The American Society of Addiction Medicine gratefully acknowledges these contributions and grants for its 2011 Medical-Scientific Conference, Courses and other events:
GOLD: $20,000 and above
SILVER: $15,000-$19,999
BRONZE: $10,000-$14,999
Chapter Meetings Scheduled for Friday, Saturday
You are invited to attend a meeting of the members in your chapter area during the conference. All meetings will be in the Gunston Room on the Terrace level, except where otherwise noted. The list of meetings is current as of Thursday.
Friday
MNSAM, 8:30 to 9:30 a.m.
CSAM, Noon to 1 p.m.
NYSAM, 1-2pm
NJSAM, 2 to 3 p.m.
Region VIII, 2 to 3 p.m.
Region X, 4 to 5 p.m.
MDSAM, VASAM, WDCSAM, 5:15 to 6:45 p.m. in Lincoln East on the Concourse Level
TXSAM, 8:30 to 9:30 p.m. in Georgetown on the Concourse Level (during Dessert Reception)
Saturday
GASAM, 10 to 11 a.m.
OHSAM, 1 to 2 p.m.
New Members Have Opportunity to Win iPad at ASAM Booth
There are plenty of good reasons to join ASAM, but here’s one more: Everyone who becomes a new member or renews their existing membership will be entered into a drawing for an iPad.
Stop by the ASAM Exhibit Booth (No. 303) during normal exhibit hours to enter.
ASAM is the leading professional society actively seeking to define and expand the field of addiction medicine. Members get free subscriptions to the Journal of Addiction Medicine and ASAM News, and discounts on courses, conferences, workshops and other publications. They are also able to access online job boards and provided with the opportunity to participate in the ASAM Mentoring Network and other networking opportunities with members.
Discounted memberships are also available for medical students and residents.
Print Out CME Certificates Using ASAM Live Learning Center
Handouts, brochures, business cards. There is plenty of paperwork to deal with after attending a conference. Thanks to the ASAM’s Live Learning Center, Medical-Scientific Conference attendees have one less thing to worry about when they get home.
By logging into the Live Learning Center, users will have a chance to see what CME credit they earned at the conference and print out the certificates from work or home.
“This is a great, simple process,” said Lisa Watson, ASAM director of meetings and conferences. “While members are at the conference they should keep record of which courses they have attended. Then they can either come by the ASAM Exhibit Booth (No. 303) where we’ll have computers available for them to log their hours, or log them on their own computer.”
The Live Learning Center will be available about six weeks after the conclusion of the Medical-Scientific Conference through a link on the ASAM home page (www.asam.org).
Sign up to Receive ASAM Weekly, all the Society news
Stay up to date on all the news in the Society by receiving the ASAM Weekly by email.
If you are not receiving ASAM Weekly, stop by the ASAM Exhibit Booth (No. 303) to sign up to receive ASAM Weekly.
All Conference Attendees Registered for PCSS-M and PCSS-P Projects
All Medical-Scientific Conference attendees are automatically registered for ASAM’s Physician Clinical Support System-Methadone (PCSS-M) and Physician Clinical Support System-Primary Care (PCSS-P) projects.
Look for your confirmation email with opt-out instructions when you return home from the conference.
Creator of Video Series to Receive Media Award Saturday
Dirk Wales, creator of the eight-video series from several years ago, “Wearing Masks,” will receive ASAM’s third Media Award Saturday at the Awards Luncheon.
The series educates viewers about the dangers of addiction among anesthesia personnel, physicians, and the addicted population at-large. Addicted individuals hide their disease behind a mask of normalcy; the series removes that mask and exposes addiction in full.
A new video made in honor of the award includes Michael M. Miller, M.D., FASAM, FAPA, Penelope P. Ziegler, M.D., FASAM, and Paul H. Earley, M.D., FASAM, chatting, as well as ASAM’s Definition of Addiction, adopted by the Board of Directors a few months ago.
Copies of a DVD of this 30-minute video, which is built around excerpts from the original “Wearing Masks” series, have been inserted into the conference tote bags and given to every on-site attendee at ASAM’s Booth in the Exhibit Hall.
Update your ASAM Membership information by visiting ASAM Exhibit Booth.
Participate
Be a participant in ASAM’s Patient Placement Criteria research study. Visit the ASAM Exhibit Booth for more information.
ASAM Merchandise
Purchase your “Treat Addiction -Save Lives”TM merchandise at the ASAM Booth. Proceeds benefit Chapters Council programming.
Advertise
Place your advertisement in ASAM’s on-line membership directory/doctor finder during Med-Sci and receive a discount off the regular rate. – See more at: http://asam-365.ascendeventmedia.com/Highlight.aspx?id=2734&p=261#sthash.LEJZx3zc.dpuf
At a conference as large and comprehensive as the ASAM’s Medical-Scientific Conference there are bound to be some hard decisions and missed opportunities regarding which courses to attend.
But just because attendees can’t be in two rooms at the same time doesn’t mean they have to miss any sessions. This year the ASAM is debuting the Live Learning Center. This online extension of the ASAM Website will contain audio from all of the presentations and printable versions of all handouts.
What’s more, accessing the Live Learning Center is free to everyone attending the conference. Non-attending ASAM members will have the option to purchase access to either specific workshops and courses or the entire conference. All content from the Ruth Fox Course for Physicians and the Pain and Addiction Common Threads courses will also be available.
While only 22 hours of CME credit are physically available at the conference, users can earn up to 51 credits through the Live Learning Center.
The Live Learning Center will be available at the end of May through a link on the ASAM homepage (www.asam.org).
The ASAM Medical-Scientific Conference examines a wealth of important and interesting topics for addiction professionals, many of which are addressed in special symposia, courses, and workshops.
One of the dominant topics at the conference is the integration of addiction care into primary care, which will be addressed in a symposium and three workshops Saturday, and in a Sunday workshop that focuses on primary care in a rural setting. Symposium 10, “Addressing Substance Use Disorders in Primary Care and the Patient-Centered Medical Home,” will feature four speakers from 2 to 4 p.m. in the Jefferson Room.
“There is a huge focus on primary care, especially on Saturday,” said Gavin Bart, M.D., FASAM, chair of the conference planning committee. “These are big topics that are getting a lot of attention in different forums. They showcase not only the latest research in the symposium, but hands-on, how-to approaches in workshops.
“To diagnose or treat those issues, or prevent them from occurring, we need to integrate our specialty into primary care and provide support and educational opportunities to primary care physicians so they are aware of how to recognize, treat, and, when they need help, refer to addiction specialists.”
Two related topics are prescription drug addiction and addressing the needs of military personnel returning home from theaters of operation, Dr. Bart said. Both topics will be addressed in sessions Friday. Symposium 2, “Treatment of the Returning Military Veteran,” will be presented from 11 a.m. to 2 p.m. in Jefferson East. Symposium 3, “Prescription Drug Abuse,” will be presented from 3 to 5 p.m. in the International Ballroom West.
Other interesting sessions highlighted by Dr. Bart:
More than 100 ASAM members took advantage of the conference location Wednesday to lobby with members of Congress for addiction-related issues on Lobby Day.
Lobby Day is an annual effort led by the ASAM Legislative Advocacy Committee to speak to members of Congress about issues of importance to the specialty, an effort that has the strong support of ASAM President-elect Don Kurth, M.D., FASAM, who is also involved in politics, serving as the mayor of Rancho Cucamonga, Calif.
“There are significant issues in addiction medicine and the treatment of people with addiction that are still hampered by residual moral thinking about addiction and the absence of a true medical disease model among the majority of the lay population, and that includes legislators,” said Ken Roy, M.D., FASAM, chair of Legislative Advocacy Committee.
“Our effort seeks to help legislators understand that addiction is truly a medical illness and what the data has so far demonstrated about the effectiveness and cost-effectiveness of treatment,” he said.
Lobby Day began Wednesday with a training session in the morning, which included an address by Rep. Paul Tonko (D-N.Y.) and a lobbying professional who provided advice on how to speak to legislators. In the afternoon, members went to Capitol Hill in pairs or teams of four to meet with representatives from their home states and districts.
Participation in Lobby Day this year is at an all-time high with the conference taking place in Washington, D.C., but the training can also be applied in state legislatures, Dr. Roy said.
Among the legislative issues on which ASAM members have lobbied in the past is parity in insurance coverage for treatment of addiction, he said. Currently, the major issue for ASAM is health care reform.
“We are faced with this legislative session where health care reform itself is on the table,” Dr. Roy said. “We have a strong interest in advocating, for whatever evolves, that it continue to include the treatment of addiction at parity in insurance coverage with that for other health conditions.
“The fight’s not over with the passage of legislation because there is subsequent rule-making and then actual practice. We have specific requests and educational goals.”
The 2011 “Ruth Fox Course for Physicians” addressed nine topics Thursday, with an emphasis on sex addiction and sexual disorders.
Topics addressed included adolescent sexuality, integrating addiction treatment into primary care, paraphernalia and forensic issues in sexual addiction, spirituality in addiction, health information technology, treatment of sexual addictions, drugs and hypersexuality and an annual literature review.
Stanley E. Gitlow, M.D., FASAM, a former ASAM president, opened the course by reflecting on the life and work of Dr. Fox before other speakers delivered their presentations.
Sex Often Tied to Substance Abuse in Young Adults
When it comes to sex, teenage boys and girls are very different, with boys ready in an instant while girls are not so easily aroused. Bridging that gap are drugs and alcohol, which was discussed in “Adolescent and Young Adult Sexuality: The Relationship to Substance Abuse and Dependence.”
“The population that has the greatest percentage of sexually transmitted diseases is the 15- to 19-year-old age span, more so than any other five-year age span,” said Anthony Dekker, D.O., FASAM, director of addiction medicine, Ft. Belvoir Community Hospital U.S. Army, Ft. Belvoir, Va. “The 20- to 24-year-olds and 25- to 29-year-olds have more sex more often than adolescents, but teenagers have a higher rate of sexually transmitted disease. So, the question is, ‘How can they have less sex and more disease?’
“One of the reasons is that most teenagers, when they are having sex, have impairment with alcohol or other drugs of abuse.”
Many of those experiences are tied to use of alcohol, marijuana, or other drugs of abuse, Dr. Dekker said.
“Doctors need to interview in a non-pejorative way about sexual histories when they are talking to substance-abusing adolescents or young adults,” he said. “There is also a need to emphasize the need for screening, contraceptive care, and treatment of sexually transmitted diseases.
Treating Addiction Issues in Primary Care
Health care reform makes primary care the hub in the wheel of patient care, emphasizing the patient-centered medical home approach that will initiate treatment for many diseases and illnesses, including addiction. The coordination of addiction care in this environment was addressed in “Getting Addiction Treatment into Primary Care.”
“Health care reform wants to improve care and save money. If we are willing to address substance abuse disorders in primary care, we can accomplish that easily,” said Norman Wetterau, M.D., FASAM, ASAM liaison to the patient-centered primary care cooperative. “The patient-centered medical home emphasizes that we individualize treatment and educate, motivate, and connect them to other groups.”
Primary care physicians can screen for tobacco, alcohol, and drug abuse, but the addiction community needs be involved in building systems to help educate the entire primary care team — nurses, nurse practitioners, physician assistants, and office staff — in this process, he said.
“If a doctor does not have systems that work, it won’t get done,” said Dr. Wetterau, who practices at Tri-County Family Practice, Nunda, N.Y. “If we are willing to empower the patient and use rest of staff to do some of the work, it can be much more effective. The patient-centered medical home emphasizes the team and involving the patient.”
Some of this can involve teaching patients about websites such as QuitNet and Rethinking Drinking for those who want to stop smoking or drinking, he said. The primary care staff can follow up with telephone calls or emails to check on a patient’s progress.
This all sounds feasible on paper, but Dr. Wetterau gave Ruth Fox attendees an exercise to help them carry out the plan. Attendees were asked to complete practice surveys about how they deal with patients who have tobacco, alcohol, and drug issues, and to write down ideas from the sessions about how they might change their practices.
“I want them to go back to their office staffs and go over it with them,” he said. “You can leave this conference with all the ideas in the world, but it won’t get done unless we can get people on board.”
If addiction physicians are not directly involved in primary care practices, they can serve as consultants for cases where their expertise is needed.
“Smoking, drinking, drug abuse, and prescription drug abuse are what primary care will handle, and refer other things out,” Dr. Wetterau said. “We want them to do screening, prevention screening, and brief interventions before the problems become more serious.”
Sexual Addiction Treatment: A Familiar Model
The treatment of sexual addiction may follow the paths of drug and alcohol treatments from past decades as counseling and medical therapy increasingly replace incarceration.
“Primary care providers with training in addiction, and other addiction-certified physicians can play a larger roll in the screening, evaluation, and management of paraphilias and sexual addictions. They will have to, because the criminal justice system will offload the responsibilities to the medical community in a model that resembles alcohol and drug abuse chronicled in the last 50 years,” said William R. Morrone, D.O., M.S., who presented “Paraphilias, Paraphernalia and Forensic Issues in Sexual Addiction.”
Driving addiction treatment down this familiar path is the permanent shortage of psychiatrists and the recognition that it is less expensive to prevent people from progressing toward sexual addiction than to jail them later, he said.
“We are at the beginning of that trend in addiction and in sex crimes, a trend we are going to see in the next decade. Stakeholders are going to expect that progressive governing policy can medicalize this diagnosis and treat people,” said Dr. Morrone, the assistant program director of family medicine at Synergy Medical Education Alliance and an assistant clinical professor in the departments of family medicine, psychiatry and pediatrics at Central Michigan University College of Medicine.
The medicalization of deviance is a policy of the Department of Justice that dates to the 1980s, when funding moved from law enforcement to medical and health care, he said. The complication is that epidemiology is difficult and no medicines have been developed to treat sexual addiction. The best medical option is to use pharmaceuticals and treat with off-label uses.
The result is a potential public health threat to communities and an even greater need for primary care providers with training in addiction.
“It’s not a joke we should snicker about. Everybody should be concerned for community health and safety because it is a problem that affects safety in our communities. There is help for everybody,” Dr. Morrone said, adding that the pressure will fall on primary care. “If you don’t treat it yourself (because you are uncomfortable with treatment), refer people out for specialty care. In the past, too many medical providers would say ‘I don’t do that, there is nothing to do, and I don’t know where to send them. I don’t want any medical providers to say that.”
Spirituality a Strong Anchor in Battling Addiction
Patients need to call on their inner strength to overcome addiction, but they also need help from outside sources in the form of spirituality, which was discussed in “Spirituality in Addiction Treatment.”
“Spirituality is an attempt to make contact with a transcendent object. Whether it is a person or whether it is our concept of God, it is to a higher power, something greater than ourselves. By doing that, patients get a sense of fellowship, a sense of relaxation, a sense of safety, a sense of peace in this communication with a higher power,” said John P. Scanlon, D.O., assistant professor of family medicine and addiction medicine, Pikeville College School of Osteopathic Medicine, Pikeville, Ky.
No matter what the addiction is, the principles of spirituality in addiction treatment are the same, he said, adding that spirituality is different from religion.
Religion is probably man’s attempt to package spirituality,” Dr. Scanlon said. “Where spirituality and religion have a lot of things in common, there are aspects of the two that are quite different. Religion tends to be structured. You generally have to have a professional leader, like a rabbi, priest, or minister. Spiritual feelings we have are not necessarily bound by a sacred textbook or something other than our spectrum of feelings.”
An important part of evoking spirituality is for patients to learn relaxation techniques, such as closing their eyes and using deep breathing, music and the spoken voice. Using relaxation techniques before psychotherapy helps patients explore their past and the deeper meaning of their feelings, he said.
“The big spiritual technique is the bonding, the feeling of fellowship between the people participating in group therapy or the bond that occurs between the physician and the patient by using relaxation techniques or suggestions, using points of departure to take the patient to previous events in his life. By using relaxation techniques to prepare the patient for this, we can evoke feelings of relaxation and safety that will provide more effectiveness in our other therapeutic ventures,” Dr. Scanlon said.
Examine Consequences in Treating Hypersexual Disorder
Sexual addiction can be defined in many ways by many people, but the key in recognizing and treating hypersexual disorder is to examine the patient’s quality of life, said James C. Montgomery, M.D., who presented “Comprehensive Evaluation and Treatment of Sexual Addictions.”
“The big key is that sexual addiction is less about understanding behavior and the initial diagnosis than it is about the identifying consequences,” said Dr. Montgomery, medical director, Sante Center for Healing, Argyle, Texas. “Has the patient lost significant things like relationships, jobs, and money? Has he or she put energy into controlling behaviors? Have they tried to quit? How many times has the control or quitting only led to resumption of the same behavior? Does it come back with a vengeance? How much time and energy does it take from their lives?
“You need to look at the consequences and implications of the behavior.”
Diagnosing hypersexual disorder is difficult because it is a broad issue that is not clearly defined, but involves sexually out-of-control behavior, Dr. Montgomery said. A key is to use a diagnosis template to list and categorize behaviors. For example, the behaviors in any patient may range from anonymous, safe behaviors, such as phone sex, Internet chats and cybersex, to soliciting prostitutes and engaging in dangerous acts that require pursuit and seduction, or violent sex.
Primary care addictionists can use templates to recognize and support patients with hypersexual disorder, but ultimately should refer these patients to specialists for treatment, he said.
“It is probably too involved and intimate for primary care,” Dr. Montgomery said.
The ultimate goal is to help patients get back on the road to improving their quality of life.
“Sexual addiction recovery is not about abstaining from sex, even though celibacy and abstinence are really key parts of early recovery,” he said. “Recovery is about quality of life, quality of relationships and that internal — almost spiritual — path they lost in addiction.”
Addiction Physicians Face Health IT Challenges
An important part of the health care reform law is incentives for physicians and institutions to add electronic health record (EHR) systems to their practices. However, addiction medicine physicians face challenges different from other physicians because of the confidentiality concerns of patients.
Physicians who want to take advantage of incentives offered through the EHR incentive programs must choose between either the Medicare or Medicaid programs, said H. Westley Clark, M.D., J.D., M.P.H., FASAM, director of the Center for Substance Abuse Treatment, Substance Abuse Mental Health Services Administration, U.S. Department of Health and Human Services. Dr. Clark discussed the incentive programs and other challenges for addiction physicians in “Health Information Technology.”
Many addiction medicine physicians have mixed practices, and addiction medicine is only a part of their practices. To be eligible under Medicaid, addiction medicine physicians must meet the patient volume criteria, he said.
In addition, several entities where addiction medicine physicians often practice are not eligible, including community mental health centers, substance abuse treatment programs and recovery programs.
With EHR comes increased access to health records, which raises the question of how to ensure patient confidentiality and trust, Dr. Clark said. To achieve any level of systemic durability and success, electronic exchange efforts must establish trust relationships with all participants, including patients, so the applicability of 42 CFR Part 2 needs to be addressed.
Ultimately, the solution lies in finding common ground that involves engaging patients in the importance of health information exchange, education efforts, and tight restrictions on data access, including stringent penalties for misuse, he said.
Sexually Addicted Find Inappropriate Use for Drugs
Health care professionals need to be aware of the variety of drugs and the variety of uses their patients may have discovered to further their stimulation and therefore advance sexual compulsivity, which were issues addressed during “Drugs and Hypersexuality.”
“There are some drugs used to facilitate sexual behavior and then there are different drugs of abuse used to heighten sexual sensation,” said Darrin R. Mangiacarne, D.O., an addictionologist at Pine Grove Behavioral Health and Addiction Services, Hattiesburg, Miss.
Dr. Mangiacarne discussed how some drugs — legal and illegal — are used by those engaged in hypersexual behavior, and addressed myths and misconceptions.
Dopaminergic drugs often used for restless leg syndrome have the side effect of increasing sexual drive. Additionally, testosterone is used by those who are sexually addicted to decrease the lag time between erections.
“It is not uncommon for these patients to try to masturbate multiple times per day,” Dr. Mangiacarne said. “If you are treating young, otherwise healthy males and they are complaining about erectile dysfunction, that is a red flag.”
It is important to be aware of these off-label uses of drugs because they can be dangerous, Dr. Mangiacarne said.
Literature: The Year in Review
The good news is that the literature about addiction disorders is growing, and the bad news is that the literature is growing, making it difficult to keep up with all the available information.
Stephen A. Wyatt, D.O., filled the role of consultant-librarian for addiction professionals — a role he said he thoroughly enjoyed — preparing for the Ruth Fox Annual Literature Review. Dr. Wyatt is an addiction psychiatrist at Middlesex Hospital, Middleton, Conn., who focused on 10 articles during his presentation.
“I tried to look at all the literature, including journals outside those specific to addiction medicine,” he said. “I looked at a variety of areas of addiction medicine, including pharmacology, education, adolescence and various drugs of abuse.
“Addiction medicine affects all areas of medicine. As a specialty it is relatively young. What struck me is that things we have known for a while and ways we have been practicing are starting to be further refined in the current literature. We are starting to become to a truly specialized area of medicine.”
Articles reviewed ranged from new research to important reviews culled from peer-reviewed journals in a variety of medical specialties, all focused on improving the practice of addiction medicine.
“Many of articles are things we have known about, and they may be conventional wisdom, but maybe the conventional wisdom has been switched a little bit or has been refined.” Dr. Wyatt said. “We can begin to practice in a much more defined way as knowledge in our field continues to grow.”
Donald J. Kurth, M.D., FASAM
Welcome to ASAM’s 42nd Annual Medical-Scientific Conference and 8th Annual Legislative Day in our nation’s capital, Washington, DC. As the incoming president of the pre-eminent addiction physicians’ education, research and treatment organization in America, I am pleased to extend my warmest greetings to each and every one of our friends, visitors, guests, and members.
This year’s conference is just packed with activities spanning the entire week. Someone once said, “No margin — No mission.” If we cannot find a way to live within our available resources, we can never accomplish the great goals we have set for ourselves. But I can tell you this, we are up for that challenge.
On Wednesday, our policy-minded physicians reached out to our nation’s leaders during the ASAM Legislative Day to help move national addiction public policy in a thoughtful, compassionate and evidence-based direction. On Thursday, our internationally famous pre-conferences took center stage just packed with useful information for both the entry level and the seasoned veteran addictionists.
Med-Sci Committee Chair Gavin Bart, M.D., FASAM, CME Committee Chairs Adam Gordon, M.D., and Edwin Salsitz, M.D., and their hard working committees have put together a line-up of educational talks this year may be the best we have ever seen at ASAM’s Med-Sci. Following the ASAM Business Meeting on Friday morning, our Scientific Plenary and Distinguished Scientist Lecture Award winner, George E. Vaillant, M.D., kicks off Med-Sci with his talk, “Using Occam’s Razor on Dual Diagnosis.”
Let me touch a just a few highlights. Symposium No. 4 includes International Society of Addiction Medicine President Hannu Alho, Gabriell Welle-Strand, M.D., and others discussing innovative addiction treatment models from around the world.
On the public policy front there are two big initiatives that I will mention. The first, of course, is our successful battle for national addiction treatment parity, which was signed into law by President George Bush on October 5, 2008. Parity became fully enforceable as of January 1, 2011. However, the battle is not over and we simply cannot sit on our duffs and wait for successful implementation of these laws. We and our patients still must continue the fight to be ensured the rights we have won.
The second public policy initiative that you will be hearing more about is The Americans in Recovery Act (TARA). Just as the Americans with Disabilities Act brought those suffering from physical disabilities out of the shadows, so TARA will allow our patients in successful recovery from drugs and alcohol to finally become full-fledged citizens of the U.S..
Before closing, I want to thank Immediate Past President Louis Baxter, M.D., for the fine job he has done as ASAM president these past two years. We have a great organization in fine shape to tackle the challenges of the future. And next, I want to welcome all of our new ASAM officers and Board members to the leadership of our wonderful organization. Our new officers include Stanley Gitlow, M.D., president-elect; Herb Malinoff, M.D., secretary; and Lori Karan, M.D., treasurer. We have some stiff challenges ahead, but I know each one of them is up for the job.
Finally, I want to welcome our new Executive Vice President Penny Mills and Deputy Director, Louis Shomette, on board, and offer my heartfelt thanks to all of our ASAM staff for all that they do to keep ASAM the premier addiction physician organization that is it.
I want all of our membership to feel free to contact me at any time for any reason. I would love to hear whatever is on your mind. Please enjoy yourselves and have a wonderful time at the best Annual Med-Sci Conference ASAM has ever presented.
Louis E. Baxter, Sr., M.D., FASAM
When I assumed the presidency of ASAM in 2009, I pledged to represent and serve you, the ASAM member, and your highest aspirations as caregivers. I also outlined my goals for continuing to define and develop this unique organization called ASAM, in its evolving role as a well-recognized, well-established and increasingly respected professional specialty society. Optimistic and goal-driven as I am, it would have been impossible then to anticipate all we have accomplished.
Advocating for Enlightened Public Policies
ASAM’s Government Relations Department has worked diligently to advance our Society’s influence in shaping addiction-related federal policies, including the recently enacted health care reform legislation and the interim regulations implementing the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008.
During my tenure as ASAM president, I have commissioned four new task forces to address some of the most important issues facing our field. The task forces are the Justice System Action Group, the Health Information and Technology Action Group, the Diagnostic and Descriptive Terminology Action Group, and the Medical Marijuana Task Force.
Also in the past two years, ASAM’s Board has approved a number of new and updated public policy statements.
Improving Access to Care, Quality of Addiction Treatment
Prescribing of methadone has grown substantially in recent years because a growing number of individuals need treatment for either of the indications for which methadone is FDA-approved — opioid addiction or chronic pain.
In response to the need for training and mentoring in this field, ASAM launched the Physician Clinical Support System for Methadone (PCSS-M) to assist practicing physicians and other health care providers in prescribing for, and managing patients on methadone. With the SAHMSA-funded PCSS-M in the third year of operation, ASAM recently launched a sister project, the NIDA-funded Physician Clinical Support System for Primary Care (PCSS-P). The PCSS-P strengthen efforts to increase alcohol, tobacco, and drug screening and interventions in primary care settings through mentoring, education and training.
In late 2010, the Harvard Business School began a one-year project to help expand the use of the ASAM Patient Placement Criteria (PPC). A team of four students will help ASAM pursue a commercial software developer to take the PPC text and produce an end-user, counselor-assessment software application.
In regards to the access to treatment in criminal justice settings, I was elected to the Board of Directors of the National Association of Drug Court Professionals, which is working to reverse the current dismal situation. I am also a member of the White House Office of National Drug Control Policy’s (ONDCP) small group of experts who helped develop President Barack Obama’s Strategic National Plan to address the addiction treatment needs in the U.S.
Strengthening ASAM and Enhancing Member Service
I have long believed that ASAM has the potential to be — indeed, has a moral obligation to be — a leader within the house of medicine. ASAM can do so by helping to shape the awareness, knowledge, and practices of the larger group as they relate to the disease of addiction, the evidence base for addiction treatment, and the clinical specialty of addiction medicine.
During the past two years, the Society’s courses and conferences brought together experts from the U.S. and abroad to meet with our members so as to advance the knowledge base in addiction medicine and related medical specialties. These include:
During my presidency, ASAM has embarked on a vigorous expansion of its publications program, updating publications that include our newsletter and journal, our well-respected textbook and more specialized publications. Some of the highlights include the Fourth Edition of Principles of Addiction Medicine, the new Supplement on Pharmacotherapies for Alcohol Use Disorders, and a new ASAM reference work, Essentials of Addiction Medicine.
A high priority throughout my tenure has been defining and delivering new ways we can serve ASAM’s members, such as a new ASAM Weekly newsbrief, a new online Career Center, an onsite newspaper at the Med-Sci Conference and a new Live Learning Center.
Even as I take pride in our achievements during the past two years, I am well aware of the challenges ahead. ASAM must continue to focus on finding new sources of funding for workforce development, expand our roles into new and emerging health care markets, and continue our collaboration with key stakeholders in Congress and the federal agencies, as well as organizations representing education, research, and business.
As always, ASAM’s elected officers, board, council chairs, and staff encourage and welcome your involvement. Thank you for all you have done, and for affording me this opportunity to serve. – See more at: http://asam-365.ascendeventmedia.com/Highlight.aspx?id=2728&p=261#sthash.NYLkcags.dpuf
Thursday’s full-day course, Pain and Addiction Common Threads XII: Safety First: Best Practices, featured seven presentations focusing on topics that included clinical aspects of sedative dependence, sedative hypnotics, sleep issues, opioid and sedative use and misuse, the role of the family in addiction, and federal and state initiatives on prescription drug misuse.
Mixing BZDZ and Opioids Creates Problems
Benzodiazepines (BZDZ) are one of the most widely prescribed medications for anxiety, depression, or insomnia. In one year alone, more than 2 billion tablets of diazepam were prescribed in the United States.
But while BZDZs are widely prescribed, research shows that they lose efficacy over time. As the drug fails to treat the condition, patients are sometimes prescribed an opioid to assist the BZDZ. According to Edward Covington, M.D., of Cleveland Clinic Foundation, this dangerous cocktail can lead to addiction and fail to treat the chronic symptoms for which it was originally prescribed.
Dr. Covington discussed the research behind his findings and how to better treat patients with chronic pain in his presentation “Clinical Aspects of Sedative Dependence in Pain and Addiction.”
There is a group of people with chronic pain who use both opioids and BZDZs, often in high doses, who show high levels of functional impairment, pain, addiction, and comorbid psychiatric pathology, he said.
The highly addictive nature of BZDZs and opioids sometimes leads to criminal behavior. More than 1,800 pharmacies were robbed between 2008 and 2011, usually looking for oxycodone, hydrocodone, and alprazolam. In 2006, diazepam and clonazepam were selling for $2 to $4 a pill on the street. Buyers either purchased the pills for a quick feeling of euphoria or to cope with a current addiction.
Although these figures paint a bleak picture, Dr. Covington said BZDZ-use disorders are but a small portion in the scope of addictive disorders, both in the U.S. and around the world. Twelve percent of adults and 40 percent of pain patients either have, or currently use, some form of BZDZ. Most of the problems stem from alcoholics and opioid or cocaine addicts who use BZDZs because of chronic pain. Not only does the medication not help the pain, it impairs function and escalates the pre-existing levels of addiction.
Although these patients represent the minority, they are significant enough that alternatives should be used if appropriate, he said. If prescribing a BZDZ is absolutely necessary, it should only be for short-term use. Long-term BZDZ patients should be weaned off their prescriptions, and other antidepressants or automated external defibrillators should be used for anxiety and sleep disorders.
Physicians Need to Examine Alternatives to BZDZs
When a patient complains of anxiety, insomnia, or muscle spasms, BZDZs are frequently prescribed. But when trying to treat these symptoms, which are particularly common among patients being treated for chronic pain, physicians may unknowingly be planting the seeds for — or enabling — an addiction.
Michael Miller, M.D., medical director of the Herrington Recovery Center, Rogers Memorial Hospital, Oconomowoc, Wisconsin, explored alternative treatments in “Non-benzodiazepine Sedative Hypnotics That Cause Clinical Problems.”
“Patients without addiction can misuse pharmaceuticals by taking them by different routes or getting them from different sources than their doctor intended. We, as physicians, need to look for safer alternatives and methods,” he said.
Dr. Miller addressed the role of BZDZs and the incidence of addiction and withdrawal to BZDZ-receptor agonists. He discussed addictive non-barbiturate non-BZDZ sedative-hypnotics, as well as how to manage the discontinuation of, and withdrawal from, several classes of medications often used during chronic pain management.
Dr. Miller also noted that pain and addiction are complicated conditions that can cause much distress and dysfunction for patients. It requires skill to manage their chronic nature on an outpatient basis — especially when they co-occur.
“Some meds considered alternatives are not as safe and problem-free as physicians assume,” Dr. Miller said. “Unfortunately, there is no magic bullet or easy path. Physicians always need to be aware of benefits and risks in making decisions, these included.”
Treatments for One Condition Affect Others
It happens frequently: A patient complains of insomnia or chronic pain, so the physician writes a prescription to solve problem. In reality, that prescription may be compounding another condition said Lynn Webster, M.D., who discussed the relationship between sleep, pain, and addiction in “Pain and Addiction: Sleep.”
“People with addiction have pain problems most addictionologists are aware of, but they may not be aware of the relationship between pain and sleep,” said Dr. Webster, medical director and co-founder of Lifetree Clinical Research and Pain Clinic, Salt Lake City.
Besides discussing the relationships between pain, addiction and sleep, he also addressed the basics of sleep neurophysiology and treatment options for treating patients with sleep disorders, pain and the disease of addiction.
“We can’t treat a disorder in a silo,” Dr. Webster said. “Most patients with one of these have one or both of the other problems. Fifty to 60 percent of people with insomnia have pain. Individuals with a diagnosis of addiction have pain, and almost all have drug-induced sleep disorder.”
Dr. Webster also reviewed common therapies for pain, sleep, and addiction, and the ramifications a treatment for one condition may have on the other two, as well as long- and short-term pharmacology management strategies.
“Some (treatment options) treat pain effectively, but then have side effects,” he said. “Another therapy might not be optimal right now because the right resources aren’t in place or the meds aren’t as successful as we think.”
While there is no magic bullet to solve the problem, Dr. Webster said he hopes to get physicians thinking differently before they reach for their script pads.
“I think sometimes we prescribe sleep meds without considering other conditions,” he said. “We are complex organisms. It is very difficult to isolate a single disorder and treat it independently of other factors.”
Opioids and Sedatives: A Deadly Mix
High doses of opioids combined with sedatives have led to the deaths of celebrities Michael Jackson, Anna Nicole Smith, and Heath Ledger. This deadly mix also threatens the lives of people far from the spotlight.
“The combination of two very potent central nervous system depressants can act in an unpredictable fashion that can lead to respiratory depression and death,” said Mark A. Weiner, M.D., who presented “The Clinical Implications of Opioid and Sedative Use/Misuse in Patients with Addiction and Chronic Pain.”
Although seemingly innocuous, sedatives such as diazepam, alprazolam, and zolpidem are addictive substances that are associated with decreased activity levels, increased disability, and depression. Plus, the use of these benzodiazepines and benzodiazepine-like drugs can cause patients addicted to opioids to have either a cross-addiction or a stimulation of their opioid addiction.
According to studies, patients on opioid replacement therapy, such as methadone and buprenorphine, who are also using sedatives can experience a reactivation of their addiction.
“A large proportion of opioid replacement therapy deaths are not just from taking too much methadone,” said Dr. Weiner of Pain Recovery Solutions, and Pain and Addiction Medicine at Saint Joseph Mercy Hospital, Michigan. “In these deaths, we have found that many of our addicted patients are also using sedatives. The rate of sedative use in opioid replacement patients is very high, probably 50 to 80 percent.”
Patients who are addicted often turn to sedative drugs, rather than other relaxation techniques, when experiencing sleep disturbances, anxiety, and psychosocial stresses, such as unemployment.
Sedative use is also a growing problem for patients being treated for chronic pain. “The patients who are prescribed methadone for pain are also reporting psychosocial stresses and sleep problems, and often being prescribed very high doses of sedatives on top of opioids,” Dr. Weiner said. “And those people are dying at a much higher rate than the addicted population.”
Combinations of sedatives and opioids can be dangerous and should always be used with caution, he warned. He recommended using substitution therapy or cross-taper with different medications, such as phenobarbital, to help patients who are dependent on sedatives kick the habit.
Families Important in Recovery from Pain, Addiction
Family members often play pivotal roles in the recovery of patients with chronic pain. In some instances, in fact, the beliefs and behaviors of spouses, children, parents, and significant others may perpetuate or even increase a patient’s pain.
“If there’s chronic pain within a family system, the clinician needs to pay attention to the family as well as the patient,” said Mel Pohl, M.D., FASAM, co-presenter with Claudia Black, Ph.D., M.S.W., of “Pain and Addiction: All in the Family.” “There is an extensive amount of co-dependency in a family where chronic pain is the predominant phenomenon.”
Understanding the impact of pain, especially when associated with drug addiction, on patients and their loved ones is key to successful treatment. Dr. Pohl pointed to the case of a woman with scoliosis, whose husband’s life revolves solely around her pain and drug use. Fixated on her treatment, he has given up his own independent activities. As she recovers, he may not be able to change his role and adapt to their new relationship.
“When someone’s pain is getting better, and his or her drug abuse is also being treated effectively, the family must respond accordingly,” said Dr. Pohl, medical director of the Las Vegas Recovery Center, where Dr. Black is a senior clinical and family service provider. “Unless they are attended to by a physician or a counselor, they can actually sabotage the recovery.”
A doting spouse may, in fact, make problems worse.
“Recent studies show that solicitous spouses may result in the person in pain experiencing more pain,” Dr. Pohl said.
Insights into family relationships and roles can help clinicians in the treatment of pain and drug addiction. Clinicians, in turn, can help families learn how best to work with the affected family member and assist in the recovery process.
Dr. Pohl urged caregivers to “be mindful of the family when treating someone with co-occurring pain and addiction” and to recognize that issues that come up are based on an emotional connection that can range from healthy to unhealthy.
Finding A Balance in the Use of Opioids
In an Indian fable, six blind travelers come upon an elephant, and each forms a concept of the animal based on touching only one part, such as the ear, side, or tusk. Similarly, health care providers, pharmacists, patients, law enforcement officials, and legislators may see only a small piece of issues related to opioid use.
“Challenges associated with opioids are complicated, and what you see depends on where you sit,” said Seddon Savage, M.D., M.S., presenter of “Finding Balance in Policy: Emerging Federal and State Initiatives on Pain and Prescription Drug Misuse.” “Pain specialists may want to promote pain treatment and may not see as much of the fallout from using opioids. But from the perspective of addiction specialists, virtually all prescription opioid addiction comes from being treated for pain.”
For nearly four millennia, people have been trying to find a balance between using opioids to relieve pain and avoiding the harm associated with misuse. For periods of time, opioids have been widely used therapeutically and then prohibited due to safety concerns.
Today, a number of solutions are being offered to address such challenges as climbing rates of opioid addiction and mortality.
“We’re hoping to get a handle on these problems using our scientific understanding of pain and addiction and the pharmacology of opioids as well as technology that allows us to communicate better,” said Dr. Savage, director of the Dartmouth Center on Addiction, Hanover, N.H.
A number of new and proposed federal and state initiatives aim to maintain quality health care for patients with chronic pain, while preventing prescription drug misuse and addiction. These include:
“Solutions need to be multidimensional and engage stakeholders in diverse disciplines, from the public to health care providers to law enforcers to legislators,” said Dr. Savage. “We need to find a balance, listen carefully to one another, and work together.”
Stanley E. Gitlow, M.D., FASAM, reflects on the work and life of ASAM founder Ruth Fox during the Ruth Fox Course for Physicians Thursday.
As the chair of the committee that planned ASAM’s 42nd Annual Medical-Scientific Conference, Gavin Bart, M.D., FASAM, knows the highlights of the coming days, but he said the conference itself is the greatest highlight.
“In general, the conference is a phenomenon because there really are no other opportunities for practitioners who deal with patients and families affected by addiction to gather in one place, exchange information and ideas, and network with each other,” he said.
Adding to the momentum of so many addiction professionals gathering is the place they are meeting — Washington, DC — because health care reform remains a prominent issue in Congress.
“There is increased national attention to addiction and developments in mental health and addiction parity, as well as developments in health care reform that are really going to impact how addiction medicine is practiced. This can create an opportunity for addiction medicine to become more integrated into primary care,” Dr. Bart said.
The conference offers many individual highlights, he said, starting with the Opening Scientific Plenary and Distinguished Scientist Lecture Award, from 9 to 10:30 a.m. Friday in the International Ballroom on the Concourse level.
“The opening plenary brings us addresses from leaders at the National Institutes of Health and the Substance Abuse and Mental Health Services Administration, as well as the Distinguished Scientist Lecture Award. These are the true leaders in the field who contributed to shaping how the field currently exists.”
Presenting the Distinguished Scientist Lecture, “Using Occam’s Razor on Dual Diagnosis,” is George E. Vaillant, M.D., professor at Harvard Medical School and director of research for the department of psychiatry, Brigham and Women’s Hospital, Boston. In his research, Dr. Vaillant has followed the drinking habits of a group of individuals for more than 60 years.
At the opposite end of the spectrum are Paper Sessions I and II, presented from 11 a.m. to 1 p.m. and 3 to 5 p.m. in Georgetown East, on the Concourse level, Friday featuring the work of young researchers, Dr. Bart said.
Another session highlight is the ASAM Awards & ABAM Certification Recognition Luncheon, from 12:15 to 2 p.m. Saturday in the International Ballroom.
One new feature for conference attendees is that they are automatically registered for the ASAM Live Learning Center, giving them 24-hour online access for six months to videos of all sessions, starting three weeks after the conference. This access allows attendees to earn up to 51 continuing medical education credits from the conference.
And in the Exhibit Hall, open from 10 a.m. to 6 p.m. Friday and 7 a.m. to 4:15 p.m. Saturday, attendees can see the educational offerings of dozens of vendors, further expanding the value of the conference, Dr. Bart said.
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