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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 Hawai`i, 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

  • October 17, 2017

    Topic – Meditation and derivatives

    A link is featured this week to a Journal of Addiction Medicine piece by Sean Grant and co-authors, reviewing the efficacy of mindfulness-based relapse prevention (MBRP) for substance use disorders, through a review of nine randomized controlled trials with 901 participants. The conclusions were not convincing. 

    Variations on mindfulness meditation (MM) have been employed in several settings. A brief review of recent studies includes one on smoking cessation effect by Margaret Maglione and colleagues (2017), in which MM “…did not have significant effects on abstinence or cigarettes per day…” [http://www.sciencedirect.com/science/article/pii/S030646031730031X]. In 2013, Lauce et al. performed a systematic review and meta-analysis centering on a mindfulness approach to fibromyalgia; they concluded “…only a weak recommendation can be made” for Mindfulness-Based Stress Reduction (MBSR). While pain, nicotine use, and general substance use disorders may be said to represent different therapeutic targets, a common denominator in these reviews and others have been the lack of truly robust findings and the paucity of well-structured placebo-controlled clinical trials.

    I am inclined to want mindfulness meditation to prove useful, in fact any form of meditation. If there is a trait that is remarkable in its deficiency among those with substance use disorders, it is surely serenity. But just as I may have found meditation useful for myself, and have heard others in my field advocating it with vigor, that is not the same thing as saying that we have a solid platform on which to predicate a general application of this approach. One counter-argument to this view is – exempting those with active psychosis – “It can’t hurt!” Yet it can, just not in the usual sense of a direct impact on the patient’s well-being. Addiction medicine, more than most any other specialty with the possible exception of those that are chronic and involve lethality, such as cancer, is subject to hucksterism and snake-oil salesmanship. The desperation of families has caused some addiction physicians to put wishful thinking ahead of scientific rigor, at a time when we strive to earn public trust. But rather than raising an obstacle, it would seem like the interim approach should consist in obtaining consent through information, advising the patients that if they choose to engage in meditation, the evidence for its benefit has not quite reached the threshold of scientific proof; but it is well-rooted in other principles of recovery: rest, self-soothing, and for many, spirituality. All that is necessary is to be honest with the patient. And then it truly can’t hurt.

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

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

  • October 10, 2017

    Engagement of and Education for the Recovery Community

    Recovery, whether through twelve-step programs or otherwise, has been powerfully abetted by those with personal experience of the illness. Yet over the past eight decades, supervision of withdrawal and initiation of early recovery has increasingly been assumed by professional resources, such as treatment centers. We no longer expect the sponsor to show up with a quart of beer and a bottle of Karo syrup; and the field is better, where it is available, for this. But the chronicity of addiction requires long-term, even life-long attention, akin to that we provide for schizophrenia or diabetes; and this is neither commonly available nor reimbursed. The greater need in recovery is that of a mature guide for personality re-development. Stephanie Brown, PhD, (Treating the Alcoholic: A Developmental Model of Recovery, 1985) among others has been instrumental in our seeing that the process of addiction recovery obliges different skill sets, with different goals at successive phases. So, increasingly the question should be asked, in relying on the altruism of those who volunteer, whether we can provide the information needed to provide good guidance. May we not want to do more for sponsors and families of what we do for ourselves, in teleconferences and colloquia? Most sponsors have a script, predicated on their own respective recovery; but that necessarily projects one experience upon the listener. And, while most sponsors rise to the occasion just as most parents do a good job of raising kids, few parents deny that additional training would have been a blessing. 

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

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

  • October 3, 2017

    The 30 September New York Times editorial entitled, "America's Eight-Step Program for Opioid Addiction," includes commentary from Dr. Kelly Clark, President of ASAM, and Dr. John Renner, President of AAAP; it is a brief read. It consolidates appropriate, highly supportable policy recommendations in one document. However, while the points that NYT makes are important and necessary, they are not sufficient. The authors can be forgiven in the interest of concision; when the need for a cohering policy is immediate, a comprehensive document can be an enemy. But I believe that at least two additional, brief points are needed: 1) partners in this public health response must include those who have had measurable success, and cannot by rights exclude the recovering communities represented by Narcotics Anonymous and others – the “patients,” themselves; 2) the response to the opioid crisis must be tied to the larger needed response, to all addiction. I have remarked before that this is not an opioid epidemic, any more than there could be a salt or a sugar epidemic; the wave on which the public’s attention is surfing  is that of opioid poisonings. The disease of addiction is endemic

    NYT link 30 SEP 2017:  https://www.nytimes.com/2017/09/30/opinion/opioid-addiction-treatment-program.html

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

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

  • 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