mandatory-prescriber-education-july-10-2017.pdf?sfvrsn=0]Physicians for Responsible Opioid Prescribing (PROP) and other knowledgeable professional organizations also submitted testimony critiquing the Blueprint draft.
    2. Jane C. Maxwell, Ph.D., of the University of Texas at Austin, commented on last week’s references to Supervised Injection Rooms (SIRs), by remarking the experience in Sydney, NSW, AU: [https://uniting.org/who-we-help/for-adults/sydney-medically-supervised-injecting-centre/inside-the-medically-supervised-injecting-centre]
    3. An acerbic example of “What Your Patients Are Reading” is today’s satire by The Onion: [http://www.theonion.com/article/oxycontin-maker-criticized-new-it-gets-you-high-ca-56373?utm_medium=RSS&utm_campaign=feeds]

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

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

  • July 4, 2017

    A considerable dollop of this week’s contents bear on the effort to control the consequences of drug misuse, and of addiction. One topic coming increasingly to these pages is the provision of supervised injection facilities (SIFs), as a means of diminishing the risk both of unintended fatality from over-estimation of dosage; and of co-morbidity from shared injection devices – e.g., hepatitis, HIV, or even as-yet-unrecognized infectious agents that will become the HIV of the 2020s. It is difficult to know toward which end of the field to run, in this case. To provide an SIF is to risk accusation of “enablement.” To fail to do so is to implicitly encourage the illness and deaths of many whose judgment is impaired. Unfortunately, in the latter case, there will be injured bystanders, as well.

    The solution of relying on long-term clinical trials for guidance is not yet at hand.Clinical Trials are cumbersome and dependent on Federal funding is wishful. And, of course, no one likes injection drug users (IDUs). It is the ultimate confound in trying to diminish the tide of illness, that our patients are unattractive. They do stupid and larcenous and sometimes harmful things, to others as well as themselves. So enlisting sympathy and cooperation on their behalf asks a lot of the many, those who do not use drugs and yet have difficult lives.

    Sir Max Hastings, in Winston’s War (2009, p.483), writes in the context of apologizing for Winston Churchill’s racial and class biases: “…almost all of us are discriminatory, not necessarily racially, in the manner and degree in which we focus our finite stores of compassion.” Advocacy for crippled children, for veterans, and for those with cancers is not so difficult; it takes special forbearance, intelligence, and energy to advocate for those with addictions. The SIF should be understood in this connection, that it is an expression less of cynicism than of compassion.

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

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

  • June 27, 2017

    The 13 June 2017 ASAMW carried a precis of an article in the 31 March issue of Pain Medicine, followed by a lay periodical commentary. The authors’ interpretation of the findings suggested that prescreening of patients with chronic noncancer pain, looking for substance use disorders, is associated with safe long-term prescription of short-acting opioids. While the conclusion is reasonable that it is important to prescreen patients under consideration for opioid therapy, there is a presumption of therapeutic benefit in using short-acting opioids for chronic noncancer pain that is unsupported. Moreover, as all opioid use disorders begin after a period of life without opioid use disorder, screening for addictive risk without fully-validated instruments and in the absence of (as-yet nonexistent) biological markers is unlikely to be meaningful. The current increase in opioid misuse in this country appears driven largely by those who were opioid naïve. The original article concludes that those "… In selected populations such as private, community based practices,” are likely to be at lower risk; but as this is a euphemism for the higher-payer-mix population that is employed and enjoys social supports, it seems to be more of a sociological conclusion than a diagnostic one. The editors would only wish to emphasize that no opioid is without risk of inducing addiction, and no population is without susceptibility to such risk.

    Retraction: In the 20 June 2017 issue of ASAMW, reference was made to the repatriation of the remains of Lord Nelson following the Battle of the Nile. Dr. Raymond Bertino correctly pointed out that to do so would have been premature, and certainly would have altered the course of history; Lord Nelson did not fall until the Battle of Trafalgar.

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

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