Saturday Conference News

Society News

Addiction Performance Project set for 6:30 tonight
The National Institute on Drug Abuse will present the Addiction Performance Project, featuring actors Harris Yulin and Blythe Danner, at 6:30 p.m. Saturday in the Jefferson Room on Concourse Level.

In Addiction Performance Project, the actors perform readings from a Pulitzer Prize-winning play about one family’s struggle with alcoholism and prescription drug abuse. Then, a multidisciplinary panel briefly shares responses to the performance, relating their experiences caring for patients with substance abuse and addiction, followed by a facilitator-guided audience discussion using the play’s key themes to focus on the experience of addiction from patient, caregiver, and societal perspectives.

The Addiction Performance Project is funded by the National Institute on Drug Abuse.

Mobile App Developed for Journal of Addiction Medicine
Members of the American Society of Addiction Medicine may access Journal of Addiction Medicine articles from their mobile phones, thanks to this service from journal publisher Wolters-Kluwer Health, a unit of Lippincott Williams & Wilkins. All ASAM members need to do to is access their mobile application store, enter “search,” type in “Unbound Medicine” and then select the Journal of Addiction Medicine from the various health and wellness titles Wolters-Kluwer offers. ASAM members will need to submit their subscription log-in information, which is the same one members use to access the journal’s website. (Activation of an ASAM members subscription online requires the 12-digit code that is on your mailing label.) Once on the Journal of Addiction Medicine, access the article of your choice and read it from the convenient portability of your mobile device.

Chapter Meetings Scheduled for 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. This is the meeting list as of Saturday.

Saturday

  • GASAM, 10 to 11 a.m.
  • NNESAM, noon to 1 p.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.

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.

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.

ASAM Spearheads New Primary Care Addiction Programs

Related Sessions Presented Saturday

Two related sessions about integrating addiction medicine into a primary care practice will be presented Saturday.

10 a.m. to Noon: Workshop C: How to Establish and Integrate Addiction Medicine into an Existing or New Family Care, Internal Medicine Practice, in the Georgetown East Room on the Concourse Level
2 to 4 p.m.: Symposium #10: Addressing Substance Use Disorders in Primary Care and the Patient Centered Medical Home, in the Jefferson Room on the Concourse Level. Among the speakers will be Edwina Rogers, executive director of the Patient Centered Primary Care Collaborative (PCPCC), a group of 700 medical groups, including ASAM, as well as insurance companies and major businesses that are supporting the patient-centered medical home concept.

Health care reform is driving many changes in medical practice, with primary care physicians being a focal point in the development of the patient-centered medical home. The role of addiction medicine in these changes was discussed in a Component Session Thursday night.

Among the topics addressed in “Addiction Medicine and Primary Care: Recent Positive Developments” were the training of primary care physicians in addiction counseling, a training program to screen for substance abuse, and the role of a private group in moving addiction medicine into primary care.

“Those are exciting things ASAM is involved with to get patient-centered medical homes and primary care physicians to address substance use disorders and provide help in education,” said Norman Wetterau, M.D., FAAFP, FASAM, who led the discussion. Dr. Wetterau is also the ASAM liaison to the Physician Clinical Support System for Primary Care (PCCS-P).

Many positive developments are happening in this area because of increased federal support, including grants for these primary care goals, he said. First among them is the PCSS-P, a mentoring program to provide support to primary care physicians (see related story on page 7).

PCSS-P is funded by a grant administered by ASAM and funded by the National Institutes of Health’s National Institute on Drug Abuse (NIDA). Under the program, primary care providers can gain access to clinical resources, information, and materials about managing substance abuse. Resources include addiction clinical experts serving as mentors and providing education about managing substance abuse via phone or email. These mentors can also assist primary care physicians in incorporating substance abuse screenings, brief interventions, and treatments into their practices.

ASAM has also just launched a new online skills training for primary care providers on Screening, Brief Intervention, and Referral to Treatment (SBIRT). www.SBIRTTraining.com is a NIDA-funded program that is being conducted in collaboration with one of ASAM’s leading institutional partners, Clinical Tools. The program offers training for primary care physicians to improve their skills for screening for substance abuse and work with substance abuse specialists.

SBIRT offers screening tools for tobacco, alcohol, and drug abuse; teaches implementation of brief interventions and other treatments; explains referral and follow-up processes; and offers case-based learning with patients.

Another facet of the cooperation with primary care is the development of COPE  — the Coalition on Physician Education in Substance Use Disorders — a not-for-profit group. It is dedicated to training physicians to prevent, identify, and provide specialty-appropriate interventions for patients who use tobacco or illicit drugs, or are involved in the unhealthy use of alcohol or non-medical use of prescription drugs.

Also discussed during the session was Society of Teachers of Family Medicine, which got its start during an ASAM conference two years ago. The group will have a conference in two weeks with a focus on helping family practice residency faculties teach addiction medicine training to trainees.

Prescription Drug Abuse Examined from Different Views

The speakers at Friday’s symposium on prescription drug abuse discussed the outlook and challenges from the federal, state, and individual physician’s perspectives.

Timothy Condon, Ph.D., Science Policy Advisor, Office of National Drug Control Policy, opened the session by reviewing a set of troubling prescription drug abuse statistics, followed by a description of the Obama Administration’s Prescription Drug Abuse Action Plan, which will be released April 19.

He said the plan would focus on education for parents, patients and prescribers, as well as monitoring programs, medication disposal, and enforcement.

Prescription drug abuse is a big problem with teens. Studies show they think prescription drugs are safer, less addictive, and less risky than street drugs. Six of the top 10 abused substances by high school seniors are prescription drugs. And in what Dr. Condon called “the most disturbing data,” new initiates to psychotherapeutic drug use exceed those for marijuana in 2008 and 2009.

Education is also an issue for doctors. “You all know that in medical school little attention is paid to substance abuse,” said Dr. Condon. “So we need to do a better job.”

Because painkillers and anxiety prescription drugs are often dispensed in quantities greater than necessary, the leftovers end up sitting in medicine cabinets — thus the disposal issue.

“We need to change the norm, we need to actually make this like recycling, where we safely dispose of prescription drugs. You can’t just take them back,” said Dr. Condon. The Drug Enforcement Agency will have a national medication take-back day every six months; the next one is April 30.

Joshua Sharfstein, M.D., Secretary of Health, Maryland, noted that take-back programs collected 121 tons of prescription drugs in 2010.

Seven million Americans reported non-medical use of prescription drugs in 2009, Dr. Condon said. The consequences for the nation are huge in terms of emergency room visits — which almost doubled from 2004 to 2008 — drug-induced deaths, and economic costs — which were estimated to be $53 billion in 2006 due to opioids taken for non-medical use.

Then there are the deaths. Since about 2006, drug-induced deaths actually outnumbered suicides, firearm accident deaths, and homicides. In 17 states and the District of Columbia, drug-induced deaths outnumber those from motor vehicle accidents.

Dr. Sharfstein lamented that drug overdose death rates have never been higher. “We’re talking about more than 11,000 unintentional deaths (per year) — really tragic,” he said.

Regarding prescription drug monitoring, Dr. Sharfstein said that when pushing for legislation to create such a system in Maryland, “We explained this was a very big public health problem, not a law enforcement issue.”

“I think there’s a tremendous opportunity for public health and addiction medicine to work together to save a lot of lives,” he said.

Herbert Malinoff, M.D., FACP, FASAM, Department of Anesthesiology, University of Michigan Medical Center, said physicians who have access to an automated prescription service, like the one in Michigan, should use it. – See more at: http://asam-365.ascendeventmedia.com/Highlight.aspx?id=2756&p=261#sthash.6MHLZ9vB.dpuf

Symposium Addresses Naltrexone Indications

Symposium #1, "Naltrexone: New Formulations and Indications," drew an overflow crowd Friday morning as attendees found room on the floor to hear presentations.

Symposium #1, “Naltrexone: New Formulations and Indications,” drew an overflow crowd Friday morning as attendees found room on the floor to hear presentations.

Oral naltrexone had once been viewed as a magic bullet because it is highly selective for opioid receptors, but the major clinical obstacles for this agent occur in the induction and adherence phases. This was a conclusion presented by Sandra D. Comer, Ph.D., one of 13 speakers to address attendees of the Friday symposium “Naltrexone: New Formulations and Indications.”

In her presentation “Oral Naltrexone for Opioid Dependence,” Dr. Comer said that naltrexone completely antagonizes opioid effects, is orally bioavailable, and reaches peak blood levels in one hour. Naltrexone has a half-life of four hours compared with 6-B-naltrexol, which has a half-life of 13 hours.

“Nevertheless, daily dosing with naltrexone is possible,” said Dr. Comer, Professor of Clinical Neurobiology, College of Physicians & Surgeons, Columbia University, New York State Psychiatric Institute. “Naltrexone is primarily metabolized by the liver and reaches target plasma concentration of 1 to 2 ng/ml, providing good clinical benefit. Antagonist effects don’t appear to diminish over time.”

With oral naltrexone, two different dosing regimens are used: 50 mg daily or 100-100-150 mg every Monday, Wednesday and Friday. Naltrexone is also safe to administer over long periods, Dr. Comer noted. Treatment with naltrexone begins after initial detoxification with first an induction and then a maintenance phase.

“Our group has found that the use of supplemental medications is really critical during detox,” she said. “Buprenorphine, clonazepam, and clonidine are useful supplemental medications during detox. It’s also important to start with small doses of naltrexone at 3 mg or 6 mg.”

During the maintenance phase, adherence is the major obstacle to naltrexone treatment, Dr. Comer said. No consequence comes from stopping naltrexone, so discontinuing the medication is easy for patients.

“The biggest risk with discontinuance is that they will resume heroin use and overdose,” she said. “Pain relief for the patient who has an acute medical condition requiring opioid agonist treatment can be an issue and tricky to manage.”

The clinical experience with naltrexone is that the outcomes are clinically poor primarily because of poor medication adherence, Dr. Comer said.

“Nevertheless, the drug can be effective in highly motivated individuals,” she said. “Behavior therapy has been shown to improve outcomes as well.”

Good candidates for naltrexone are those with high motivation for abstinence, while poor candidates are those with a history of overdoses especially following detox. Also poor candidates are those who need opiate agonists to feel normal, those in chronic pain requiring chronic opioid treatment, and those with severe GI or cardiovascular disorders exacerbated by opioid withdrawal or abstinence.

“A possible solution to the obstacles in the induction and adherence phases may be the sustained release formulation naltrexone,” Dr. Comer concluded.

In his presentation “Opioid Modulators: Future Research Directions,” Elliot Ehrich, M.D., Senior Vice President of R&D and Chief Medical Officer, Alkermes Inc., said that opioid receptors may be good targets for drug development. He set the stage by describing receptors in the endogenous opioid system, including the G-protein coupled receptors of Mu, Delta, Kappa, and nociceptin (NOP). These interact with opioid peptides and cause signaling. Receptors differ in their actions, depending on where they are located. The Mu and Kappa opioid receptors, for example, are largely located in the limbic system, including the hypothalamus, which is part of the reward system.

“As we begin to understand more about the opioid receptor, we have the potential to develop a variety of therapies to target different parts of the body with different specificity,” Dr. Ehrich said. “There is the ability to leverage our knowledge of opiate receptor systems, particularly the Kappa and the NOP receptors, to develop new, improved therapies for addiction.”

Heroin-Assisted Treatment Model Discussed

A refractory heroin-dependent patient can expect to lose 25 years of life expectancy as a result of the addiction, a stark statistic presented by Wim van den Brink, M.D., Ph.D., during Friday’s symposium “Innovative Models of Addiction Treatment from the International Context.”

During “Heroin-Assisted Treatment for Treatment of Refractory Heroin-Dependent Patients,” Dr. van den Brink, Director of the Amsterdam Institute for Addiction Research, Academic Medical Center University of Amsterdam, reported on a possible treatment approach in light of a troublesome U.S. study published in 2001. These data showed 48 percent of heroin addicts from an average age of 24.5 to 57.4 had died during the 33-year course of follow-up data.

“Heroin addiction is a chronic, relapsing, and potentially fatal disease,” he said. “Over the long term, only 20 percent achieve stable abstinence. Things could look very differently in terms of morbidity and mortality with more effective treatment.”

While methadone is the most effective in terms of treatment retention and reduction of heroin use, clearly the approach has effectiveness limits, as does treatment with buprenorphine, Dr. van den Brink noted. That led addiction experts in the Netherlands to consider an alternative approach — heroin-assisted treatment.

Two randomized, controlled trials were conducted from 1998 to 2002 in the Netherlands using the experimental treatment of oral methadone in combination with heroin in inhalable or intravenous doses. At the end of 12 months, noticeable improvements were seen in reducing heroin use and in study participants’ physical health and mental status. Quite telling is what happened when participants came to the end of the study a year later and returned to more traditional approaches to their heroin addiction. Eighty-two percent deteriorated significantly after discontinuing heroin-assisted treatment, Dr. van den Brink said.

“Heroin-assisted treatment is an effective additional treatment option for chronic treatment-refractory cases,” he said. “It is also effective, safe, and cost-effective with positive long-term outcomes. Still, nearly 50 percent of patients are not responding to this approach. Additional treatment and care options need to be developed for these patients.”

Also addressing Friday’s symposium was Steven Gust, Ph.D., Director of the National Institute of Drug Abuse International Program.

“Drug use is reported in every country of the world, and it has a huge impact in the health sector as one of the top 20 health risk factors globally,” he said. “Injecting drug use is reported in 151 countries, and the United Nations has estimated that drug abuse costs can equal up to 2 percent of the gross domestic product. ”

A recent Institute of Medicine report recommended that the U.S. government scale up existing interventions; generate and share knowledge; invest in people, institutions, and capacity building; increase U.S. financial commitments to global health; and engage in respectful partnerships, Dr. Gust said. The National Institutes of Health supports $600 million a year in global health research.

ASAM Launches Physician Clinical Support System for Primary Care

More patients are confiding in their primary care physicians about their addiction problems, and helping these doctors help their patients will be the American Society for Addiction Medicine’s newest mentor network, the Physician Clinical Support System for Primary Care (PCSS-P).

“Increasingly, primary care physicians are faced with the complications of substance abuse disorders on their patients’ medical outcomes and may be limited in training and tools to evaluate and treat these problems,” said a PCSS-P medical director, David A. Fiellin, M.D., professor of medicine, Yale University School of Medicine, New Haven, Conn. “The increased prevalence of addiction issues makes it necessary for primary care physicians to address these cases directly.”

The PCSS-P is funded by a grant from the National Institutes of Health’s National Institute on Drug Abuse (NIDA), and is administered by the ASAM, with the New York Academy of Medicine providing the evaluation component. Through the PCSS-P, participating primary care providers may access clinical resources, information, and materials, and link up by phone or email to addiction clinical experts who will serve as mentors in providing education about managing substance abuse. Mentors can also assist primary care physicians in incorporating into their practices substance abuse screening, brief intervention, and treatment.

“The important message is for primary care physicians to identify those patients for whom they can provide direct care and those patients in whom it is best to refer to specialty treatment programs,” Dr. Fiellin said. “Part of the strategy is to make effective referrals and motivate patients to seek outside support in a way that increases the likelihood that they will receive the assistance they need.”

Primary care clinicians may sign up with the PCSS-P by calling the warm-line service 877-630-8812, sending an email to PCSSproject@asam.org, or visiting the website www.pcssmentor.org. (Warm line means a reply within 24 hours.) Additionally, the NIDAMED website www.drugabuse.gov/nidamed provides a compilation of evidence-based tools and resources for managing substance abuse in a primary care setting. One particularly useful screening tool, NIDA Med ASSIST, helps primary care physicians in developing a recommended plan of care in substance abuse cases.

The PCSS-P was created to increase the use of these tools in clinical settings and to advise NIDA on the ways in which these tools can be made more useful for practicing primary care clinicians, Dr. Fiellin said. The structure of PCSS-P is modeled after the recent Physician Clinical Support System for Buprenorphine coordinated by ASAM that resulted in a successful six-year run. Other key elements of the PCSS-P include oversight by two leading addiction experts, Louis E. Baxter, Sr., M.D., FASAM, and Dr. Fiellin, as medical directors, and counsel provided by the Clinical Advisory Committee of family medicine, internal medicine, and emergency medicine leaders.

“The goal will be to work as much as possible with major medical organizations that serve primary care physicians to promote the services of the PCSS-P,” Dr. Fiellin said. “We anticipate that our clinical advisers will conduct brief sessions at local, state, or national meetings to go through the tools available from the NIDAMED website, get direct feedback from primary care clinicians about how useful they find these types of resources, and what they would like to see in future versions.”

It was a natural role for ASAM to serve as a coordinating partner with NIDA in bringing the PCSS-P services to primary care physicians.

“Because we are a leading organization in the field of addiction medicine with many physicians trained in primary care specialties,” Dr. Fiellin said, “we are particularly sensitive and aware of the knowledge, skills and attitudes that are needed to address substance use and addiction in primary care settings.”

Medical Marijuana Hot Issue at Chapters Meeting

The Chapters Council meets four times a year, but three of them are conference calls. The chance to discuss topics and interact face-to-face with colleagues makes the Med-Sci Conference Council an important annual event.

Thursday evening’s meeting included discussions on medical marijuana, potentially broadening ASAM’s membership requirements and reports from state chapters.

“It is always good to hear what new and different things other states are doing to recruit, retain and educate members,” said Richard Soper, M.D., J.D., M.S., FASAM, Chapters Council chair.

Medical marijuana has again become a contentious issue. Eighteen additional states have approved use of medical marijuana, while Montana, which had approved its use for the past six years, repealed its consent. Regardless of its legislature’s stance, every state chapter has been affected by this matter, and members weren’t shy about voicing their thoughts and experiences.

“The discussion wasn’t to take a position on the issue, but to talk about the science and policy behind it,” Dr. Soper said. “We as physicians do not condone inhalant use of other substances, yet turn around and say OK to the use of something even less standardized. It’s a thorny dichotomy.”

In some states, such as California, patients need only to call their doctor to get a prescription for medical marijuana.

“There was an interesting discussion about physicians being asked to provide a prescription for something with no continuity of care,” Dr. Soper said. “What are the ramifications of certifying a prescription for a patient you’ve never had an encounter with?”

Adding to the discussion, Andrea Barthwell, M.D., FASAM, and ASAM past-president, presented an update on the ASAM medical marijuana white paper.

Another lively dialogue focused on expanding ASAM’s membership standards.

“There has been a lot of push in medicine over the last 20 years to have a more collegial, team approach to patient care. Nurse practitioners, physicians, PhDs and pharmacists now all work together to inform the process,” Dr. Soper said. “This is a good conversation that arises every few years, and it’s always an important one to have.”

Although no formal votes were held on any of the topics, he said he felt the evening was worthwhile.

“Everything discussed was for informational purposes,” Soper said. “I thought we had some good give-and-take. It was a productive meeting.”

Parity to Bring Change and Opportunity

Changes brought on by two federal acts will bring immense opportunities for addiction medicine specialists to practice in holistic ways for the benefit of Americans needing treatment.

The possible upshot and positive outcomes of the Mental Health Parity and Addiction Equity Act and the Patient Protection and Affordable Care Act, were addressed Thursday evening during Component Session VII, “Parity and Health Care Reform: Changing the Way Addiction Treatment Providers Do Business.” Summarizing the major issues discussed during this session was moderator A. Kenison Roy, III, M.D., FASAM, founder and Medical Director of Addiction Recovery Resources Inc., New Orleans.

“The main sense of what we talked about is that change is coming,” he said. “The practice of medicine, particularly addiction medicine, will not be the same. The opportunity is for us to resume the role and function of physicians to lead, teach, and manage the treatment of patients with addiction.”

Newer models of addiction medicine will no longer involve just seeing one patient right after the other as the practice has often been for many addiction specialists. The older model restricted these physicians to the one-dimensional prescription practice rather than the holistic patient care model, Dr. Roy said. The new role will evolve to include a nice mix of responsibilities — partly team manager, partly team leader, and partly face-to-face patient care.

The newer models will expand opportunities for physicians to participate in ways unlike ever before and will include structures, such as the patient-centered medical home, accountable care organizations, and larger groups formed by independent practice associations of smaller practices. Dr. Roy said these new models would be part of relationships being incentivized with hospitals and a wider spectrum of the health care delivery system to integrate addiction care in every aspect of that whole spectrum. The newer models will also require the use of electronic health records, new payment and delivery models, new billing and reimbursement practices, and quality reporting bonus payments.

“There are millions more patients who will not only have resources for care, but also be educated that they need the care,” he said. “It is a recognition that it is a rare addiction patient who doesn’t have medical and psychiatric co-morbidities. Those co-morbidities need to be identified and medically addressed, not to mention the fact that addiction in (and of) itself is a medical illness that needs to be managed by physicians.”

The newer models will actually save money by addressing illness (addiction) that has previously gone unrecognized or untreated, which has driven up health care costs rather than kept them down, Dr. Roy said. Historically, insurance companies have functioned in silos and consequently sought to reduce costs simply through lack of treatment of addiction or other illnesses. By integrating addiction care through the spectrum of medicine, current estimates are that this move will reduce insurance costs by $55 per person each month.

With new regulations pending and the passage of parity, addiction medicine will be on a different playing field, he said.

“The recommendations that came out of this session were for physicians in addiction medicine to be proactive in this process, to think it through, and to be deliberative,” Dr. Roy said. “The more we advocate for our patients, the more healthy our business plan will be.”

Vets Battle Modern Issues When Returning Home

Michael Kilpatrick discusses the Millennium Cohort Project during ‘Treatment of the Returning Military Veteran' Friday.

Michael Kilpatrick discusses the Millennium Cohort Project during ‘Treatment of the Returning Military Veteran’ Friday.

In this era of the modern military, with females in combat theaters and multiple deployments to combat zones, veterans face new issues as well as long-established challenges when leaving home and returning. Speakers at a symposium Friday focused on those issues and data now being collected to develop treatment strategies.

Symposium #2, “Treatment of the Returning Military Veteran” featured a detailed presentation about how combat in the Middle East has affected members of the military and their families, as well as efforts to learn more about the long-term effects of combat.

Offering the perspective of a health care professional, as well as personal experience because her former fiancé served in the Middle East, was Susan A. Storti, Ph.D., RN, CARN-AP. Dr. Storti is an investigator at McLean Hospital, Harvard University, Boston, and a research associate at Brown University Medical School.

“You need to look at them from a holistic perspective,” she said of returning military members. “They could not only have wounds from combat, but there could be issues in the home that play a role in alcohol abuse or psychiatric disorders.”

Of the 2.2 million military members deployed to Iraq and Afghanistan, 52 percent are ages 18 to 25, and 24 percent are ages 25 to 30, Dr. Storti said. While effective treatment for these traumatized veterans should require 12-16 sessions, “this group will not stick around,” she said. “They will have two or three sessions, then disappear.”

Military members and their families face an emotional cycle of deployment that includes:

Initial intense fear and worry
Detachment and withdrawal as deployment nears
Loneliness and sadness soon after the military member leaves
An adjustment period
Reunion issues
Effects of pre-existing difficulties

Instead of getting closer to their family and friends as they near deployment, military members often become more solitary, which causes more problems when they return home if issues already exist, especially in a marriage, Dr. Storti said.

During deployment, family members must cope with limited communication and frightening news reports, she said.

When the military member returns home, everyone must learn to adjust to a changed family structure — from spouses to children to parents. Mothers returning home from duty increasingly find that their children act out, sometimes leading to legal issues, Dr. Storti said.

Other factors to consider when treating returning military members are that they feel out of place and often translate their coping techniques from combat to their homes. In addition, individuals also face physical problems, such as loss of limbs, traumatic brain injury, loss of hearing, musculoskeletal disorders, combat trauma, and stigma.

“Military members are often afraid to seek assistance, especially if they want to make the military a career,” Dr. Storti said.

Complicating readjustment can be abuse of alcohol, narcotics, benzodiazepines, marijuana, stimulants, and steroids, she said, adding that more military members now use “spice,” a chemically treated herb that is legal and similar to marijuana.

Dealing with these issues may eventually improve because military and political leaders are finally recognizing the need to collect data and develop plans to help these returning veterans.

Michael Kilpatrick, M.D., FACP, a longtime member of the military and now a civilian, has studied deployment issues for the past 10 years. Veterans are now being surveyed in-depth three to six months after returning home, instead of answering a few questions immediately after returning home.

In addition, the Millennium Cohort Study is examining the long-term effects of military life on service members. The study began in 2001 and new members are enrolled every three years, so more than 150,000 have been sampled.

“This data will provide important indicators that will lead us to understand what other studies need to be done,” Dr. Kilpatrick said. “It is fertile ground for more research.”

Plenary Focuses on Recovery, Education

(From left) H. Westley Clark, Penny S. Mills, R. Gil Kerlikowske, Louis E. Baxter, Sr., Pamela S. Hyde, Howard Moss, Nora D. Volkow, and Donald J. Kurth.

(From left) H. Westley Clark, Penny S. Mills, R. Gil Kerlikowske, Louis E. Baxter, Sr., Pamela S. Hyde, Howard Moss, Nora D. Volkow, and Donald J. Kurth.

A group of addiction medicine leaders emphasized recovery, workforce development, and education in lectures Friday at the Opening Scientific Plenary and Distinguished Scientist Lecture.

Renowned researcher George E. Vaillant, M.D., received the R. Brinkley Smithers Distinguished Scientist Award and closed the session with his presentation “Using Occam’s Razor on Dual Diagnosis.”

The session began, though, with remarks by outgoing President Louis E. Baxter, Sr., M.D., FASAM, followed by a series of short addresses from R. Gil Kerlikowske, M.A., Director of the Office of National Drug Control Policy; Pamela S. Hyde, J.D., Administrator of the Substance Abuse and Mental Health Service Administration; Nora D. Volkow, M.D., Director of the National Institute on Drug Abuse; Howard Moss, M.D., Associate Director for Clinical and Translational Research, National Institute on Alcohol Abuse and Alcoholism; and H. Westley Clark, M.D., J.D., M.P.H., FASAM, Director of the Center for Substance Abuse Treatment.

Kerlikowske, who became Drug Czar in 2009, said, “One area I’m particularly proud of was to open up an Office of Recovery, to have people think about recovery. So we’re not just about addiction and (drug control).” He noted the new version of the federal Drug Control Program comes out next month. “It has your voice in it. It’s an excellent document,” he said. “It will include issues dear to your heart, such as (treatment of) college students and military (personnel).”

Addressing substance abuse means confronting many tough realities, said Hyde, including rising prescription drug use in all populations; disproportionate numbers of uninsured among people with mental or substance abuse disorders; and a $2.2 billion drop in mental health funding by the states.

However, she remains confident. “We can treat it and people do recover,” Hyde said.

Noting that “we have a much more challenging disease on our hands than other fields,” Dr. Volkow said this is “a period of extraordinary opportunity and responsibility for all of us. We need to build the blocks to treat substance abuse; we need education in medical schools and specialties.”

Dr. Clark told the audience, “You can function as a linchpin” for mainstreaming addiction medicine. “It’s about making the health care field aware of addiction. Health care reform cannot progress … without addressing substance abuse disorders.

“I applaud ASAM for providing physician education,” he said. “I always like to point out that when funds were being made available for the Recovery Act, behavioral health didn’t get any money. We are the orphans of the system, but we will prevail with your help and that of organizations like ASAM.”

Dr. Vaillant’s lecture focused on whether alcoholism is the cart or the horse for depression. “Occam’s razor is a fancy way to say the bumper sticker, ‘Keep It Simple,'” he said, admitting it was impertinent for him to recommend simplifying such a complex condition. “It’s a very tough disease and I’m going to try to make it simple, which you can do from a lecture podium, but is extremely hard to do in real life.”

The simplest dual diagnosis is depression and alcoholism. “Alcoholics who go to AA and recover tend not to be depressed,” Dr. Vaillant said. “Careful work … has shown that alcohol and depression certainly are genetic illnesses, but don’t overlap.”

He presented results from his 60-year Harvard study, showing AA meeting attendance correlates with abstinence. Subjects who achieved abstinence from alcohol had attended more than 100 — in some cases 140 — AA meetings. The study also showed a 20-year period before people became abstinent.

“You don’t tell someone to stop drinking on a dime,” Dr. Vaillant said. “To stop an addiction you’ve got to have a competing behavior. You’ve got to have some way to boost a person’s hope and self-esteem. You’ve got to have some kind of supervision, because alligators don’t come when they’re called. And you’ve got to have a new source of love. You need a new trusting employer or a new person to love you, who doesn’t remember what a jerk you were — and AA is a source.”