Sunday Conference News

ASAM Board of Directors Approves Candidates for Fall Election

The ASAM Board of Directors has approved a slate of candidates to participate an election for ASAM Executive Officers by the membership. Individuals elected will serve terms running from 2013 to 2015. The candidates for an ASAM Executive Office are:

  • President Elect: R. Jeffrey Goldsmith, M.D., FASAM, and Richard G. Soper, M.D., J.D., M.S., FASAM
  • Secretary: Margaret A. E. Jarvis, M.D., FASAM, Mark L. Kraus, M.D., FASAM, and Herbert L. Malinoff, M.D., FACP, FASAM
  • Treasurer: Kelly J. Clark, M.D., M.B.A., and Lori D. Karan, M.D., FACP, FASAM

“The upcoming election for 2013 is vitally important because there are opportunities to advance addiction medicine that have never been present before,” said Louis E. Baxter, Sr., M.D., FASM, Immediate Past President. “We need leadership that will advocate and advance access for patients who need treatment, and we need leadership that can fertilize and stabilize the gains we have made over the past 10 years in research, treatment, and acceptance in mainstream medicine.”

Serving on the ASAM Board of Directors offers useful experience to the individual members and provides a view of the profession that is unparalleled in depth and breadth, said Dr. Baxter.

“It is an absolute honor to be elected by your peers to serve as an ASAM officer. Anyone who is selected and then is elected to serve has a very important responsibility, not only to the entire membership, but also to the entire field of addiction medicine,” he said. “Elected officers must broaden their outlooks and understanding about addiction and addiction treatment. ASAM is a big tent, and all of our members and their interests must be represented.”

For more information, please email elections@asam.org. The complete list of candidates for executive positions and Regional Directors is on the ASAM website, www.asam.org, under the “About ASAM” link within the “About Us” tab.

Regional Directors/Alternates are elected solely by the members of their ASAM Region. The Regional Director will be the individual receiving the highest number of votes cast, while the Regional Alternate Director will be the individual receiving the second-highest number of votes cast. Regional Director/Alternates candidates are as:

  • Region I Nominees—New York: Merrill S. Herman, M.D., and Jeffery A. Selzer, D.O.
  • Region II Nominees—California: David R. Pating, M.D., and Jeffery N. Wilkins, M.D.
  • Region III Nominees—Connecticut, Massachusetts, Maine, New Hampshire, Rhode Island, and Vermont: Kenneth I. Freedman, M.D., M.B.A., FACP, and Stephen J. Ryzewicz, M.D.
  • Region IV Nominees—New Jersey, Ohio, and Pennsylvania: Jason M. Jerry, M.D.; Mark Philip Schwartz, M.D., FASAM; and John J. Verdon, Jr., M.D., FASAM
  • Region V Nominees—Delaware, District of Columbia, Georgia, Maryland, North Carolina, South Carolina, Virginia, and West Virginia: J. Ramsay Farah, M.D., M.P.H., FAACP, FACMP, FASAM, and P. Bradley Hall, M.D.
  • Region VI Nominees—Iowa, Illinois, Indiana, Michigan, Minnesota, and Wisconsin: Gavin Bart, M.D., FASAM, and Carl Christensen, M.D., Ph.D., FACOG, FASAM
  • Region VII Nominees—Arkansas, Oklahoma, Kansas, Louisiana, Missouri, Nebraska, and Texas: Robert M. Westcott, M.D., and Howard C. Wetsman, M.D., FASAM
  • Region VIII Nominees—Alaska, Arizona, Colorado, Hawaii, Idaho, Montana, New Mexico, North Dakota, Nevada, Oregon, South Dakota, Utah, Washington, and Wyoming: Gary D. Carr, M.D., FASAM, and William F. Haning, III, M.D., FASAM
  • Region IX Nominees—Canada/International: F. Charles MacKay, M.D., C.M., and Melanie D. Willows, M.D.
  • Region X Nominees—Alabama, Florida, Kentucky, Mississippi, Puerto Rico, Tennessee, and Virginia: Terry L. Alley, M.D., FASAM, and Bernd A. Wollschlaeger, M.D., FAACP, FASAM

Synthetic Drugs Creating Havoc for Lawmakers

Addiction medicine specialists will encounter many patients who use two classes of synthetic drugs—synthetic cannabinoids (a.k.a. “Spice” or “K2”) and substituted cathinones (a.k.a. “bath salts”). Learn what to expect with the use of these substances and the extent of their use during Symposium 11, “Emerging Drugs: Synthetic Cannabinoids and Substituted Cathinones” from 8 to 10 a.m., today, in Grand Salon West, Salon D.

“While I am not hearing much in the way of people running into problems with them, these synthetic drugs are becoming much more prevalent in society,” says Symposium Moderator Michael Fingerhood, M.D., FACP, Associate Professor of Medicine, Johns Hopkins University. “Especially with synthetic cannabinoids, I’ve started seeing people in their early 20s who have had experiences with these drugs, and you are starting to read a lot more about them in the press as well. If people want something, they can find it, and right now they are starting to look for these drugs.”

The drugs are manufactured in a lab and are related to cannabis and cathinones, but they remain unscheduled because the creators make slight changes to their formulas to remain one step in front of the Drug Enforcement Administration (DEA).

According to the National Conference of State Legislatures, at least 39 states have already banned one or both of these substances with 2009 and 2010 legislation targeting specific versions of the drugs. Minor changes to the substances’ chemical make-up allowed manufacturers to sell similar drugs not covered in the laws.

The response to this cat-and-mouse scenario is 2011 and 2012 legislation that targets entire classes of substances and aims to prevent new formulations of synthetic drugs from remaining unregulated, Dr. Fingerhood says. This also allows for substances that are approved for medical and research purposes.

“The state legislatures have really taken the lead in fighting this battle ahead of any federal action,” he says. “This makes sense, because they are able to react more quickly, so they are sort of setting out the path for the DEA.”

Today’s symposium will cover these issues and a host of others, Dr. Fingerhood says, with four speakers presenting on various aspects of the current state of the issue. The speakers are:

  • Matthew W. Johnson, Ph.D., Assistant Professor, Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore
  • Erik Gunderson, M.D., Assistant Professor, Department of Psychiatry and Neurobehavioral Sciences and Department of Medicine, University of Virginia School of Medicine, Charlottesville
  • Elizabeth Crane, Ph.D., M.P.H., Social Science Analyst, the Drug Abuse Warning Network (DAWN), which is part of the Substance Abuse and Mental Health Services Administration (SAMHSA)
  • Robert Bell, Staff Coordinator, Synthetic Drugs and Chemicals Section (ODS), DEA

“The last speaker will talk about what the Justice Department believes are the most important points regarding these drugs, as well as what they think is coming down the road,” Dr. Fingerhood says. “That will focus mostly on what has to happen to schedule this class of drugs under the Controlled Substances Act.

“The lack of general knowledge and the risk these drugs pose is an issue that we all need to be very aware of. Young people become  extremely paranoid, and addiction medicine physicians need to be aware of the warning signs that will help them zero in on the patients who might be using these products.”

Researchers Examine International Addiction Efforts

Addiction medicine researchers from Israel, Italy, and Spain shared findings Saturday from studies that examined substance abuse among recently discharged soldiers, prevalence and treatment of addiction and mental illness in the European Union (EU), and psychiatric disorders related to cocaine use.

“An International Perspective on Combined Addiction and Mental Illness” was co-sponsored by the International Society of Addiction Medicine (ISAM) and the National Institute on Drug Abuse (NIDA).

Haim Mell, M.D., head of the Israel Anti-Drug Authority, presented “A Drug Treatment Program for Young Israeli Military Veterans.” In Israel, all young men and women serve in the military, and it is common for them to celebrate the end of their service by going backpacking in India.

In this environment, drug abuse is common, and the most commonly used substances are cannabis. To combat this issue, Israel has started education programs, such as putting help information on passport covers, and establishing a rescue program and Kfar Izun (harmony village) to treat and rehabilitate these ex-soldiers.

“The results excite me,” Dr. Mell says. “I can say since Kfar Izun has opened … 50 percent or more are going on with their lives without the stigma.”

Giuseppe Carra, M.D., M.Sc., Ph.D., presented “Combined Addiction and Major Mental Illness in Europe,” in which he detailed how the 27 states in the EU attempt to treat the growing issues of substance abuse and mental health disorders.

Research on drug use is readily available, but statistics for mental health disorders and treatment are lacking, he says. The overriding problem is that the many European nations and regions have very different approaches to dealing with drug use and mental health disorders.

“We have started to think about integrating programs, but the last available data shows a fragmented situation,” Dr. Carra says. “Having lost the comfort of our geographical boundaries, we must, in effect, rediscover what creates the bond between humans that constitutes a community,” he says.

Carlos Roncero, M.D., presented “Addiction and Dual Disorders,” in which he reviewed the epidemiology, risk factors, and risk factors models in the study of cocaine-induced psychosis (CIP). He is a member of the Department of Psychiatry, Hospital UniversitariVall d’Hebron, Barcelona.

Among the possible factors researchers examined as links in CIP were the quantity of cocaine consumed, body weight, comorbidities, genetic influences, and pharmacological interactions.

“The systematic evaluation of CIP can be very useful for preventing consequences or risks of psychotic states and hostile behavior that could be dangerous to themselves or others,” Dr. Roncero says of the research reviewed.

Family, Colleagues Inspire ASAM Awardees

ABAM Board Member Mike Miller, M.D., FACP, FASAM, (left) presents the ABAM and ABAM Foundation President's Award to ABAM Immediate Past President Kevin B. Kunz, M.D., M.P.H., FASAM.

ABAM Board Member Mike Miller, M.D., FACP, FASAM, (left) presents the ABAM and ABAM Foundation President’s Award to ABAM Immediate Past President Kevin B. Kunz, M.D., M.P.H., FASAM.

The presentation of ASAM’s most prestigious awards Saturday brought two standing ovations and left attendees in awe of the tireless efforts of their fellow members.

First up, A. Thomas McLellan, Ph.D., Chief Executive Officer, the Treatment Research Institute, Philadelphia, received the Public Policy Award.

“I was happy to serve, and I am delighted to be thought worthy of such an award,” Dr. McLellan says. “I congratulate ASAM on the years it contributed to public policy in addiction, and I see nothing but the brightest of futures for this organization.”

The Young Investigator award went to Anne Neumann, Ph.D., M.A., Researcher, the Statue University of New York Primary Care Research Institute, Buffalo.

“Thank you very much. Thank you for the opportunity to be here. I have been learning a lot,” Newman says.

Two ASAM Annual Awards were presented, the first to Elizabeth F. Howell, M.D., DFAPA, FASAM, who shared the credit for her award with ASAM members.

“Anything we’ve done, I really can’t take any credit for it. It’s the work of you and other members of ASAM. I’m happy that I could be part of that and getting things started,” says Dr. Howell, Associate Professor Psychiatry, University of Utah Neuropsychiatric Institute, Salt Lake City.

The second recipient was Gerald D. Shulman, M.A., MAC, FACATA, President of Shulman & Associates, and an addiction and mental health training consultant, Jacksonville, Fla.

“I can’t tell you how honored and humbled I feel,” Dr. Shulman says. “I’ve had a driving force in my professional life, which is to make a difference in the lives of people who have substance abuse disorders and their families. ASAM has given me the opportunity to work toward that goal and with some people who started as colleagues and ended up as friends. These people helped me become a better trainer, consultant, clinician, and, in the final analysis, a better person.”

Accepting the Annual Media Award on behalf of Judith and Bill Moyers was their son, William C. Moyers, who shared his own story of recovery from addiction, beginning in 1994.

“Ever since, my parents and I have never shied away from being open about just how close to home addiction hit in the Moyers family, just like it strikes so many families in this country and around the world,” Moyers says. “That’s why I am honored by this ASAM honor, and why they are honored by this ASAM award.”

After David R. Gastfriend, M.D., a Newton, Mass., addiction psychiatrist, gave the John P. McGovern M.D. Award and Lecture on Addiction and Society, he thanked his supporters and family, including his father, who survived Nazi Germany’s concentration camps.

“His Jewishness and humanitarian values survived as well,” Dr. Gastfriend says. “I believe that was the source of my yearning to help the needy and victims of prejudice that formed the foundation of my career aspirations. My three kids have been an unending blessing. My wife has nurtured me, loved me, and tempted to balance me, sharing both the steps forward and trying to help me anticipate the falls backward.”

Bonnie B. Wilford, M.S., received the Presidential Award, sharing how her boss at the American Medical Association, Manny Steindler, also a former ASAM Executive Vice President, inspired her.

“I want you to know about him because it’s people like Manny who brought this field to where it is today,” Dr. Wilford says. “I’d like to accept this wonderful award in his honor. There’s no other area of medicine that exemplifies the difference one person can make more than addiction medicine.”

Frank Vocci, Ph.D., Becomes Third Co-Editor of JAM

Frank Vocci, Ph.D.

Frank Vocci, Ph.D.

ASAM’s Board of Directors voted during the Med-Sci Conference to approve the selection of Frank Vocci, Ph.D., as the third Co-Editor for Journal of Addiction Medicine (JAM), ASAM’s official journal. The addition of Dr. Vocci comes at a critical moment in the journal’s progress and in the wake of several successes in solidifying JAM as a leading scientific journal in addiction medicine.

That’s the word conveyed by JAM Senior Editor George F. Koob, Ph.D., and Co-Editors Martha J. Wunsch, M.D., FAAP, FASAM, and Shannon C. Miller, M.D., FASAM, FAPA. Since its creation five years ago, the journal has expanded the scope of its operation and been included in PubMed, an endorsement that is considered rapid among medical journals and denotes the publication as a significant medical journal with a society base that publishes on time and fills its pages with content that is frequently cited.

“This indexing will enable JAM to finally compete on a more level playing field with other medical journals and compete for citations,” Dr. Miller says. “We have managed to increase both our impact factor and rejection rate, all without PubMed citation. PubMed citation will now provide a paradigm shift in visibility for articles published in JAM, improving our opportunity to be cited by other journals.”

Bringing Dr. Vocci on board as a Co-Editor is the next step in the journal’s progression. “Outside of his prominence in the field of addiction medicine, we are excited to have a leader with vast expertise in clinical trials,” Dr. Miller says. “His addition will help strengthen our research in clinical trials, which is key to improving the quality of addiction care.”

Dr. Vocci is President and the Senior Research Scientist at the Friends Research Institute. He earned a doctorate in neuropharmacology, has completed a fellowship in addiction pharmacology, and worked for more than 10 years at the Food and Drug Administration reviewing analgesic medications and medication treatments for addiction disorders in addition to directing the National Institute of Drug Abuse’s medications development program for 13 years.

The editors of JAM attribute the journal’s success to strong ASAM backing, a creative team effort among the editors—Drs. Koob, Wunsch, and Miller—and a small cadre of dedicated support staff.

JAM supports the mission of ASAM by helping to focus attention on addiction problems, an attention that Drs. Miller and Wunsch say has waxed and waned since ASAM was created in 1954. Lately, that attention has been on the rise, with the public showing more understanding of addiction as a disease. JAM will continue to emphasize alcohol and drug addiction, but other aspects of addiction and addiction-related conditions also receive attention in JAM, the co-editors say.

“Addiction has been around for a long time, obviously, but JAM‘s ability to flourish signals recognition of the importance of clinical research by our medical brethren,” Dr. Wunsch says.

JAM publisher Lippincott Williams & Wilkins and ASAM have agreed to support the editors’ request for more pages—pushing the number of issues from four to six per year—and the recent addition of electronic publication ahead of print. The addition of Dr. Vocci as the third Co-Editor rounds out the advances the journal has made over the past years.

All this will occur between now and 2014 and “will enable the journal to reach out to more authors,” Dr. Wunsch says. The journal has already received “an increased number of submissions and has an increasing impact factor in the past two years, at a time when most journals have held steady or seen a reduction in impact factor.” Later this year, JAM plans to supplement its core content with a separate section devoted to coverage of ASAM-generated content of high interest to ASAM members.

The editors invite all to visit JAM online at www.journaladdictionmedicine.com, and encourage authors to submit research for publication by visiting www.editorialmanager.com/JAM.

Clinicians Apply SBIRT to Adolescents and Young Adults

John Knight, M.D.: "Primary care providers have an excellent opportunity. It's a teachable moment in a confidential relationship."

John Knight, M.D.: “Primary care providers have an excellent opportunity. It’s a teachable moment in a confidential relationship.”

John Knight, M.D., shared a rich history in research of new strategies for early identification and intervention in adolescent substance abuse during Saturday’s Symposium 9, “SBIRT—Adolescent and Young Adults in General Medical Settings: Scientific Updates and Clinical Implications.”

“If you look at the trajectory of drug and alcohol abuse in adolescents, it goes from close to 0 percent at age 12 all the way up to 70 percent age 18, so there is a steady march year to year,” said Dr. Knight, Associate Professor of Pediatrics, Harvard Medical School, Boston. “Primary care providers have an excellent opportunity. It’s a teachable moment in a confidential relationship.”

The American Academy of Family Physicians and the American Medical Association recommend an annual substance abuse screening of adolescents. However, primary care physician adherence to this screening is low, he says. Fewer than 50 percent of primary care physicians screen all adolescents for substance abuse, fewer than 25 percent screen for substance-abuse driving risks, and less than 12.5 percent use a structured screening tool.

Studies have found that barriers to primary care screening include time constraints, insufficient training, competing medical care demands, lack of treatment resources, dealing with tenacious parents, and screening tools that are unknown to them. To address with these issues, he developed the CRAFFT test a decade ago to help clinicians screen for substance abuse among adolescents. It asked patients about everything from riding in a car driven by someone who is high to forgetting things while using alcohol and drugs. The CRAFFT test has also withstood the test of time and has become a valuable tool in many SBIRT initiatives throughout the country.

Recently, such SBIRT initiatives merged with the computer technology in administering the CRAFFT test and have found adolescents are more willing to take a computer test than answer questions from a physician or nurse. He is currently involved in an international trial of computer-facilitated substance use screening and brief advice for teens in primary care settings.

“The advantage of primary care in pediatrics is that you see your patients every year,” Dr. Knight said. “You get another bite of the apple when they come back the following year.”

Constance Weisner, Dr.PH., M.S.W., described how SBIRT for youths with substance use programs can work within an integrated health care system. She is currently involved in research on the medical home model for adolescent substance use problems in her position as Professor, Division of Research, Kaiser Permanente Northern California, University of California, San Francisco

“For the screening and brief intervention, we are applying SBIRT screening and managing short behavioral interventions for the lower severity problems with pediatrics,” she said. “For the treatment component, we get those children to special needs care, getting them stabilized, and then importantly, getting them back to pediatrics and keeping the care coordinated. Our SBIRT study is conceptually framed within this larger medical home model.”

A current study at Kaiser Permanente Northern California randomizes primary care providers to different modalities of delivering SBIRT—primary care physician delivery versus behavioral medicine specialists. Investigators are seeking to learn which SBIRT model produces the best screening, brief intervention and referral rates.

“Based on the findings, we will work with clinicians, health plan administrators, and consult with federal-qualified health centers and other researchers and consultants to see how to adapt this again to do a regional roll-out or a larger implementation study,” Dr. Weisner. “We have found that of those children who have had regular primary care visits each year, their abstinence rates are higher than those who have not. Of those who have had relapse, they are likely to receive a substance use treatment re-admission. That’s how we complete this whole circle with the medical home.”

Drs. Knight and Weisner were among several speakers who addressed this National Institute on Drug Abuse-sponsored symposium.

Physicians Key in Appropriate Buprenorphine Use

Buprenorphine misuse is a hot topic in Addiction Medicine, as seen by the large audience at Saturday's symposium, "Buprenorphine: Enhancing Access While Preventing Diversion."

Buprenorphine misuse is a hot topic in Addiction Medicine, as seen by the large audience at Saturday’s symposium, “Buprenorphine: Enhancing Access While Preventing Diversion.”

Misconceptions—yes or no? Buprenorphine diversion and misuse are signs that my patient is “bad” and should be kicked out of treatment. Buprenorphine is the lesser evil than using street drugs. Diversion and misuse are inevitable, so it is OK to ignore it. The answer is “no” to these misconceptions, says Michelle R. Lofwall, M.D., Assistant Professor of Psychiatry, Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, Ky., who addressed Saturday’s Symposium 6, “Buprenorphine: Enhancing Access While Preventing Diversion.”

“As for the first myth that the patients are bad and we need to fire them, the truth is the misusing and diversion are common behaviors among addicted patients,” she says. “They take opioids in non-medically intended ways for non-medical reasons. It’s part of the essence of addiction. These patients deserve treatment.”

Nevertheless, it goes too far to just ignore buprenorphine diversion and misuse, regarding it a lesser evil than injecting heroin.

“We don’t want to look like we have that attitude,” Dr. Lofwall says. “If we don’t try to address it, it could damage our treatment reputation and harm patients. Lack of attempts to prevent or decrease misuse and diversion could threaten the treatment’s availability. Individual states could decide to re-schedule buprenorphine to a more restrictive drug class and it won’t be available for office-based treatment any more.”

Buprenorphine misuse has been associated with liver damage, pancreatitis, fungal endophthalmitis, pulmonary granulomatosis, abscesses at the injection site, and death—when combined with central nervous system depressants. She also reports on the increased incidence of injecting buprenorphine tablets, which presents the unwanted potential for harming individuals, not only from the buprenorphine itself, but also from the excipients within the tablets.

To prevent inappropriate buprenorphine use, Dr. Lofwall recommends evaluating circumstances surrounding these behaviors and addressing them in treatment plans.

“We have an open conversation with our patients,” she says. “We let them know we are here to help them and not harm them. We ask them to let us know everything they are doing with their medications. If they tell us they are misusing and diverting, we have answers for that.”

She also advises weekly visits from her patients being treated with buprenorphine until they are stable.

“A therapeutic dose decreases withdrawal, craving, and illicit drug use and provides opiate blockade,” Dr. Lofwall says. “Think carefully when you are going above 16 milligrams a day. If they continue craving, think about what is going on psychosocially because lots of things can affect craving.”

Symposium 6 also featured Jody Rich, M.D., M.P.H., Professor of Medicine and Community Health, Division of Biology and Medicine, Brown University, Providence, R.I., who studied the use, procurement, and motivations for use of diverted buprenorphine/naloxone among injecting and non-injecting opioid users in Providence, R.I. Participants were recruited from a fixed-site syringe exchange program.

Of 51 injecting opioid users and 49 non-injecting opioid users in the study, 76 percent reported having obtained buprenorphine/naloxone illicitly, with 41 percent having done so in the previous month. Participants reported reasons for using buprenorphine/naloxone: 74 percent to treat opioid withdrawal symptoms, 66 percent to stop using other opioids, and 64 percent because they could not afford drug treatment.

“Diverted buprenorphine/naloxone was common among our sample,” Dr. Rich says. “Many opioid users, particularly in intravenous drug users, were using diverted buprenorphine/naloxone for reasons consistent with its therapeutic purpose, such as alleviating opioid withdrawal symptoms and reducing the use of other opioids. These findings highlight the need to explore the impact of buprenorphine/naloxone diversion, as well as improve accessibility of  buprenorphine/naloxone through licensed treatment providers.”

In addressing buprenorphine trends, Richard C. Dart, M.D., Ph.D., Executive Director, Researched Abuse, Diversion, and Addiction-Related Surveillance (RADARS) System, Denver, reports conclusions from its Opioid Treatment Program tracking and Survey of Key Informants’ Patients.

“The treatment population seems to be appreciating the fact the single ingredient (buprenorphine) is more available, it doesn’t have naloxone, and abuse of it is going up,” he says. “If you ask them how they abuse those drugs, the single-ingredient versions are endorsed much more frequently in terms of intravenous abuse. Not only are we seeing more of that, but this population has a high proportion of a high-risk route of abuse.”

Attendees Line Up to Tell the CDC to Act Now

Barbara Herbert, M.D.: "I don't think of my patients as prescription drug abusers. I think of my patients as people who have a disease. I feel like that language is critical."

Barbara Herbert, M.D.: “I don’t think of my patients as prescription drug abusers. I think of my patients as people who have a disease. I feel like that language is critical.”

Annual Medical-Scientific Conference attendees didn’t hold back their questions and comments after Ileana Arias, Ph.D., the second-in-command at the Centers for Disease Control and Prevention, presented her Policy Plenary keynote talk Saturday morning on addressing prescription drug abuse.

The Principal Deputy Director of the CDC and the Agency for Toxic Substances & Disease Registry embraced the feedback, which covered a gamut of topics. Attendees called on Dr. Arias to bring these topics to the forefront of the CDC’s efforts: addiction treatment, Internet pharmacies, elimination of the 100-patient limit for providers of buprenorphine, guidance for communicating with patients about moving off opioids when they are not helpful, teenage “pharm parties,” seeing the issues not as an epidemic but as a “pain health problem,” mechanisms for pharmacies to keep dispensing in check, the increase in opioid use after the Joint Commission declared pain as the “fifth vital sign,” laws that prevent communication about addiction between providers, and mandatory education for prescribers.

A common theme among the audience was to improve advocacy for patients who rightly rely on opioids to relieve their pain, but suffer from an undeserved stigma.

In her passionate remarks, Barbara Herbert, M.D., who works in a community practice in Boston, recalled the CDC’s advocacy for those with HIV.

“The CDC was a real leader, and they directly took on the issue of stigma,” Dr. Herbert says. “I’m very concerned about the ways our patients are characterized. I don’t think of my patients as prescription drug abusers. I think of my patients as people who have a disease. I feel like that language is critical. The CDC has been so important in taking on HIV directly and talking about stigma and bias. I plead with you. Do it again.”

Lee Tannenbaum, M.D., Bel Air (Md.) Center for Addictions, asked that the CDC widely distribute public service announcements.

“When we had the flu epidemic, it was the No. 1 story on the news for weeks and weeks at a time. Within a month, every person in my community had alcohol-based hand sanitizer in their offices and homes,” Dr. Tannenbaum says. “Why have we not seen a single PSA that says: ‘Lock up your prescription medicines just like you lock up your Drano. Keep your Percocet and oxycodone under lock and key. Your medicine cabinet is not enough'”?

While Dr. Arias says opioid misuse and overuse will not be eradicated, she is optimistic.

“We can make a significant difference. We have the tools now, and we know that more can be developed,” Dr. Arias says. “We’re right with you on that.”

CDC Taking Steps to Combat Opioid Deaths

Ileana Arias, Ph.D.: "We all need to be bound together in the effort to address opioid abuse and overdose deaths if we are going to be successful."

Ileana Arias, Ph.D.: “We all need to be bound together in the effort to address opioid abuse and overdose deaths if we are going to be successful.”

The Centers for Disease Control and Prevention (CDC) estimates that enough opioids were sold in 2010 to give every American adult a 5 mg Vicodin tablet every four hours for a month.

That startling statement by Ileana Arias, Ph.D., Principal Deputy Director of the CDC and the Agency for Toxic Substances & Disease Registry, brought a collective gasp from Saturday’s Policy Plenary audience.

During “Addressing Prescription Drug Abuse: Role of the Physician in Counteracting Diversion, Misuse, and Addiction,” she looked at the impact of drug overdose deaths involving opioids, drivers for abuse, and CDC policy recommendations.

Calling interest in opioid abuse and death unprecedented in its momentum, Dr. Arias says its degree of urgency and multidimensional nature requires that various sectors have an appropriate role.

“We all need to be bound together in the effort to address opioid abuse and overdose deaths if we are going to be successful,” she says.

Heart disease and cancer are the leading causes of death for all Americans, according the CDC. However, unintentional injury surpassed motor vehicle crashes as the leading cause of death for young Americans (birth to age 34 or 45, depending on surveillance year) in 2008.

In overdose deaths where a drug was specified, according to the CDC, nearly 75 percent involved prescription drugs. Of those deaths, opioid pain relievers were the cause of almost 75 percent. In 2009, more than 15,000 people died from overdoses involving opioid pain relievers.

Faced with an overabundance of supply of these powerful drugs, the misuse and abuse of the medications, and high economic costs, which are estimated to cost insurers $72.5 billion every year, the CDC sought to determine portals of accessibility that lead to misuse and overdose.

Those areas are pill mills: prescribers who have not been trained in appropriate pain management or addiction; Emergency Department and hospital prescribers who are unaware of patient prescription histories; pharmacies that fail to determine if they are dispensing legitimate prescriptions and do not identify patients who pharmacy shop; insurer and pharmacy benefit managers who manage prescriptions; ill-informed patients and the public (one study found 70 percent of people who use pain relievers nonmedically acquired them from a friend or relative); and people at high risk for overdose.

The CDC is responding in several ways, including through continuous support and development of surveillance systems at the federal, state, and local levels to identify problems early and respond in a timely manner. The organization also seeks to provide appropriate public, patient, and professional education about the risk and appropriate use of opioids as means to change practice.

To gain momentum, the CDC also is looking to several efforts, including prescription drug monitoring programs; patient review and restriction programs; laws, regulations and policies; insurers and pharmacy benefit manager mechanisms; and clinical guidelines.

Not only are these powerful and fast-acting, they also are relatively cheap compared to other more traditional public health interventions and efficient, Dr. Arias says.

“The CDC essentially is bringing science to prevention and informed policy to achieve population change,” Dr. Arias says. “We can’t do it alone. I thank you for your efforts and partnership, and I am more than interested in your feedback—suggestions you may have for what it is that the CDC, specifically public health, can add to the effort and then learning from you about potential avenues to pursue.”

What did you think of Saturday’s Policy Plenary Session?Martin“I’m incredibly pleased that the CDC is taking the leadership on this. The points they made are on target. It is interesting to see ASAM practitioners, who have followed these principles for years, and now suddenly it is becoming governmental policy.”Patrick Martin, M.D.
Wilmington, N.C

 

Chiarottino“I thought it was biased toward the enforcement side of the problem. I agree there is a huge problem with availability and overprescribing, but there was very little mention of treatment. In California, the drug enforcement agency and state medical board are applying pressure on us to limit the problem when patients who need treatment and want it can’t get it.”

Michael Chiarottino, M.D., FASAM
Mill Valley Calif.

Ahmad“This was an excellent session and it’s great input to see the CDC’s leadership is giving us. There were some great questions about seeing more regulations put in for opioid prescriptions to make them more readily available.”

Seeme Ahmad, M.D.
Tucker, Ga.

Gordon“It is the best collaboration I have seen between federal agencies involved in issues of addiction and our medical society. It generated discussion of the issues and I think there is a real interest in working together. I suggested that we need to adopt a new paradigm that everybody is inspecting this problem though the same lens, and that lens would be the war on addiction as opposed to the war on drugs.”

Michael Gordon, M.D.
Atlanta

Lee“It was interesting to hear about addressing the epidemic of prescription drug overdose. It is something the public needs to learn about, and I think the Deputy Director did a great job giving an overall picture of the problem and ways it can be addressed.”

Jinhee J. Lee, Pharm.D.
Rockville, Md.

Jacobs“I’m glad to see the CDC is taking an interest. I hope they continue to move forward with publicizing the opioid epidemic we have in this country. I hope they will continue to work to help us get patients to treatment. It’s such a horrific problem that we need to publicize it and treat it the way we did the AIDS epidemic.”

William S. Jacobs, M.D.
Jacksonville, Fla.