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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

  • September 26, 2017

    Concomitant BZ & opioids; alcohol use disorder prevalence

    1. The FDA Drug Safety Communication regarding concomitant use of opioid agonist treatment (MAT) for opioid use disorder and benzodiazepines has generated much controversy. Apparently intended to reduce the impediments to inclusion of MAT candidates in treatment, the remarks risk being misinterpreted as a legitimization of unchallenged, continued benzodiazepine use. However, a full reading of the text provides an understanding of the reasoning behind the qualified warning, and a reminder of physician discretion.
    2. Grant, Chou, Saha et al.’s report on NESARC data in JAMA is linked below. We believe that its significance warrants re-emphasis. Our original editorial comments on this are reprinted here:

    “The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) is the bellwether recurring survey of high-risk alcohol use in the US. This JAMA Psychiatry advance report from 09 August (published September), flagged by Nick Athanasiou, represents populations of 43K in 2002 and 36K in 2012, thus across one decade. The full text article may be read here,  http://jamanetwork.com/journals/jamapsychiatry/fullarticle/2647079, with free downloadable PDF version on registration. The analysis (2016) and conclusions are striking for their description of an increasing pervasiveness of alcohol use in this country, at the same time that urgent national responses have been advocated for cocaine, synthetic cannabinoids, cannabis itself, methamphetamine, and opioids. The article begins with a rhetorical question, “Have the 12-month prevalences of alcohol use, high-risk drinking, and DSM-IV alcohol use disorder increased between 2001-2002 and 2012-2013?” to which the authors reply, ‘yes.’” 

    An important policy inference when considering the variety of substance use disorders calling for attention is that no one among them should rightfully take precedence over the others. The issue is not the particular drug, but the over-all prevalence of addiction, and the need to respond to the disease process. The  drug(s) of use will dictate much of the initial treatment response – eg, the withdrawal phase – but the specific drug is not the illness, any more than meningococcus is the illness itself rather than the initiating agent of meningitis. A period of increased prevalence does not warrant diversion of research and treatment assets from one substance use disorder to another, but instead invites a more unified-field approach to the condition of addiction."

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

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

  • September 19, 2017

    Community-based Recovery

    Journals of all stripes have focused upon the peak in opioid use in this country. Unsurprisingly, perhaps because of the medical literature’s and the popular media’s attention to the drug class, it has generated a focus on pharmaco-therapeutic responses, above other forms of treatment. The “others” include a range of interpersonal therapies (IPTs), somatic therapies, and social or mutual support approaches. In fact, the subdued attention given community-based programs reflects at least partly a distinction between the concepts of “treatment” and “recovery.” This is an appropriate time to consider the subject of organized mutual support, and the philosophies that drive the versions of this.    

    Familiarity with the 12-Step programs such as Alcoholics Anonymous is fairly general in the treatment community, if not always uniform; textbook and journal references are numerous. But others which choose to self-designate as “non-secular,” sometimes even affecting a scientific origin (e.g., Rational Recovery), are generally less well-understood; and have sufficient community and professional support to warrant understanding, particularly at the addiction fellowship training level. A suggested beginning is William L. White's most recent discussion of SMART Recovery, linked below; a second link gives a chronology of the enterprise as of 2013.

    http://www.williamwhitepapers.com/blog/2017/09/smart-recovery-2017.html

    (2013 Chronology:  http://www.williamwhitepapers.com/pr/Chronology%20of%20SMART%20Recovery.pdf)

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

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

  • September 12, 2017

    The Board of Directors of ASAM met this past weekend to pursue periodic strategic planning for the Society. In the course of casual discussions, there was general agreement that opioid use disorders constitute a small portion of the general prevalence of addiction; and when measured against the consequences of alcohol and tobacco use disorders in the US, less of an epidemic than a flare within a prevailing endemic. Urgent attention is warranted, that is not in contention. But the greater goal of eradication, even control of all addiction, requires reliance on an accurate understanding of both proportions and causes. An example of a study that clarifies both is the JAMA article surveying procedures associated with prolonged opioid use, below, by Schoenfeld AJ et al., accompanied by an LA Times review. On reading the piece, I asked Dr. Jon Streltzer (Hawaii) for permission to include an extract of his remarks from a separate exchange, relating to the trends of US opioid usage: 

    “The opioid epidemic in the United States and Canada began in the 1990s fueled by 'thought leaders' in pain management such as Russell Portenoy, who promulgated the idea that opioids were vastly under-prescribed by 'opioid-phobic' physicians resulting in unnecessary suffering in chronic pain patients. A pain management culture developed based on many false beliefs. These included non-evidence-based beliefs that daily opioids retained analgesic efficacy over the long term; that there was no upper dose limit; that addiction risk was minimal in patients suffering from pain; that chronic pain without objective findings can occur due to 'central sensitization'; that NMDA blockers could prevent and reverse hyperalgesia; that 'opioid rotation' could counteract tolerance; etc. This pain management culture was widely taught in pain fellowships and has been instrumental in creating economic benefits for pharmaceutical companies and physician 'pain specialists'. As the culture of overprescribing has been finally turning around in the past few years, its residual is the increased acceptability and accessibility of illicit opioids.”

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

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

  • September 4, 2017

    Childhood drug use - 

    Of this week's selections, three, and arguably parts of several more, relate specifically to the pediatric and ephebiatric populations. When measured against adults, they underscore the greater adverse impacts upon children, apart from neurologic structural damage, from cannabis, opioids, tobacco, and stimulants. A supplemental point of view is that provided by Dr. Taryn Park, the lead author of an article on adolescent stimulant use in Child and Adolescent Psychiatry Clinics of North America, July 2016 (https://www.ncbi.nlm.nih.gov/pubmed/27338967): in it, she summarizes literature suggesting that adolescents may experience higher rewards from methamphetamine than that witnessed in adulthood. “…Animal models also reveal that the rewarding effects of methamphetamine may be more powerful in adolescence than adulthood. If adolescents experience less aversive properties of methamphetamine use, they may be even more vulnerable to the rewarding effects of use. These findings may help explain the predisposition to use and difficulty with relapse that adolescents experience.” 

    This reaffirms some basic parenting practices; the notion that children require special protections is not novel. The special susceptibilities of the immature brain are compounded by the very nature of childhood and adolescence, where curiosity is at its most intense in the service of cognitive structuring and skills development. The same curiosity that leads to experimentation and learning, however, also impels the seeking of new sensations. In the unrelenting argument about the role of police and judicial action in restricting substance use, this is the area exempt from doubt. The juvenile population is where interdiction, family restraint, and social control are still clearly required and deserve strong support.   

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

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