April 26

New Formulations, Combinations May Improve Buprenorphine Efficacy

Jag Khalsa, PhD, MS

Jag Khalsa, PhD, MS

Buprenorphine holds great promise in the treatment of opioid addiction, but its use and outcomes have lagged. However, new research and new formulations may make it more accessible—and effective. A symposium presented twice today will explore those advances.

Symposium 1, “Buprenorphine: New Formulations, Medication Combinations, Indications, and Longitudinal Effects,” will look at an implantable delivery system that could improve adherence, and new combinations for its use. The symposium will be presented from 10:30 am to 12:30 p.m. and from 2:30 to 4:30 pm in Continental A on the lobby level of the Hilton Chicago.

“There are new formulations of buprenorphine, especially ones that can be implanted under the skin for a slow release of the medication so the patient does not have to get treatment more frequently,” said the symposium organizer, Jag Khalsa, PhD, MS, Chief of the Medical Consequences Branch, National Institute on Drug Abuse (NIDA).

The new delivery is expected to improve adherence and outcomes, which will be discussed in the session. Also discussed will be new drug combinations that hold promise. A combination of buprenorphine and ALKS 33, an opiate antagonist, is being tested to treat cocaine dependence and depression.

Presenters in the symposium also will discuss buprenorphine when reviewing the results of the NIDA Prescription Opioid Addiction Treatment study (POATS); its role in psychiatric comorbidity; its effects on the liver and other findings from the Starting Treatment with Agonist Replacement Therapies (START) trial; and the design and methodology considerations of the Cocaine Use Reduction with Buprenorphine (CURB) study.

“We will discuss the liver complications of buprenorphine because it is important that we know not only the positive effects of the medication but also the potential adverse effects of the medication,” Dr. Khalsa said.

Geetha Subramanian, MD, of NIDA, and Gavin Bart, MD, of the University of Minnesota, organized the session with Dr. Khalsa, and they both will be speakers. Other speakers will be: Roger Weiss, MD, Professor of Psychiatry at Harvard Medical School and McLean Hospital; Andrew Saxon, MD, Professor and Director of the Addiction Psychiatry Residency Program at the University of Washington; Ryan Turncliff, PhD, Alkermes; Fredrik Tiberg, PhD, Camurus; Katherine L. Beebe, PhD, Titan Pharmaceuticals; Elliot Ehrich, MD, Alkermes; and Walter Ling, MD, Professor of Psychiatry and Director of the Integrated Substance Abuse Programs at the University of California, Los Angeles.

ASAM Chapters to Address Issues Developing in Addiction

Several ASAM state and regional chapters will meet during the Med-Sci Conference to address issues ranging from the impact of medical marijuana and legalized marijuana to the implementation of the Affordable Care Act to the role of the ASAM Patient Advocacy Task Force.

The ASAM Chapters Council met Thursday, and seven chapters are meeting today and Saturday.

“ASAM is a membership-driven organization, and membership is represented through its various regional and state divisions,” said Gavin Bart, MD., PhD, FASAM Chapter Council Chair. “The Chapters Council is that body of state and regional leadership that communicates issues from the membership to the central offices of ASAM to make sure ASAM remains a membership-driven organization.”

Dr. Bart encouraged members to attend their chapter meetings because health system reform is driving so many changes in health care. In particular, many states are taking new directions with Medicaid expansion.

“The chapters forum can not only serve as a means of communicating membership issues to the central office, but it is a way states can learn from each other,” he said. “A great example of this is the Patient Advocacy Task Force and what some of the state chapters had noticed with legislation in their states regarding time and dosage restrictions related to specific treatments for opiate addiction.”

A case of sharing experience among chapters can be seen in Maine, where new legislation limited the treatment of opiate dependence to two years. Maine was first to take this step, and several other states have followed.

“Mark Publicker [MD, FASAM] was very involved in working with Maine to help combat this restriction on treatment,” Dr. Bart said. “He shared his experience and advice with other chapters so as their states began to deal with these legislative restrictions, they were able to follow his playbook. Without something like the Chapters Council we would not have this forum to exchange information.”

In 2012, two states, Washington and Colorado, legalized marijuana, and other states may follow that path, which could have significant clinical consequences for patient management.

“The ASAM state chapters need resources from the national office to help them, but we can learn from their experiences so as other state chapters deal with this, they can be prepared,” Dr. Bart said. “This is a bidirectional exchange, and it traverses all of the state chapters through the committee meetings.”

Another issue being addressed by state and regional chapters is the possibility of expanding ASAM membership to non-physicians.

“All of medicine is increasingly becoming collaborative care, perhaps even more so within addiction medicine,” Dr. Bart said. “If we are going to embrace a collaborative care model, can ASAM be an organization that is restricted to MDs and DOs only? It is a controversial topic within ASAM. The Chapters Council is the forum through which a lot of these debates about our future identity take place.

“This is a reminder that there is always space for new members. We strongly welcome more members to become more involved in chapters at the committee level or even running for office. Without their input and involvement, this organization could not exist.”

Interventions in Primary Care Are Effective

What is the secret to conducting effective yet inexpensive screening and brief intervention for substance use in primary care settings? How has care for addictions found a seat at the table of the primary care patient-centered medical home? Norman Wetterau, MD, FASAM, Addiction Medicine Specialist and Family Physician, Tri-County Family Medicine, Dansville, N.Y., discussed key insights to such questions that he and two other primary care and addiction medicine physicians presented during Thursday’s Component Session 2 “Addressing Substance Use Disorders in Primary Care: How Can We Improve?”

“Each year, the ASAM Primary Care and Family Medicine Work Group conducts a workshop to report on substance use issues that arose during the year to get input from the entire group,” said Dr. Wetterau, Component Session 2 organizer. “This year, screening and brief intervention, and the patient-centered medical home were selected as topics for this session.”

Session speakers J. Paul Seale, MD, Professor and Director of Research, the Department of Family Medicine, Medical Center of Central Georgia and Mercer University School of Medicine, Macon, Ga., and Abdel Fahmy, MD, physician and administrator, DuPage Medical Group, Chicago, shared their considerable expertise in providing screening, brief intervention, and referral to treatment (SBIRT) in primary care settings in the absence of reimbursement for it. Dr. Seale has been involved in SBIRT programs throughout the South and Dr. Fahmy works with federally qualified health centers in medically underserved, low-income metropolitan Chicago neighborhoods.

“A key point they made is that when you don’t have a grant to fund SBIRT, it’s difficult to implement it,” Dr. Wetterau said. “Still without funding, flexible and simple approaches make SBIRT possible in primary care practices.”

One efficient approach involves delegating screening questions and full substance use audits of patients to medical assistants. Then the physician can provide expert review of the audit and a brief intervention, if necessary.

“This system is simple and it works,” Dr. Wetterau said. “Many primary care physicians have struggled with setting up SBIRT in their practices without grant money to fund it, so this effective, less expensive method is a feasible alternative.”

During the session, Dr. Wetterau discussed his service to the Patient-Centered Primary Care Collaborative (PCPCC), a large national organization of physicians, medical organizations, insurance companies, and employers collaborating to develop the Patient Centered Medical Home. He was appointed in January to the Care Delivery and Integration Center Leadership Team that includes 15 organizations, including ASAM. The team’s objective is to provide programs and assistance to help transform primary care practices into patient-centered medical homes.

“We wanted to make sure that addiction medicine is integrated into these primary care homes,” he said. “We have had some successes with this endeavor.”

For example, the non-profit National Committee for Quality Assurance (NCQA) now requires medical homes to ask about drug and alcohol use. Dr. Wetterau also is working on this team to provide links to primary care addiction websites and to develop webinars about the potential for substance use treatment in patient-centered medical homes. Additionally, ASAM is planning a section on its website that can be linked to these sites.

“Our presence there really helps everyone realize that substance use issues are really important to the patient-centered medical home,” he said. “ASAM is helping to suggest resources and find speakers for the webinars.”

PTSD, Addiction Complicate Treatment Options for Veterans

Combat veterans with post-traumatic stress disorder (PTSD) aren’t just haunted by memories of their wartime experiences—they have “a new brain” that complicates treatment. This challenge will be examined during Course 2, “Combat Trauma and Addiction,” from 10:30 am to 12:30 pm today in the Waldorf Room on the third floor of the Hilton Chicago.

“Severe trauma can change your brain like addictions can,” said Larry Ashley, EdS, LCADC, CPGC, who will present the course. “That’s why addictions and PTSD together are so significant. Each one by itself can cause permanent brain change. When they’re together, that heightens the change.”

Dr. Ashley is Addictions Specialist and Mental Health Coordinator at the Department of Educational and Clinical Studies, and Clinical Associate Professor of Addiction Medicine, Department of Internal Medicine, University of Nevada School of Medicine.

PTSD is characterized by three symptom sets—hypervigilance, re-experiencing, and numbing and avoidance—that make it difficult for veterans to readjust to civilian life. Between 35 percent and 75 percent of veterans with PTSD are reported to abuse drugs and alcohol. Combat trauma also can lead to behavioral disorders such as problem gambling, hypersexual behavior, and eating disorders, he said.

Veterans exhibiting hypervigilance startle easily, may have trouble sleeping, and might not trust people.

Re-experiencing isn’t just a bad memory. “You’re there,” Dr. Ashley said. “Your brain has put something back in motion.”

A Vietnam veteran reported that diesel fuel was one of his “triggers” when he came home from war. “I can remember in the summer, driving by a gas station with the windows down, smelling the fuel from the gas station, and that put me right back into Vietnam, right out of the blue,” one veteran told Dr. Ashley.

Combat veterans who experience numbing and avoidance do so as a defense mechanism to block out what they saw during war, but the effects can spill over into daily life, he said, adding.

Veterans have abused substances to deal with the horrors of combat since at least the Civil War, when troops developed morphine addictions. While mental health treatment doesn’t carry the same taboo today as it did after earlier wars, it still can be difficult to successfully treat some veterans. Those veterans “don’t trust the system” and won’t go to the Department of Veterans Affairs for help, Dr. Ashley said, while those still serving in the military may view treatment as a career “kiss of death.”

Medications and counseling can be used to treat veterans with addictions, but Dr. Ashley said his preferred treatment is exposure-based cognitive behavioral therapy.

“We go back, look at some of the events that led up to what’s happening today,” he said. “I believe we have to deal with the past in order to go forward.”

Revised ASAM Criteria to Roll Out with Book and Software

asam-criteria-cover_SMALLThe revised ASAM criteria will soon make its debut through a new publication, The ASAM Criteria: Treatment Criteria for Substance-Related Addictive and Co-occurring Conditions, and The ASAM Criteria Software. David Mee-Lee, MD, chief editor of The ASAM Criteria, discussed key ways the new criteria will be particularly useful to addiction medicine specialists and how the book and software will facilitate application of criteria to addiction medicine daily practice. He and other ASAM criteria experts also addressed the user-friendly features of these two soon-to-be-released resources during Thursday’s Component Session 1, “Update on The ASAM Criteria: The Revision and Software.”

“Many things have changed since the publication of the 2001 edition,” Dr. Mee-Lee said. “We received feedback about the need for the ASAM criteria to be applicable to various settings where addiction medicine specialists work. The result is that we have updated this edition to be useful to specialists working in different settings and with different populations.”

Those populations and settings include working within the criminal justice system, with older adults, with parents of children who need treatment, and with patients in safety-sensitive occupations (pilots, physicians, etc.). The revised edition of The ASAM Criteria also address tobacco-use disorder and gambling disorder, and will be compatible with the American Psychiatric Association’s DSM-5 for consistency in terminology.

Dr. Mee-Lee also promises a book that will be significantly more user-friendly than the 2001 edition.

“We have set out to parallel the process that people go through in treatment from assessment to service planning to placement in the level of care,” he said. “It also will be more user-friendly in terms of the use of graphics and layout so that people can access information much more specifically and efficiently. It will be much easier for readers to find the section of the book they are looking for.”

In tandem with the release of this new edition, is The ASAM Criteria Software, an application-focused resource whose concepts are explained by the book, which will provide a standardized way to apply the ASAM criteria, Dr. Mee-Lee said.

“By using the software and the book together, addiction medicine specialists can really understand how to implement the criteria fully,” he said. “We want to emphasize the point that you need the book to help you understand the criteria, and these are interdependent together. It’s not just using the software alone or the book alone, but rather using the book as a foundation guide to implementing the software.”

The ultimate goal of the book and software is to adhere to the criteria to enhance assessment, placement, and care management processes for providers and payers. Both addiction medicine specialists and payers spend significant amounts of time and resources communicating back and forth in the treatment approval process, he said. Providers spend time seeking authorization for obtaining treatment services for their patients, and payers spend considerable time in utilization management to authorize those treatments. That approval process could be streamlined considerably if providers and payers use The ASAM Criteria Software.

“If we get those payers and providers using it, this could speed up and make authorizations for the levels of care much more efficient,” Dr. Mee-Lee said.

During Thursdays’ Component Session 1, he presented an overview of the new criteria and the layout of The ASAM Criteria: Treatment Criteria for Substance-Related Addictive and Co-occurring Conditions. Attendees can pre-order the new edition of The ASAM Criteria at The Change Companies®, Booth 327. The Change Companies is partnering with ASAM to publish the new edition and will be offering a web-based version of the full text that includes interactive and video components, among other features. Additional products and services will follow the release of the book.

Additionally, David Gastfriend, MD, Vice President for Scientific Communications, Alkermes, Inc., Waltham, Mass., discussed The ASAM Criteria Software; Paul Earley, MD, FASAM, Earley Consultancy, LLC, Atlanta, discussed the software and individuals who work in safety-sensitive occupations; and George Kolodner, MD, Medical Director, the Kolmac Clinics, Silver Spring, Md., spoke about withdrawal management.

Attendees can participate in a hands-on workshop—offered three times on Saturday—where they can try the software on computers in an interactive workshop. Space is limited, so visit Booth 518 to register for one of the available workshops.

Smithers Lecture: Use Mindfulness to Avoid Burnout, Improve Treatment

Because of the life-and-death pressures of the job, burnout has long been a problem for physicians. Those working in fields of addiction medicine and psychiatry face the additional challenge of dealing with patients who have behavioral issues, where burnout can in turn affect treatment.

Joseph Westermeyer, MD, PhD, MPH, will address these issues when he presents the R. Brinkley Smithers Distinguished Scientist Award and Lecture, “Symmetry and Asymmetry in Addiction Medicine: The Balance Between You, Your Patient, and Your Setting.” Dr. Westermeyer will deliver his lecture during the Opening Scientific Plenary, from 8:30 to 10 am today the Grand Ballroom on the second floor of the Hilton Chicago.

“This talk is about the symmetry between us and our patients, and between us and the systems for which we work and in which we operate,” said Dr. Westermeyer, Professor of Psychiatry and Adjunct Professor of Anthropology at the University of Minnesota, and now a staff psychiatrist, and former Medical Director, of the Addictive Disorders Service at the Minneapolis VA Medical Center. “The focus will be more on the patients.”

The lecture took shape for Dr. Westermeyer as he saw an increase in physician burnout. He saw physicians quitting practice in their 40s and 50s because of issues ranging from dealing with third-party payers and licensure to treating patients with drug and alcohol addictions.

“I got to thinking about why that might be happening, why I’m not burning out at 76. I work 100 percent of the time during the 75 percent of the time while I’m in town,” he said. “I love my work; why was I not burning out?”

What Dr. Westermeyer saw was longstanding problems of dealing with behavioral problems in patients, and that is complicated by substance abuse becoming a greater societal problem, as well as institutions and third-party payers making decisions affecting physicians without consulting physicians.

“The decisions are sometimes good, sometimes bad, and sometimes terrible,” he said. “I will focus on patients, but also talk about these system issues. I want to focus on how we can tap into symmetry or asymmetry with patients using a new mindfulness approach, which is being used with patients as well as in clinicians with training.

“There is even a fair amount of research about being mindful—another term is ‘mentalizing’—about teaching patients to do that. Some clinicians may see patients who have these skills. The mindfulness leaves them with free-floating emotions or ideas, but without a concept of knowing what to do about them.”

In his lecture, Dr. Westermeyer will discuss three models to achieve mentalizing/mindfulness and channel it into interactions with patients.

“These three concepts are not only cognitive, but are also experiential,” he said. “I hope people can walk away with the ability to use at least one of them. I have been using all th three for the last 40 years, but it took several years to acquire them.”

New ASAM Members Gather at Reception

New members of ASAM networked with ASAM officials, including ASAM President Stuart Gitlow, MD, MPH,MBA, FAPA, (center) Thursday evening at the New Member Reception.

New members of ASAM networked with ASAM officials, including ASAM President Stuart Gitlow, MD, MPH,MBA, FAPA, (center) Thursday evening at the New Member Reception.

ASAM has experienced tremendous growth in membership over the past few years. In 2012, 626 physicians joined the society, and 351 physicians have already joined the society so far in 2013. Many of those new members gathered to meet one another Friday night at the New Member Reception.

ASAM has added many new and enhanced benefits for members, and these can be broken down into three main categories.

Information: The Journal of Addiction Medicine, ASAM’s research journal, is now published six times a year. Peer-reviewed articles published in the Journal focus on developments in addiction medicine as well as treatment innovations. ASAM also recently launched ASAM Magazine as an online publication, with a dynamic and engaging online format. This new publication features timely news on member benefits and ASAM activities, and allows readers to comment on articles and provide feedback.

Education: ASAM’s e-Live Learning Center offers audio-synchronized PowerPoint presentations and printed materials captured from many of ASAM’s live courses. Members may purchase and download content at discounted member rates, and more than 200 hours of content is available for CME credit. Last fall, ASAM also launched the Interactive Exam Preparation (IEP), as a study companion for those preparing to take the certification exam in addiction medicine. The IEP includes more than 350 sample test questions and answers presented in an interactive and engaging format.

Discounts: Members are eligible for discounted member pricing on all ASAM conferences and publications, including the revised Patient Placement Criteria, now known as The ASAM Criteria, which will be released this fall. The ASAM Criteria is the most widely used and comprehensive set of guidelines for placement, continued stay, and discharge of patients with addictive disorders. ASAM also recently launched a Member Rewards program that offers discounts on hundreds of items that members purchase for their practice and personal use.

Have Questions? Get Answers at Med-Sci Booths

If you have questions during the Med-Sci Conference, there will be several locations to get answers.

ASAM Membership Information Desk: Located near the Registration Desk, this desk will be staffed by the Membership Department. Staff will be able to assist members with their benefits and answer any questions they may have. Members also can review their profiles in the membership database, adjust their privacy settings, and add additional information to their public profile.

ASAM Booth in the Exhibit Hall: Attendees can stop by the ASAM booth, no. 330 in the Exhibit Hall. In addition to all of the same resources offered at the Membership Information Desk, the booth will offer ASAM merchandise for sale, information about how to be a featured member on ASAM’s website, and an opportunity for members to have professional headshots taken by the ASAM photographer. Stop by the booth from 4:30 to 6 pm today or from 3:30 to 4:30 pm Saturday to have your photo taken.

Education Help Desk: Located near the Registration Desk, this desk will be staffed by Education Department staff members who will be available to assist with questions related to ASAM courses, CME, and more. Demos of the e-Live Learning Center will be available. Education staff will be available to answer any questions you may have about all ASAM live and online courses. There will be information available about the new ER/LA Opioids REMS Course, as well as information about hosting a REMS course.

Awards Luncheon to Honor Leaders, Researchers, new Diplomates

Med-Sci Conference speakers, researchers, ASAM leaders, and newly certified diplomates will be honored during the Annual ASAM Awards Luncheon from noon to 2 pm Saturday in the Grand Ballroom on the second floor of the Hilton Chicago.

Tickets for the luncheon are available for $65 per person and are available at the Registration Desk. Honored at the luncheon will be:

  • Nora D. Volkow, MD, Director of the National Institute on Drug Abuse at the National Institutes of Health, the recipient of the John P. McGovern Award, who will deliver the Lecture on Addiction and Society.
  • Joseph Westermeyer, MD, MPH, PhD, will receive the R. Brinkley Smithers Distinguished Scientist Lecture Award. He is Professor of Psychiatry and Adjunct Professor of Anthropology at the University of Minnesota, Minneapolis.
  • H. Westley Clark, MD, JD, MPH, will receive the Public Policy Award for “outstanding contribution in advancing addiction treatment policy.” He is Director of the Center for Substance Abuse Treatment at SAMHSA.
  • Timothy Wiegand, MD, will receive the Medical-Scientific Program Committee Award for his paper, “Addiction Training During Medical Toxicology Fellowship,” which received the highest rating for its scientific merit among abstracts submitted for presentation at the conference.
  • Kay Russos-Ross, MD, will receive the Young Investigator Award for “Increasing Trends in Neo-Natal Abstinence Syndrome, What is the Cost?” which was judged the best abstract submitted by an author who is within five years of receipt of a doctoral degree.
  • Mike Miller, MD, will receive the Annual Award “For outstanding contributions to the growth and vitality of our Society, for thoughtful leadership in the field, and for deep understanding of the art and science of addiction medicine.” Dr. Miller is Medical Director, Herrington Recovery Center, Rogers Memorial Hospital, Oconomowoc, Wisc.
  • The 672 new ASAM Diplomates who passed the examination for Certification.

Workshop to Unveil, Critique Presentation on Addiction Basics

ASAM members are often asked to teach other professionals about the basics of addiction and the treatment of patients who suffer from substance use disorders, but find themselves challenged to summarize their life’s work in one hour. However, help is on the way.

Workshop 1, “All of Addiction Medicine in 60 Slides and 60 Minutes,” will premiere a PowerPoint presentation developed to help addiction specialists teach non-addiction professionals about the basics of the field. The two-hour workshop will be presented at 10:30 am today in Williford A, on the third floor of the Hilton Chicago.

The 60 slides will be presented as advertised—in 60 minutes—and the second hour of the workshop will be dedicated to attendees giving feedback to Petros Levounis, MD, MA, FASAM, and Abigail Herron, DO, who developed the workshop.

“Our thought is that the presentation will help addiction doctors teach the fundamentals of our field to our colleagues who are eager to learn but do not have any formal training or expertise in addiction medicine. It is designed to be a slide set people can use when they are asked to give a talk to attending physicians, allied health professionals, trainees, and students,” said Dr. Herron, Director of the Fellowship in Addiction Medicine at the Addiction Institute of New York.

The presentation does not look at the field of addiction from 10,000 feet, but provides a surprising amount of depth by drawing heavily from the ASAM Review Course, the ASAM textbook on the principles of addiction medicine, and other review courses, said Dr. Levounis, Chair of the Department of Psychiatry at the University of Medicine and Dentistry of New Jersey-New Jersey Medical School.

“We want to present specific information about what intoxication and withdrawal syndromes look like, what medications we use in addiction medicine, and what major counseling and psychotherapeutic techniques have shown scientific evidence of success,” he said. “In developing the 60/60, we have been careful not to just keep saying ‘It’s important to know about alcohol and drugs. It’s important to understand that treatment works. It’s important to pay special attention to screening adolescents and elderly patients.’

“We don’t want to simply scold and shame people into feeling bad about all the things they don’t know—but they should. On the contrary, we want to capitalize on their enthusiasm and give useful information that they can use at the end of 60 minutes. So, instead of saying ‘It’s important to know we have safe and effective medications in addiction treatment,’ we do show them these medications.”

The presentation also is aimed at physicians, nurses, social workers, counselors, and law enforcement officials who have some experience in dealing with addiction. Dr. Herron called it a “Cliffs Notes version for someone who has read the book—or, perhaps more importantly, for someone who has heard a lot about the book, has not read it, but likes the cover, and would like to learn its most salient contents.”

“We tried to touch on all the major areas. One of the sections of the presentation we are most proud of is the neurobiology of addiction, which tends to be intimidating and thus off-putting to most non-experts. We have simplified receptors, neurotransmitters, and circuitry to make the material accessible to everyone with a college-level biology background,” she said.

For Drs. Levounis and Herron, the second hour of the workshop is as important as the PowerPoint presentation because they want feedback on their efforts.

“We are bracing ourselves for everything,” Dr. Levounis said. “Our workshop reminds me of someone who decides to put together a list of the top 60 athletes or best actors of all time. This is hypothetical, and clearly overambitious; someone should immediately expect a slew of reactions—‘How can you claim to give us the best actors of all time and not have Meryl Streep in there? You are at best an ignoramus and at worst a malignant fraud!’ We are bracing ourselves for people who are going to be rather upset about our slide selections.

“This is a standalone presentation that provides the basics of addiction medicine. We hope it imparts both an overall framework and specific content, and does not simply point people to doors that open to a vast world of information. At the same time, we are aware there is a lot more to be learned about motivational interviewing, 12-step programs, medicines, and a number of things we touch on.”