2015 Conference News

Five-Year Recovery Model Proposed as Standard of Treatment

While addiction is often considered a chronic disease, treatment assessments have a short-term focus. A new model of treatment outcome evaluation that calls for the assessment of patients for five years after entering treatment will be examined in a Sunday session.

Robert L. DuPont, MD, FASAM

Robert L. DuPont, MD, FASAM

“We want to lengthen the time horizon so people don’t think only about what happens to the patients when they are in a treatment program. They need to think about, ‘Then what happens?’ Now, most programs assess what is happening during treatment,” said Robert L. DuPont, MD, FASAM.

Dr. DuPont is the organizer of “Five-Year Recovery: A New Standard for Assessing Effectiveness of Treatment.” The session will be presented from 8 to 9:30 am Sunday in Governor’s Ballroom D, Fourth Floor.

The long-term approach to assessing the success of addiction treatment was developed when Dr. DuPont and two other addiction leaders looked at the State Physician Health Programs. Dr. DuPont is President of the Institute for Behavior and Health, Inc., Rockville, Maryland

“The most striking thing about addiction treatment is how frequent relapses are,” he said. “Often, they are considered a defining characteristic of the disease of addiction. A number of patients in my practice were physicians who were monitored in in the Physicians Health Program and they did very well, so I thought, ‘Let’s look into that.’ There were a number of state programs that had reported good outcomes.”

The Federation of State Physician Health Programs supported a study of 16 state programs where the standard was five years of monitoring program participants with random testing for any use of drugs and alcohol, as well as active career management, including participation in community support programs. The group also examined criminal justice system programs that had intensive long-term monitoring with serious consequences for any alcohol or drug use. Substance abuse treatment of these physicians occurred for only a few months of those five years.

“We were fascinated by the question with respect to all substance abuse treatment, ‘What happens to those people when they leave the treatment?’ What everybody wants out of treatment is to have the disease under control so it is not adversely affecting the person’s life,” Dr. DuPont said. “That standard also is what is used for cancer survival to measure cancer treatment where a standard is five-year survival.

“When you start treating a person, what is the likelihood that person will be in recovery—not using drugs or alcohol or having problems with the disease of addiction—five years later? That is a very important way to level the playing field of assessment for medication-assisted treatment, for abstinence-based treatment, and for all kinds of interventions. If five-year recovery became a standard, all treatment programs would compete with each other to get the best five-year outcomes, like various cancer treatments are compared to each other.”

Other speakers at the session have been involved in the development of the five-year model:

  • Wilson M. Compton, MD, Deputy Director of the National Institute on Drug Abuse, will discuss the brain science behind a long-term evaluation, focusing on brain changes from addiction that are long-term, if not permanent.
  • Thomas McLellan, PhD, Board Chairman of Treatment Research Institute, will discuss how this evaluation treatment model fits into health care in the United States.
  • DuPont will discuss the development of the treatment assessment model and its current status.
  • Mark S. Gold, MD, FASAM, Adjunct Professor, Washington University, St. Louis, will discuss the Physician Health Program and the study of these groundbreaking programs.

“Our paper says, ‘Let’s think about the goal of substance abuse treatment.’ We are proposing that the central goal is sustained recovery. How do we assess the extent to which any treatment program succeeds in achieving that goal?” Dr. DuPont asked. “Of course there is plenty of controversy in the field about whether this is the right goal for treatment.”

Policy Plenary Opens Debate on Buprenorphine Prescribing Limit

Countering all the positive outcomes of buprenorphine treatment for patients with addiction are the negatives of the drug’s misuse that are frequently cited by critics, including legislators who oppose expanded use of pharmacotherapies to treat addiction. Saturday’s ASAM Policy Plenary opened the door to a passionate discussion of how to address the problem.

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(From left) H. Westley Clark, MD, JD, MPH, CAS, FASAM; Scott A. Teitelbaum, MD, FAAP, FASAM; and Mark Kraus, MD, FASAM.

The session, “Consequence of Changing the Buprenorphine Prescribing Limit,” featured H. Westley Clark, MD, JD, MPH, CAS, FASAM, reviewing facts about buprenorphine use and misuse. Then, he and session moderators Scott A. Teitelbaum, MD, FAAP, FASAM, and Mark Kraus, MD, FASAM, opened the floor to discussion from attendees, but the session ended with about a dozen people still lined up at microphones waiting to speak.

Opinions ranged from those supporting physicians being allowed to prescribe buprenorphine beyond the 100-patient limit, to those who questioned a need for that expansion, to suggestions for other options. Two themes often cited by speakers were to remember the patients and to remember what caused concerns about drug misuse.

“From my perspective, it is premature to be discussing the issue of caps. Maybe we should be talking about the quality of care,” said Dr. Clark, the former Director of the Center for Substance Abuse Treatment, part of the Substance Abuse and Mental Health Services Administration. He is now the Dean’s Executive Professor of the Public Health Sciences Program at Santa Clara University.

Dr. Teitelbaum, Professor and Vice Chair, Department of Psychiatry, at the University of Florida, also reminded everyone, “You better pay attention to the opposition and what they are saying. People are trying to do the right thing, and the reality is there is a problem out there.”

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Mark R. Publicker, MD, FASAM, makes a comment during the session, as other attendees line up behind him to speak.

Audience member Michelle Lofwall, MD, University of Kentucky, Lexington, said she had concerns about the lack of physicians in rural areas who had obtained waivers to prescribe buprenorphine, and suggested a compromise to the 100-patient limit.

“Maybe we need a more nuanced approach,” she said. “If we had someone at the limit, let them increase that limit when they are in a dire situation. Maybe we should be tweaking the approach.”

ASAM President-Elect R. Jeffrey Goldsmith, MD, DLFAPA, FASAM, speaking from the audience, discussed the broad patient population he has treated at a VA hospital. When it was suggested that more physicians could prescribe buprenorphine after taking ASAM’s eight-hour course, he said that was not the solution.

“I think we need to get out of narrow-minded thinking. It is not just the prescription,” he said. “People avoid going to treatment. There is a complicated set of problems. You have to appreciate the complexity of the situation and deal with it.”

Following a discussion of the time required to adequately diagnose and treat a patient, Dr. Clark offered a comment repeated during the session: “We want to make sure we don’t become the next pill mill.”

Other comments from audience members:

  • “I have concerns about lifting the limit. I work in inpatient care, and I would have trouble treating more than 100 people.”
  • “We would have fewer deaths if we could increase the numbers. Every time I prescribe, I am taking somebody away from a dealer.”
  • “Legislators listen to us, but they also listen to our patients. We need to look beyond our walls and partner (with patient groups).”

 

Thank You to Corporate Round Table Members

Thank you to ASAM's 2015 Corporate Round Table Members

Ingenuity Health Dominion Diagnostics Cigna Amneal Alere Mallinckrodt Kaleo biodelivery sciences Alkermes orexo ACLS Millennium Health Indivior

Media Award Winner Focuses on Prescription Drug Addiction

The Hungry Heart follows the story of Fred Holmes, MD, (right) seen with patient Dustin Machia.

The Hungry Heart follows the story of Fred Holmes, MD, (right) seen with patient Dustin Machia.

The Hungry Heart, a movie about patients struggling with prescription drug addiction seen from the perspective of a Vermont pediatrician, will receive ASAM’s 2015 Media Award at the ASAM Annual Awards Luncheon. The movie, with a discussion following, screens Saturday during ASAM Movie Night, at 8 pm in Governor’s Ballroom E, Fourth Floor.

Made by Vermont filmmaker Bess O’Brien and Kingdom County Productions, the film follows Fred Holmes, MD, who collected the stories of his patients with the assistance of one of those patients, Katie Tanner.

“They wanted to do a project highlighting the stories of these folks. They wanted to humanize them and break the stereotype of who these kids were,” said O’Brien, who directed the film. People who go through recovery and hit bottom, who go through the eye of the needle and come out the other end, are truly wise and amazing folks. It’s been an honor to be part of their lives and tell their stories.”

The movie, released in late 2013, had such an impact in his state that Vermont Governor Peter Shumlin focused his entire State of the State Address in January 2014 on prescription drug addiction, and he referenced the film several times in the address.

Bess O'Brien

Bess O’Brien

“It was amazing. It was a big deal because no governor had ever focused his State of the State on one issue, or on prescription drugs and opiate addiction,” O’Brien said. “The next day, The New York Times, The Boston Globe, CBS, NBC, Al Jazeera, etc. were focused on Vermont. The idea that the governor in the beautiful state of Vermont was talking about us having a problem was a shock to the system. He pushed the issue nationally.”

Since then, The Hungry Heart has moved from being a regional film to a national statement playing from Alaska to Arkansas to New York. A related educational package has been distributed around the world, she said.

“It is a wonderful way of putting a human face on this issue. The film continues to be booked all over the place, from small towns to cities,” O’Brien said, adding that those wanting to show the movie or have her speak at a showing can visit the Hungry Heart website.

O’Brien has a background in theater and is married to a filmmaker, so she fell into filmmaking more than 20 years ago. She has produced a variety of topical films in Vermont, where she lives, covering subjects such as misuse of opiates, domestic violence, and teenagers. Her next film will be about body image and eating disorders.

“This film came to me through Fred,” she said. “This is just one of many films. I don’t have any direct connection in my family to addiction in that way. I like revealing human stories around particular issues that are a hot topic and sometimes seen only through the eyes of sensationalism or public safety. The Hungry Heart is an intimate look at people struggling with addiction on a daily basis in their lives.

“I am interested in human stories and people’s vulnerability and going straight to the source. I like to hear from the people who are in the trenches. It fascinates me.”

ASAM’s Media Award is presented annually for excellence in print or electronic journalism. This Award is bestowed for a newspaper, magazine, television, radio or website story, column, or program that improves the public’s understanding of addiction, addiction treatment, recovery, or the profession of addiction medicine. A full listing of past award winners is available on ASAM’s website.

Claim CME Credits Using the New e-Learning Center

114x76 bannerAn important part of attending ASAM Annual Conference education sessions is earning continuing medical education (CME) credits, so remember to claim your CME hours using a new process.

ASAM recently launched its new e-Learning Center, which replaced the e-Live Learning Center. Everyone who registered for the Annual Conference or the Pain & Addiction Course automatically has a preloaded account on the e-Learning Center site.

How to Access the e-Learning Center, View Slides and Claim CME:

Go directly to the e-Learning Center, or go the ASAM home page and click on the e-Learning Center button.

Full Registrants-Annual Conference and Pain and Addiction

  1. Select Dashboard from the left menu
  2. Select the conference registered for-Check out slides
  3. Select the sessions attended-For CME
  4. Enter verification code when prompted-For CME:
  • For ASAM Annual Conference: ANNUAL2015
  • For Pain and Addiction: Common Threads XVI: PAIN2015

The CME process has changed from previous years because the new e-Learning Center is a learning management system, an upgrade from the e-Live content capture system. The new system is designed to allow more options for online learning in addition to housing conference education sessions. At the end of the Annual Conference, it will have more than 340 hours of content, and more content will be added in the near future.

You can track your CME credits or print a certificate showing the credits in the Transcript area of the site. All CME credits are archived in the Transcript area so you can go back to print a certificate at any time. You also can save the certificate as a PDF on your computer so you can print it at any time.

ASAM Annual Awards Luncheon

Several people will be recognized during the ASAM Annual Awards Luncheon, from 12:30 to 2:30 pm Saturday in Governor’s Ballroom A-C, Fourth Floor. This is a ticketed event, and tickets can be purchased at Registration.

“We use the Awards Luncheon to take an opportunity to thank our committee chairs and officers who have committed time and effort to ASAM’s mission,” said ASAM Past President Louis E. Baxter Sr., MD, FASAM. “It is an opportunity to recognize people in government who have championed our cause and who have made contributions to the advancement of addiction and addiction treatment.

“We also give young investigators awards to encourage them to become interested in addiction medicine and recognize people in the media who have produced books, movies, and documentaries that add to our visibility and the understanding of the addiction to the general public.

Awards that will be presented are:

  • Presidential Award, Alexis Geier-Horan, MPP
  • Public Policy Award, Michael P. Botticelli
  • Annual Award, Paul H. Earley, MD, FASAM
  • Annual Award, H. Westley Clark, MD, JD, MPH, CAS, FASAM
  • Annual Award, Richard K. Ries, MD, FAPA, FASAM
  • John P. McGovern Award, Mark S. Gold, MD, FASAM
  • Media Award, Bess O’Brien
  • Young Investigator Award, Crispa J. Aechbach Jachmann, MD
  • ASAM Annual Conference Program Planning Committee Award, Terry Horton, MD
  • ASAM/Millennium Research Institute Annual Conference Program Committee Award, Ashwin A. Patkar, MD, MRCPsych
  • Brinkley Smithers Distinguished Scientist Award, George F. Koob, PhD

Managing Patients with Addiction, HIV, HCV a Complex Challenge

Almost 90 percent of patients with HIV also have a hepatitis C infection (HCV), and many of these patients need to be treated for addiction, too. FDA approval of two new drugs, though, has increased the options for the complex management of these patients.

The treatment of these patients is a multidisciplinary challenge that will be explored Saturday in “Clinical Management of Substance Abusers with Co-occurring HIV and HCV Infections.” The session will be presented from 11 am to 12:30 pm in Governor’s Ballroom D, Fourth Floor.

D2_3-Khalsa

Jag H. Khalsa, MS, PhD

“These two new drugs are highly effective in treating hepatitis C infection to such an extent that within 12 weeks of therapy the patient is completely cleared of the virus,” said Jag H. Khalsa, MS, PhD, session organizer. “For physicians, the problem becomes ‘What should I treat first?’ Shall I treat a patient with HIV medications first, or treat the patient with HCV medications first?

“Then, should we treat these drug-abusing patients for drug dependence because they are really not very compliant with treatment protocols? So, the clinical management of this situation of drug abuse, HIV infection, and hepatitis C infection is a very complex and difficult task.”

The new drugs used to treat patients with HCV are directly acting antivirals (DAAs), sofosbuvir and ledipasvir, which can be used separately or in combination. Several other DAAs are in development but have not been approved by the Food and Drug Administration. Previously, patients with HCV were usually treated with ribavirin or gamma interferon, also called pegylated interferon.

Patients with HIV are treated using highly active antiretroviral therapy (HAART), which uses any of the 27 antiretroviral medications or combinations of two or more drugs. Patients with addiction generally are treated with methadone or buprenorphine for addiction involving opiates, and naltrexone for alcohol addiction, said Dr. Khalsa, Chief of the Medical Consequences Branch with the Division of Pharmacotherapies and Medical Consequences of Drug Abuse, National Institute on Drug Abuse, National Institutes of Health.

Joining Dr. Khalsa to sort through these many options will be two infectious disease experts. Jeffrey H. Samet, MD, MA, MPH, Chief and Professor of Medicine, Boston University School of Medicine, will discuss pain assessment in patients with HCV. David L. Thomas, MD, MPH, Professor and Chief of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, an expert in HCV and HIV, will discuss DAA therapy.

“For the person who comes to you for addiction-related infections, this session will show what you should be aware of and how you should refer this patient for further care to an infectious disease doctor or a hepatologist or a gastroenterologist,” Dr. Khalsa said. “Both the addiction expert and the infectious disease docs need to work together on this issue of treating a complex, multidisciplinary medical problem.”

New World of Medicine Focuses on Integrating all Health Care

The evolving universe of health care is quickly moving toward more team-based treatment of patients, which will be explored for the management of addiction in “Advancing the Integration of SUD Services and Health Care.”

“This is where medicine is going—to integration of behavioral services into mainstream medicine, and vice versa,” said R. Corey Waller, MD, MS, FACEP, DABAM, the course organizer. “This course will talk about some of the practical aspects of how to do that.

“We will talk about the legislative and regulatory barriers, and, more importantly, some of the emotional barriers when trying to approach a patient with a disease that not everybody understands.”

The course will be presented from 11 am to 12:30 pm Saturday in Room 412, Fourth Floor. It will feature three other speakers discussing integrated medicine in general and specifics about how their practices use integrated approaches.

“The approach we use for integrated team-based care is also a move away from this thought of one doctor, one patient, and it is more one patient, one team,” said Dr. Waller, Director of the Center for Integrative Medicine at Spectrum Health, Grand Rapids, Michigan. “That team includes therapists, a physician, a medical assistant, and community health workers, and either you integrate those people into the current pathway of treatment, or you change the pathway of treatment so they can be integrated.”

Dr. Waller will discuss his clinic, which is fully integrated with behavioral health and mainstream medical treatments. The Spectrum Health Center for Integrative Medicine is not an addiction clinic, but 85 percent of its patients have a substance use disorder.

“We also treat their medical issues, their psychological issues, and their social issues, and we have been able to fully integrate that into a single platform,” Dr. Waller said. “Attendees will be able to see what it takes to integrate as far as the cost, the structure, the administrative aspects, the barriers, and lessons learned so they don’t have to re-invent the wheel in trying to do this.”

Becky D. Vaughn, MSEd, Vice President of Addictions for the National Council for Behavioral Health, Washington, DC, will discuss her group, which is a society of members who operate behavioral health programs that focus on integration.

“She will bring this national perspective to the table about what is happening in many places around the country and what are some of the barriers they have found,” Dr. Waller said.

Les Sperling, BA, LAC, is Chief Executive Officer of the Central Kansas Foundation, Salina. “He has worked with primary care practices to integrate the aspects of addiction treatment within a primary care setting,” Dr. Waller said.

Ned J. Presnall, LCSW, is Executive Director of Clayton Behavioral, Saint Louis, Missouri, which offers a variety of mental health clinical services. It uses the strategies of cognitive behavioral therapy to help clients understand the sources of their emotional distress and unwanted patterns of behavior.

“The hope is that people walk away knowing this is possible—and inevitable,” Dr. Waller said of integration. “We treat one patient, and to think we can’t do that in one system doesn’t make any sense.”

Workshop Offers Guidance on Helping Change through Motivational Interviewing

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Peter Selby, MBBS, FCFP, DABAM

Working with patients to help them decide what they want to do to solve a problem related to a chronic illness or a behavior change could be a challenge for addiction medicine specialists.

“In medicine, we are trained to fix things and tell people what to do. We’re always looking for what’s wrong with someone so we then can provide a solution,” said Peter Selby, MBBS, FCFP, DABAM, Professor of Family and Community Medicine and Psychiatry, Center for Addiction and Mental Health (CAMH) at the University of Toronto, Ontario.

Dr. Selby will present “Motivational Interviewing: Evoking Change Humanely” with Ramm Hering, MD, CCFP, MSc, Dip PH, who recently completed a fellowship at CAMH. The session will be presented from 11 am to 12:30 pm Saturday in Governors Ballroom E, Fourth Floor.

“Unfortunately, a communication style of trying to fix someone doesn’t work when you’re trying to motivate and inspire someone to address an addiction or change a behavior,” Dr. Selby said.

Motivational interviewing is a compassionate and open way of communicating to help individuals start to make changes they would not have made had they been confronted to make such changes.

A range of learners can participate—whether they are beginners or more advanced counselors. In this interactive workshop, presenters will engage learners with the spirit (compassion, acceptance, partnership, and evocation) and processes (engaging, focusing, evoking and planning) of motivational interviewing.

“They will learn by doing as opposed to learning by listening, making for a dynamic program,” Dr. Selby said. “Motivational interviewing is a trainable skill. It transforms your practice so you can inspire people rather than fight with people to change. Participants will come away with a better way to set boundaries, have compassion for their patients who aren’t able to change, and help those who are ready to overcome their ambivalence to change.”

Intimate Partner Violence Workshop Provides Tools for Intervention

In the United States, nearly one in four women report experiencing violence by a current or a former spouse or boyfriend at some point in their lives. Substance use plays a facilitative role in intimate partner violence (IPV) by precipitating or exacerbating violence.

During a 2:30 to 3:30 pm Saturday workshop in Room 410, speakers will share advances in the basic understanding of how to treat both victims and perpetrators with addiction.

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Richard G. Soper, MD, JD, MS, FASAM, DABAM

Richard G. Soper, MD, JD, MS, FASAM, DABAM, Chief of Addiction Medicine and Chair of the Board of Directors for the Center for Behavior Wellness in Nashville, Tennessee, and Hendree Jones, PhD, Executive Director of the Horizons Program and Professor of Obstetrics and Gynecology at the University of North Carolina, Chapel Hill, are the presenters.

“Most victims have a huge sense of personal shame, embarrassment, and fear. Almost all suffer from post-traumatic stress disorder and depression. A lot use substances to self-medicate,” Dr. Soper said. “There is no way we’ll ever turn some of this around if we are not willing to intervene. We need to help break the chain so the next generation realizes the behavior they have witnessed in their homes between adult companions is not acceptable.”

The workshop will provide clinicians with specialized and practical tools to competently identify past and current IPVs, make brief office interventions to assist IPV victims, and offer strategies to refer victims for subspecialty and community-based evaluation, treatment, and advocacy.

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Hendree Jones, PhD

Health care professionals need to recognize that experiences in infancy and early childhood, including trauma, provide an organizing framework for a child’s intelligence, emotions, and personality. Dr. Jones noted that the midbrains and forebrains of children who grow up in violent and abusive living situations are affected more than their cortexes.

“They enter every interaction as one that may threaten their survival,” she said. “We need to help providers recognize that abuse often starts in childhood and may be experienced in adulthood, unless we can help recognize, address and prevent the abuse.”

“We at least need to raise the level of conversation by approaching victims in a nonjudgmental way. We can use a particular vocabulary and a survey method to screen patients so we then can provide patients with tools and other options,” Dr. Soper said. “There certainly are some boundaries. A lot of situations can be volatile and even fatal, so we need to intervene and move the victim and children to a safe house immediately.”

Intimate partner violence has no discrimination, affecting heterosexuals, lesbians, gays, bisexuals, and transgender individuals equally.

“I don’t know anyone in health care who can say none of their patients have this problem,” Dr. Soper said. “We are not here to judge our patients. We’re here to help them. If my patients can be honest with me, trust me, and talk to me, then I can try to go over our options so they don’t have to be concerned financially or about their safety,” said Dr. Soper, pointing to his center’s own 12-step program that meets weekly, community health centers where they can receive care, Junior League anger management classes, and 24-hour hotlines to get immediate transportation and housing, for example.

Attendees will leave the workshop with a view of childhood trauma that can help guide assessment and intervention with IPV victims.

“We hope to educate and raise awareness so that those who participate leave knowing they can at least have an informal dialogue about how to address intimate partner violence,” Dr. Soper said.