Saturday Conference News

ASAM Board of Directors Addresses Society Business

ASAM Acting President Stuart Gitlow, M.D., (left) and Past President Louis E. Baxter, M.D., FASAM, discuss business during the ASAM Board of Directors meeting.

ASAM Acting President Stuart Gitlow, M.D., (left) and Past President Louis E. Baxter, M.D., FASAM, discuss business during the ASAM Board of Directors meeting.

The ASAM Board of Directors convened during the Medical-Scientific Conference to conduct business on a variety of issues from new strategic directions for the organization to discussing resolutions to present to the American Medical Association’s House of Delegates in June.

In terms of new strategic directions, the Board discussed finding ways to expand membership to include non-physicians and to explore development of an accreditation program for outpatient addiction practices. The Board of Directors also addressed the revision of legislative advocacy and public policy committee membership to provide opportunities for new members and to improve committee functioning.

The Board of Directors additionally approved four resolutions that ASAM will present to the AMA House of Delegates meeting in June. One resolution is based on ASAM’s recently approved policy statement on prescription drug diversion, misuse, and addiction. A second resolution sets domestic and international public health prevention targets for per capita alcohol consumption as a means of reducing the burden on non-communicable diseases on health status.

The Board of Directors further voted to increase member dues $15 per member for 2013 to cover the increased publication frequency of the Journal of Addiction Medicine (JAM) from four times a year to six times a year and participation for all ASAM members in the International Society of Addiction Medicine (ISAM).

Frank J. Vocci, Ph.D., was approved by the Board of Directors to serve as the third Co-Editor for JAM. Dr. Vocci is President and the Senior Research Scientist at the Friends Research Institute, Baltimore. The Board also approved JAM Senior Editor George F. Koob, Ph.D., and Dr. Vocci to become Honorary ASAM members, a tribute bestowed on individuals who otherwise are ineligible to be ASAM members.

In other business, the Board of Directors approved a series of bylaws changes allowing ASAM to conduct its business electronically, as needed, and in accordance with New York State Law. Additionally, the Board approved a policy to build up ASAM’s Board-designated fund to equal three months of operating expenses, or $800,000, whichever is greater.

Finally, the Board of Directors approved creating an Action Group to begin planning the Medical-Scientific Conference for 2015 and beyond.

Sessions to Report Progress in ABAM’s MOC Process

For the addiction medicine specialty to achieve its goals, its Maintenance of Certification (MOC) procedures must be as well established as any in medicine, says American Board of Addiction Medicine (ABAM) President Jeffrey Samet, M.D., M.P.H.

“If ABAM and ASAM want addiction medicine to be accepted as a certified specialty by the rest of the medical establishment, there are certain things we’ve got to do,” Dr. Samet says. “First, we must establish a significant number of accredited residency programs. Second, and this is just as important, we must have our MOC established and running well.”

Dr. Samet says MOC is important because it provides the best way to keep physicians well trained and up to speed on the latest developments in medicine.

“It also goes a long way to assuring the public that its doctors are taking care of business and know what they are doing,” he says.

Today’s Component Session 6, “What is Tested on the American Board of Addiction Medicine (ABAM) Certification Exam: How the Core Content of Addiction Medicine Will Be Reflected in the Examination Blueprint,” will explore various topical areas covered on the test, as well as how the test is constructed each year, addressing an appropriate range of topics. This session will be from 4 to 6 p.m., today, in Rooms 206- 207.

Dr. Samet says that the ABAM Exam Committee, chaired by Dr. Michael Weaver, spends a good deal of time and effort making sure that questions fairly assess the knowledge base of the discipline.

“We use the services of the National Board of Medical Examiners, together with selected ABAM Diplomates, to come up with the basis of the test, and then we take that solid piece of material and revise it and update it over time,” he says. “New questions are always being added or revised. Last fall, Exam Committee members were all given the assignment to come up with 20 questions, which had to cover all the topic areas.

“That whole process is rigorous, but the Committee comprises a top-flight team—ASAM Directors representing a number of high-level organizations, heads of training programs—all of them leaders in the field,” he says. “Of course, the whole thing is ‘top secret’ too, because we have to maintain the validity of the test itself.”

Dr. Samet says that Sunday’s Component Session 8, “The American Board of Addiction Medicine (ABAM) and Maintenance of Certification. Our Role in the Movement Towards Improved Quality of Care,” will highlight why MOC is important to the specialty. ABAM certification is time-limited for a period of 10 years and is renewed through successful completion of the ABAM Maintenance of Certification (MOC) process. This session will be from 8 to 10 a.m., Sunday, in Rooms 206-207.

“It is imperative that we make sure our physicians are in good standing in the medical community,” Dr. Samet says. “One part of MOC is re-taking the board exam every 10 years. Some Diplomates have time-unlimited certificates, but they are also encouraged to participate in MOC to demonstrate to themselves as well as to others that they are ‘current’ in their knowledge.”

Dr. Samet says that there are challenges in taking a group of physicians who were used to practicing without MOC requirements and then impose a process that feels to some as if they are being constantly “checked up on.”

“MOC is a necessary part of medicine today,” Dr. Samet says, “and maintenance of licensure will soon be upon us all as well.

“There’s no turning back. As long as we don’t make it too arduous of a process, as long as we are pragmatic about it, we will do well as an emerging specialty. Frankly, ABAM has fully embraced this and we are proud to be developing an MOC program that meets the needs of addiction medicine doctors as well as of the larger community that expects MOC from any medical specialty board.”

Tailoring 12-Step Program to Teens, Young Adults Effective

Communicating with teens and young adults can often be a challenge, but adding substance use disorders to the equation can make the task particularly complex. Hear recommendations for effective approaches to treating this patient population during Workshop 3, “Making 12-Step Programs Meaningful for Adolescents and Young Adults,” from 10 a.m. to noon, today, in Grand Salon East, Salon B.

In the first half of the workshop, Steven Jaffe, M.D., Professor Emeritus of Psychiatry, Emory University, and Clinical Professor of Psychiatry, Morehouse School of Medicine, will present scientific studies demonstrating the effectiveness of adolescent participation in 12-step programs. He also will present the use of his workbooks that can be used to modify 12-step treatment to be meaningful for adolescents and young adults.

With the intervention workbooks, patients respond to specific, concrete questions that examine the negative consequences of drug and alcohol use. Patients present their answers during a one-on-one or group-counseling setting. During the workshop, Dr. Jaffe will demonstrate how this interaction works by presenting a role-playing exercise with a mock patient.

Through his workbooks, he strategically changes such 12-step treatment program concepts as “powerlessness” to that of “enhancing your power” so that you can have a fulfilling life by stopping the use of drugs and alcohol.

The second half of the workshop will feature Clint Stonebraker, CADC, CAC-2, CCS, Executive Director, and Matthew Meyer, CADC, CAC, CCS, Program Director, both of The Insight Program, Atlanta. This is an intensive outpatient program that emphasizes “enthusiastic sobriety” through “fun and exciting” group participation. The issue of spirituality in 12-step programs is often criticized for being “religious, sexist, and too abstract.” In this portion of the workshop, presenters will discuss strategies for making spirituality meaningful.

Dr. Jaffe says that at the conclusion the workshop, he hopes participants would have a better understanding of the research demonstrating the effectiveness of adolescent participation in 12-step groups, the value of the workbook format for adolescents to work the steps, and an appreciation of the importance of making a 12-step treatment program fun and exciting for this young population.

The ASAM Twelve-Step Recovery Action Group has a long-standing interest in programs, such as the one where Dr. Jaffe works. Marc Galanter, M.D., ASAM Board of Directors member and Twelve-Step Recovery Action Group Chair, says the group is dedicated to educating physicians about 12-step treatment programs, improving relations between the medical and addiction communities about the programs, and promoting medically grounded research of such programs. The group meets annually at the ASAM Annual Medical-Scientific Conference.

CDC Declares Prescription Drug Abuse an “Epidemic”

Centers for Disease Control and Prevention (CDC) Deputy Director Ileana Arias, Ph.D., will present the keynote lecture during the Policy Plenary, “Addressing Prescription Drug Abuse: Role of the Physician in Counteracting Diversion, Misuse & Addiction” from 8 to 9:30 a.m., today, in the Grand Ballroom East, Ballroom AB. Leading addiction medicine experts also will serve as panelists for the Policy Plenary, providing their insights and knowledge on prescription drug abuse.

Dr. Arias comes to the Policy Plenary fresh from her presentation in mid-April before hundreds of participants at the National Rx Drug Abuse Summit, where she called prescription drug abuse an “epidemic.” Hear what additional ideas and recommendations she has to share during today’s address.

“The CDC doesn’t take the word ‘epidemic’ lightly,” she says “Success [in stemming the epidemic] will come through collaboration with all stakeholders.”

At the summit, Dr. Arias specifically drew attention to the correlations between opiate sales and the number of overdose deaths in the United States. As opiate sales have gone up, so have overdose deaths from 1999 to 2010, she says, adding that opiate abusers generate more than eight times in annual direct health care costs than non-abusers.

The National Rx Drug Abuse Summit convened April 10-12 to foster a better understanding and cooperation among all stakeholders in the prescription drug abuse arena. Stakeholders include state and national leaders, law enforcement officials, medical professionals, community advocates, treatment experts, educators, insurance and benefits managers, and private industry leaders.

On its Injury Prevention and Control website, the CDC reports that 100 people die from drug overdoses every day in the United States. The agency also reports that drug overdose death rates in this country have tripled since 1990. CDC data further indicate that in 2008, 36,000 people died from drug overdoses, and most of these deaths were caused by prescription drugs. Additionally, the sale of these strong painkillers has increased 300 percent since 1999. These drugs were involved in 14,800 overdose deaths in 2008, more than cocaine and heroin combined, according to CDC data.

The Center for Behavioral Health Statistics and Quality at the Substance Abuse and Mental Health Services Administration (SAMHSA) reported in 2010 that misuse and abuse of prescription painkillers were responsible for more than 475,000 emergency department visits in 2009, a number that nearly doubled in just five years.

The CDC further reports that the drug overdose epidemic is most pronounced in the Southwest and Appalachian regions, and rates vary substantially among states. The highest drug overdose death rates in 2008 were found in New Mexico and West Virginia, which had rates nearly five times that of the state with the lowest rate, Nebraska.

The CDC Injury Prevention and Control website also drew on research from many addiction research sectors that identified patient populations at greater risk for prescription drug overdose: individuals obtaining multiple controlled substance prescriptions from multiple providers, patients taking high doses of prescription painkillers daily, low-income residents in rural areas, and the mentally ill with a history of substance abuse. CDC reports show that Medicaid recipients are prescribed painkillers at twice the rate of non-Medicaid patients and are at six times the risk of overdose from prescription painkillers.

The CDC also offers recommendations for reducing the incidence of prescription drug abuse. For starters, the agency supports prescription drug monitoring programs to track the prescribing and dispensing of these drugs to patients through databases. The CDC also endorses the implementation of patient review and restriction programs to monitor signs of inappropriate use of controlled prescription drugs. Health care providers should follow evidence-based guidelines for safe and effective prescribing of addictive painkillers. The CDC also supports federal and state legislation to prevent prescription drug abuse and diversion. Importantly, the CDC recommends better access to substance abuse treatment to reduce overdose among people struggling with dependence and addiction, as well as action on the state level to increase access to these programs.

Voice Opinions on ASAM Patient Placement Criteria

More than a decade has passed since the ASAM Patient Placement Criteria were revised, and the time has come for an update, particularly to incorporate more strength-based and recovery-oriented terminology, says ASAM Criteria Editor David Mee-Lee, M.D. He will join David Gastfriend, M.D., a Newton, Mass., addiction psychiatrist and developer of the ASAM Criteria Software, in convening Component Session 9 “Town Meeting on the ASAM Criteria Revision (PPC)” from 10 a.m. to noon, Sunday, in Grand Salon East, Salon B, to discuss the criteria and obtain feedback.

“It has been more than 10 years since the criteria were revised, and there have been changes in how those standards are applied, especially with regard to special populations, such as parents with children, older adults, people in safety sensitive positions, and those in criminal justice settings,” says Dr. Mee-Lee, Senior Vice President, The Change Companies in Carson City, Nev. “We wanted to give addiction medicine specialists more information on applying the criteria to those special populations and also in managed-care settings.”

The Diagnostic Admission Criteria are also being modified for each level of care to be compatible with DSM-5 of the American Psychiatric Association (APA), which is planning to release DSM-5 in 2013.

“That is also our target date for the ASAM Criteria revision,” Dr. Mee-Lee says. “We are not changing specific Dimensional Admission Criteria unless there are errors or updates necessary due to new knowledge since the publication of the Second Edition Revised PPC-2R in 2001, which is still the current edition.”

Sunday’s component session will follow a town-meeting format to provide participants with an overview of the changes proposed that will go to extensive field review, he says.

“We want feedback on the direction we are going with the current revisions, so we have called a town hall to give people a chance to be briefed on the changes and also to get input and feedback based on the various experiences of the audience,” Dr. Mee-Lee says. “This is not a total rewrite of all of the specific admission criteria rules unless, of course, there are obvious mistakes and errors that need be corrected. It’s about improvements to help people better use the criteria. Once we get extensive field-review feedback on drafts yet to be completed, the other workgroup chairs involved in revision drafts and I will make our final changes.”

Dr. Mee-Lee says one of the big challenges to finalizing the revision process is that all of the work groups include volunteers, who are busy with their own work.

“The first challenge is finding the time to make the changes,” he says. “The second issue is that because we want to be representative of not just physicians but other disciplines as well, that means that we have interdisciplinary groups working together, all of whom are getting input from a variety of clinicians and not just doctors. That makes for a variety of differing perspectives on what is important.”

Dr. Mee-Lee says it is essential to draw a good attendance at the Sunday town hall session.

“We need input and feedback from as many attendees at the meeting as we can get,” he says. “That is the bottom line.”

Session Examines Drug Interactions in Personalized Medicine

Evan Kharasch, M.D., Ph.D., said methadone is "very susceptible to drug interactions."

Evan Kharasch, M.D., Ph.D., said methadone is “very susceptible to drug interactions.”

Jag Khalsa, Ph.D., M.S., likens the possibility of genetic testing playing a role in treatment of patients to the arrival of Star Trek.

“I think in very near future we may be at a point when genetic testing is so cheap that we will be in a position to test if we find variability or nonresponse in a patient. We’ll say, ‘This guy does not have this enzyme, so let’s change the medication and treat him accordingly.’ Star Trek therapy is coming,” says Dr. Khalsa, Chief of the Medical Consequences Branch, Division of Pharmacotherapies and Medical Consequences of Drug Abuse, National Institute on Drug Abuse.

Dr. Khalsa and Judith Martin, M.D, FASAM, Medical Director of the BAART Turk Street Clinic, San Francisco, led a Friday session, “Drug-Drug Interactions: Role of Individualized Medicine,” sponsored by the National Institute on Drug Abuse.

The program focused on the pharmacogenetic and pharmacodynamic interactions among recreational drugs and medications used in the treatment of patients with HIV. Research is emerging on pharmacogenomics to show that the genomic profile of CYP450s in patients could be used to design therapy for individual patients.

Evan Kharasch, M.D., Ph.D., looked at the pharmacogenetics of methadone, which, he says is “very susceptible to drug interactions” and influences plasma concentrations and clearance of methadone.

The state of the art has been that studies in vitro attribute the enzyme P4503A4 as being responsible for methadone metabolism, causing conventional wisdom to credit the enzyme for methadone metabolism and clearance clinically.

A lot of papers said methadone was going to be susceptible to CYP3A4-mediated drug interactions, says Dr. Kharasch, the Russell D. and Mary B. Shelden Professor of Anesthesiology, Director, Division of Clinical & Translational Research, Department of Anesthesiology, and a Professor of Biochemistry and Molecular Biophysics, and Vice Chancellor for Research, Washington University, St. Louis.

Dr. Kharasch and his fellow researchers found that CYP3A4 has little or no influence on plasma concentrations or CL of single-dose IV or oral methadone and in single-dose IV or oral methadone N-demethylation. He found that CYP2B6 is responsible for clinical methadone metabolism.

In his talk on “Integrating Substance Abuse Treatment Into HIV Care Settings,” Patrick G. O’Connor, M.D., M.P.H., Professor of Medicine and Chief of General Internal Medicine, Yale University School of Medicine, New Haven, Conn., described buprenorphine/naloxone (bup/nx) use in patients with HIV.

Dr. O’Connor says research indicates that bup/nx decreases drug-related but not sex-related HIV risk; drug outcomes improve in HIV-infected patients receiving bup/nx; bup/nx is safe in HIV-infected patients; on-site bup/nx leads to improved outcomes compared to off-site methadone; and naltrexone treatment in HIV-infected patients appears to be safe, and it’s effectiveness is being studied.

Zeruesenay Desta, Ph.D., Associate Professor of Medicine, Pharmacology and Toxiology, Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, described the clinical use of efavirenz in HIV in his talk.

“I’m also a true believer in a personalized care. Patients do not respond or fail therapy because of a single thing,” Dr. Desta says.

Join the Fight Against Medicaid Buprenorphine Limitations

Does your state Medicaid program limit the use of buprenorphine and other opiate agonists in addiction treatment? If it doesn’t, it soon will—unless addiction medicine specialists lead the battle to maintain the availability of medical treatment.

Mark Publicker, M.D., FASAM, President of the Northern New England Society of Addiction Medicine, will discuss the limitations proposed in Maine and other states during Component Session 5, “State Medicaid Limitations on Buprenorphine: How to Fight Back.” The session runs from 10 a.m. to noon, today in Grand Salon West, Salon E.

Patients in Maine are already facing an abrupt cutoff in medication after a maximum of two years of treatment, Dr. Publicker cautions. The new Medicaid limitation is retroactive, which means patients on long-term therapy will be hit first and hardest.

“There is absolutely no clinical intent in imposing these limitations,” Dr. Publicker says. “There were no medical professionals involved in making the decisions to set this limitation. Nor were policy makers interested in copious information regarding the clinical disease and the clinical requirements for treating opiate addiction. This is completely, solely, and openly a fiscal policy to save money. No other chronic illnesses are being so targeted.”

Addiction treatment is a prime target, he says. Patients with addictive disorders are widely disliked and feared. That makes them vulnerable ideologically. And they are both small in number and politically unorganized, which makes them an easy target politically.

“Opiate addiction is a chronic brain disease,” Dr. Publicker says. “As with all chronic illnesses, it requires chronic therapy. There cannot be arbitrary limits on treatments. We know that for significant opiate addiction, long-term opiate agonist therapy with medications, such as buprenorphine and methadone, are necessary to sustain a robust recovery.”

Clinical arguments against treatment limitations are needed, he says, but carry little weight in the current economic climate. Economic arguments also are needed but should not carry too much weight.

“We can clearly demonstrate a seven-to-one benefit ratio for every dollar spent on treatment in terms of dollar savings in decreased crime and savings in decreased illnesses such as HIV, hepatitis C, and premature birth,” Dr. Publicker says. “What I have learned in this fight is that all that really matters is what is happening in the current fiscal year. It is a silo effect, and it is a political effect. The Department of Health and Human Services has different priorities than the criminal justice side has. And whoever has a closer ear to the governor wins.”

Addiction specialists in Maine joined with three other organizations to fight proposed Medicaid changes. They lost.

“It is a horrible situation,” Dr. Publicker says. “These Medicaid limitations condemn our patients to withdrawal and to the specter of active addiction.”

What budget officials in Maine see as a successful effort to cut Medicaid dollars is spreading to other states, according to the National Buprenorphine Treatment Network. In some states, buprenorphine/naloxone and other opiate agonists may not be covered for addiction treatment. Other states are imposing prescribing and refill limits.

“The fight against these limitations is just beginning,” Dr. Publicker says. “The purpose of this workshop is to provide ASAM members with information that limitations are coming and how we can develop strategies to fight back.

“The fight against limitations requires coalitions. It requires a comprehensive approach involving organizational support and cooperation, effective lobbying, developing personal relationships with legislators and the executive branch, and public information involving the media. It is important to make the clinical case and the economic case against limitations. It is just as important to take this issue to the public, to enlist patients, patients’ families, and other advocacy organizations to join in the fight. We, ASAM, are the voice of advocacy for our patients. We want ASAM members to march out of this workshop prepared to join the good fight.”

Med-Sci Meets Needs and Interests of New Members

Networking with peers was one of the attractions for those attending Thursday evening's New Members Welcome Reception during the Med-Sci Conference.

Networking with peers was one of the attractions for those attending Thursday evening’s New Members Welcome Reception during the Med-Sci Conference.

New members of ASAM converged on the New Members Welcome Reception Thursday to network with fellow new members and meet some long-time active ASAM members and ASAM Board members. When asked what brought them to the 2012 ASAM Medical-Scientific Conference, the common theme in their responses was the superb continuing medical education in addiction medicine.

“This is my field of expertise, and this is a great place to get updated and make new contacts,” says Michael Sorna, M.D., a Jacksonville, Fla., Addiction Psychiatrist. “I also trained at Emory, so I am up here to see friends and family.”

He says he attended the 2012 Med-Sci to take in the Pain & Addiction Course presentation that addressed healing the healer about physician drug abuse. He says he has interest in how it occurs and how to prevent it.

For new member Pamela Vergara-Rodriguez, M.D., Chicago, this is her second Med-Sci, and she is in Atlanta for the addiction science, policy updates, and information on research opportunities.

“This is one of the major meetings we can attend to learn what addiction specialists are doing nationwide,” she says. “It’s also an opportunity to get a sense of any upcoming policy changes and where the specialty is heading. We can also get a sense of potential grants to apply for.”

John Symeonides, M.D., Palm Coast, Fla., registered for the Medical-Scientific Conference to become more involved in Addiction Medicine, to receive the latest updates in clinical practice, and to discover which therapies are the most effective. He says he appreciates the impressive expanse of educational offerings.

“I just came out of a very nice lecture on cognitive behavior therapy,” he says. “This conference is the place to learn what is new and what is going on. Networking is also a big part of the Med-Sci Conference experience.”

This year’s conference represents the first steps for Agron Ismaili, M.D., Wolf Creek, Wis., in his quest to become an Addiction Medicine specialist. Currently, he practices internal medicine in a hospital setting, and he attends to many patients admitted for alcohol intoxication and polysubstance abuse.

“I am here looking to find direction about how to grow professionally, and I want to gain insights from the senior addiction specialists at the conference,” he says. “I would like to take the board examinations in Addiction Medicine by the end of the year, so I will be attending those courses here on how to obtain board certification.”

A seasoned Addiction Medicine specialist, Scott McNairy, M.D., Minneapolis, has attended a number of ASAM Medical-Scientific Conferences. He is the Addiction Psychiatry Director at the University of Minnesota, which is one of 10 American Board of Addiction Medicine sites for the new training fellowships.

“As this thing is getting off the ground, I finally says to myself that I need to join ASAM— I have been an American Academy of Addiction Psychiatry member for more than a decade,” he says. “I have been to ASAM Medical-Scientific Conference meetings before but had never joined up officially, so I felt it was high time.”

Dr. McNairy says he enjoyed the NIDA Blending Initiative Knowledge Exchange Meeting, which he found to be “an intriguing overview about changing levels of intervention and care for addictions.”

Earl Freeman, D.O., Kennebunk, Maine, says he needs more education in Addiction Medicine. He has been involved in addiction treatment for three years, and in that time, “I realized there is a lot to it. I am at the bottom of the learning curve, and this is the place to learn.”

Gilbert Whitton, M.D., Sydney, Australia, comes to the 2012 ASAM Medical-Scientific Conference from across the globe. He found Thursday’s Pain & Addiction Course insightful because pain and addiction is a huge problem in Australia, and he is seeking better ways of managing it. He is additionally interested in treating addictions in young people, and the connection between the criminal justice system and the health care system.

“I wanted to see how Addiction Medicine is done in the U.S.,” he says. “We have a small group of doctors practicing Addiction Medicine in Australia, and in the U.S., there’s a bigger group. It is great to attend a conference that has a large number of doctors with an interest in this.”

Pharmacotherapy Scant for Alcohol Use Disorders

A discussion of pharmacotherapy treatments for alcohol use disorders drew a standing-room-only crowd to Symposium 2 Friday.

A discussion of pharmacotherapy treatments for alcohol use disorders drew a standing-room-only crowd to Symposium 2 Friday.

Not nearly enough patients needing medication treatment for alcohol use disorders are receiving it. This recurring message emerged in the first presentations of Friday’s Symposium 2, “Update on Medications for Alcohol Dependence and Their Implementation into Practice,” cosponsored by the National Institute on Alcohol Abuse and Alcoholism, and ASAM.

The Veterans Health Administration (VHA) “should be a national model for implementation of medication treatment for alcohol dependence, but we are not. Only a tiny fraction of veterans with alcohol use disorders is being treated—3.4 percent,” says Alexander Harris, Ph.D., Director and Research Coordinator, VA Substance Use Disorder Quality Enhancement Research Initiative, and Associate Director, Program Evaluation and Resource Center, Center for Health Care Evaluation, VA Palo Alto Health Care System, Menlo Park, Calif.

The reason the VHA should be the beacon is its policies encouraging medication treatment for alcohol dependence. In fact, the current VHA Handbook states that prescribing staff must be dedicated to providing pharmacotherapy for all patients with alcohol or opioid use disorders in the VA’s 220 specialty addiction treatment programs in the United States.

To discover why VHA addiction treatment programs were not fully using effective pharmacotherapy, Dr. Harris initiated a study on the barriers and facilitators among clinicians, managers, and pharmacists in VA addiction treatment programs. In facilities with low pharmacotherapy adoption, he found either no prescribers available or limited access to prescribers. He also discovered limited staff or time to treat patients, lack of skills or knowledge about medications, pharmacy formulary restrictions, and provider reluctance to prescribe. The reverse was true in high pharmacotherapy adoption treatment programs.

Intervention strategies to promote pharmacotherapy in these facilities included 11/2 days training for addiction, mental health, and behavioral health staff, Dr. Harris says.

“Strategies to promote adoption of pharmacotherapy for addiction disorders should be modified to fit the needs of the system, practice, and individual patients,” he says. “Multifaceted efforts directed through all three of these levels may be needed to speed pharmacotherapy.”

Substance abuse disorder treatment providers across the board in the United States “have been slow to adopt medications for treatment of alcohol use disorders (AUD), resulting in a research-to-practice gap,” says Amanda J. Abraham, Assistant Research Scientist and Assistant Director, National Treatment Center Study, University of Georgia, Athens, Ga. She reported on a study to examine the availability of medications for alcohol use disorders—disulfiram, tablet naltrexone, acamprosate, and injectable naltrexone.

Of the 293 study participants, few centers adopted AUD medications—only 12.3 percent adopted disulfiram, 18 percent adopted acamprosate, 13.7 percent adopted tablet naltrexone, and 7.2 percent adopted injectable naltrexone.

“Only 25 percent of programs prescribe any single AUD medication, and only 28 percent of programs have physicians on staff to accommodate prescribing these medications,” she says. “Of 175 programs with a physician on staff or on contract, 65 percent did not prescribe any AUD medications.”

In addressing the efficacy of pharmacotherapy to treat AUD, Bankole A. Johnson, D.Sc., M.D., Alumni Professor and Chairman, Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlottesville, says, “It really is not enough just to provide psychotherapy. Relapse rates are lower when psychotherapy is combined with pharmacotherapy. The goal is to find the right medicine for the right patient at the right time and for the right length of time.”

He recommends improving the efficacy of medications by improving existing methodology of alcohol clinical trials, developing promising medication targets and approaches, validating screening models with animal and human lab paradigms, and advancing personalized medicine.

“There are many genetic variants that allow us to personalize medicine,” Dr. Johnson says. “Alcoholism is a 60 percent heritable disorder. The genetic pathway is so very important. This is going to be developed in a way to look at genome-wide studies by which we can define responders and non-responders. We are going to use mapping models to understand who we can identify and target for future treatment.”

Opening Plenary Speaker: Interventions Require “Highest Level of Evidence”

Richard Saitz, M.D.: "What I'm really in favor of is practice that is based in science, but we need to know what that science is in order to then base practice on it."

Richard Saitz, M.D.: “What I’m really in favor of is practice that is based in science, but we need to know what that science is in order to then base practice on it.”

Ask Richard Saitz, M.D., M.P.H., FACP, FASAM, if he is for or against screening and brief intervention for alcohol and drug disorders, and he’d call your question silly.

“If anything, I have a bias in favor of these practices having value. What I’m really in favor of is practice that is based in science, but we need to know what that science is in order to then base practice on it,” says Dr. Saitz, a Primary Care Internist who has been training primary care physicians to conduct such screenings for decades.

Dr. Saitz gave the R. Brinkley Smithers Distinguished Scientist Lecture Award, “Screening and Brief Intervention for Unhealthy Alcohol and Other Drug Use: Where the Evidence Is…and Isn’t” during Friday morning’s Opening Plenary.

Screening and brief intervention has been promoted widely for a range of substances, severity, and settings, and he looked at the evidence as a means to inform practice.

Dr. Saitz is a Professor of Medicine and Epidemiology at Boston University Schools of Medicine and Public Health; Director of the Clinical Addiction, Research, and Education Unit at Boston Medical Center; and Director of the Division of Clinical Research Resources, Clinical Translational Science Institute, and Associate Director of the Office of Clinical Research at Boston University Medical Center.

Dr. Saitz says 10 common arguments are evidence for the efficacy of screening and brief intervention (SBI) or screening, brief intervention and referral to treatment (SBIRT): 10. Unhealthy alcohol use is a common problem. 9. It is the cause of health problems. 8. It often goes unrecognized. 7. Most people don’t receive help. 6. We aren’t helping people with problems before they develop. 5. SBI seems unlikely to be harmful. 4. SBI should work because there is a teachable moment in health care. 3. “Treatment” works. 2. SBI is relatively inexpensive, and we can do it. 1. What should we do? Nothing?

“SBI is a population-wide service,” he says. “We need the highest level of evidence—things like systematic reviews of randomized trials. We also need evidence for patient characteristics or settings that we suspect might alter effectiveness.”

According to Dr. Saitz, too often physicians seek research that supports what they think. “We need to be careful,” he says, “but I’m not naïve to think that evidence is the only thing that we need to practice. It’s necessary, but then we have to add more information.”

SBI has efficacy, he says, for nondependent unhealthy alcohol use when there are multiple contacts in the primary care setting, but its effectiveness is unclear for others, such as those using other drugs, seeing someone outside primary care, having single or very brief contact, and drinking heavily.

Inroads are being made. Substantial national service delivery and training efforts have been instituted; billing codes for SBI have been added; accreditation has been put in place as a result of data from trauma centers; and performance measures tied to incentives are now being developed in ambulatory settings, general health settings and hospitals.

Three leaders from the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute on Drug Abuse (NIDA), and U.S. Department of Health & Human Services (USDHHS) also provided updates from their organizations: Kenneth R. Warren, Ph.D., Acting Director of NIAAA; Wilson M. Compton, M.D., M.P.E., Director of the Division of Epidemiology, Services and Prevention Research at the NIDA, and RADM Peter J. Delany, Ph.D., LCSW-C, Director of the Center for Substance Abuse Treatment, Substance Abuse Mental Health Services Administration, USDHHS.

Question of the Day: What Did You Find Most Interesting About Friday’s Opening Scientific Plenary Session? 

Winsberg“It’s just fascinating to see how many people on a national level are working in addiction from so many different angles. While I can’t point to one specific thing from the session, it was incredible to hear all the things different addiction specialists are doing, and it’s great to be a part of it.”

Mark Winsberg, M.D.
Rochester, N.Y.

Fuller“The lecture on the screening and brief invention was wonderful, and for Dr. Saitz to highlight that showed its importance. It was useful that he described the difference between screening and brief intervention and the SBIRT [Substance Abuse and Mental Health Services Administration’s Screening, Brief Intervention, and Referral to Treatment] initiative.”

Elizabeth Fuller, M.S.
Sandpoint, Idaho

Johnson_Farris“I am excited about the changes in policy. We are looking more scientifically at the disease of addiction and looking at outcomes so that we become more scientifically based rather than empirically based.”

Farris Johnson, M.D.
Athens, Ga.

Boone“The screening and brief invention talk by Dr. Saitz really made me realize that we take so many things for granted, and we really don’t have the scientific basis to know whether it is true or not. It makes me want to re-examine the things I believe.”

Daniel Boone, M.D.
Hunt, Texas

Vinson“I have been following Dr. Saitz’ work for some time and appreciate his rigorous attention to what the science actually does say. My first reaction is that it makes my depression about this worse to think that we really don’t know the scientific base.”

Daniel Vinson, M.D.
Columbia, Mo.

Casoy“This session showed all the effort and updates going on about how scientific evidence is being properly integrated in all sectors from academia to government to industry. It is very important.”

Julio Casoy, M.D.
Waltham, Mass