April 27

Report Details Substance Abuse Problems in Military

Moderator David C. Lewis, MD, discusses an Institute of Medicine report on substance abuse in the U.S. military.

Moderator David C. Lewis, MD, discusses an Institute of Medicine report on substance abuse in the U.S. military.

Reacting to growing concerns about rising rates of alcohol and prescription drug abuse in the U.S. military, the Department of Defense (DoD) asked the Institute of Medicine (IOM) to analyze military policies and programs related to substance use disorders. Members of the IOM committee charged with that task reviewed its findings at a symposium Friday.

Committee members painted a picture of frustration when faced with out-of-date treatment approaches and an unwillingness to accept modern addiction medicine treatments, they said in Symposium 3, “Treatment of Military Personnel and Their Families.” The committee published the report Substance Use Disorders in the U.S. Armed Forces last fall.

“One of the most important things we learned is that the military has a different culture than civilian or VA cultures,” said the session moderator, David C. Lewis, MD, Professor Emeritus of Community and Health Medicine and Donald G. Millar Distinguished Professor of Alcohol and Addiction Studies at Brown University. “It is much more complex.

“We spent a lot of time in the report spelling out what evidence-based treatment is about. In a culture where you have to be battle-ready and you have to worry about testing positive, the issue of confidentiality is huge.”

Constance Weisner, PhD, MSW, Professor of Psychiatry, University of California, San Francisco, and Associate Director for Health Services Research, Kaiser Permanente, talked about the levels of substance abuse.

Substance use disorder ranked seventh among 139 conditions, and first in hospital bed days in the military, she said.

“What is the current situation in the military? The levels of drinking and substance use are a concern,” Dr. Weisner said. “The military population is young and impulsive.”

Complicating matters was a zero tolerance policy for drug use; drug testing is the main screening mechanism, she said.

“Primary care is the single largest missed opportunity for early and confidential identification of alcohol or drug misuse,” Dr. Weisner said. “DoD and service branch policies and practices do not encourage primary care interventions.”

Charles P. O’Brien, MD, PhD, Chair of the committee was blunt in discussing the military’s approach toward addiction treatment.

“The way treatment is given is not modern and is not evidence-based. It is hard to get things changed,” said Dr. O’Brien, Kenneth E. Appel Professor of Psychiatry and Vice Chair of Psychiatry at the University of Pennsylvania School of Medicine.

While contemporary treatment of substance use disorder is maintenance medication, the military has no long-term programs and does not allow the use of maintenance mediations, he said.

“The VA/DoD treatment manual for substance abuse is excellent, but it is not followed,” Dr. O’Brien said. “Everyone agrees this is a major problem in the military.”

Discussing prevention options was Mathea Falco, JD, President of Drug Strategies, Inc., Washington, D.C., who joined the parade of criticism with her opening statement, “The military is a universe of its own.”

An example of the attitude problem in the military is that drug testing is often considered a prevention strategy. “Drug testing does not deter drug use,” she said.

“The IOM committee came out with a recommendation that should implement comprehensive policy,” O’Brien said. “This is not happening. Current prevention efforts fall short. There is no consistent or systematic evaluation of prevention programs that are currently in place.”

She agreed that alcohol and drug abuse is tied to an attitude problem.

“I would start with a change in attitude. Heavy drinking is just not acceptable. The norm today in the military is that drinking is the macho thing to do,” O’Brien said, adding that even females in the military drink heavily.

Addiction Medicine Faces Challenge of Developing Quality Standards

A discussion of the effect of health system reform and the need for quality standards for addiction medicine drew a large crowd to Symposium 2 Friday.

A discussion of the effect of health system reform and the need for quality standards for addiction medicine drew a large crowd to Symposium 2 Friday.

The Affordable Care Act promises to bring more support for addiction treatments, but that funding comes with requirements for setting and meeting standards of care. A symposium Friday examined expectations of federal agencies for quality standards and ASAM’s plans to develop addiction medicine treatment standards.

Symposium 2, “Clinical Quality Measurement in Addiction Medicine,” featured four presentations that looked at different aspects of quality measures, followed by a panel discussion with questions from the audience about the plans of ASAM’s Practice Improvement and Performance Measurements Action Group (PIPMAG).

H. Westley Clark, MD, JD, MPH, CAS, FASAM; Director, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration (SAMHSA) discussed the needs of regulating agencies.

“In less than eight months, you are going to have a lot of people presenting for treatment. If you accept federal funds, you are stuck with the federal lens that scrutinizes what you do,” he said in referencing requirements of the Affordable Care Act that take effect in January 2014.

“You have to address the question of what you are doing. You need to quantify that. It is not good enough to say ‘It’s just my training.’ The question is ‘Why are you treating that person the way you treat them?’ and you need to document that. It is important for us to adhere to standards of care and performance.”

Another piece of the changes is that primary care and specialty care will soon be partners, Dr. Cark said.

“That presents a challenge in dealing with consistent care and quality measures. This is significant as we move to more integrated models of care,” he said, adding that the future holds physicians working together in patient-centered medical homes and accountable care organizations.

To meet that challenge of documenting that addiction medicine physicians are meeting standards of care, ASAM developed PIPMAG, which is chaired by Michael M. Miller, MD, FASAM, FAPA, Medical Director, Herrington Recovery Center, Rogers Memorial Hospital.

Because of the afflictions it treats, addiction medicine lags behind other specialties in being able to document its performance, he said. The first step in the documentation process is to develop standards.

“Do you practice quality medicine? How do you know? You can’t just say it works,” he said. “You have to measure a baseline. Performance measures are metrics. You have to measure the frequency with which physician and others adhere to practice processes that have been deemed to be best practices via practice guidelines.

“But they are not practice guidelines—which generally are developed by professional specialty societies based on extensive literature review and a ‘grading of evidence.'”

The PIPMAG committee started the process of developing standards by making assumptions about what defines high-quality practice, Dr. Miller said. The committee has set a timeline for this year to review those assumptions and then take action to establish standards of care.

“We realized our field does not have the starting point of orthopedics or pediatrics with regard to well-developed practices guidelines,” he said, adding that addiction medicine must now work hard to catch up.

Margaret Jarvis, MD, FASAM, Clinical Assistant Professor at Penn State University, is now a member of a PIPMAG committee working on the development of standards. The committee has developed domains for standards, and now the details of those domains must be added.

“They must be written broadly enough to cover a number of different kinds of practices and philosophies of practice,” she said.

Task Force to Fight Limitations on Addiction Treatments

Jutting into the Atlantic at the very northeast corner of the United States, Maine appears to be pointing the way for the other states, and in its reaction to Medicaid budget cuts for treating addiction, it is.

The path Maine is taking, though, is not really forward, but more of a step backward, according to some addiction specialists. Maine has implemented policies that limit patient access to buprenorphine and methadone, medications used to treat opioid dependence. It is not the first state to do so, but its policies are among the most restrictive. Other states have followed suit, but ASAM and its chapters also are taking notes on how to fight a battle that began in Maine.

“Maine is where the firefight was defined,” said Mark L. Kraus, MD, FASAM, Co-chair of the ASAM Patient Advocacy Task Force (PATF) created to lead the fight against other states placing treatment limits on opioid addiction pharmacotherapies such as buprenorphine, methadone, and injectable naltexone. The role of the PATF and ASAM’s efforts to reverse this trend will be addressed in Component Session 7, “Patient Access to Medication Assisted Treatment: Responding to State.” The session will be presented from 2 to 4 pm today in Williford C, on the third floor of the Hilton Chicago.

“We are talking about a personal disaster for the entire population of patients on buprenorphine and methadone. People who are building good lives, raising families, and working would be thrown into withdrawal,” said Mark Publicker, MD, FASAM, a PATF member and President of the Northern New England Society of Addiction Medicine who is leading the fight against restrictions in Maine. “The majority undoubtedly would have a relapse to drug addiction and all of the problems that you would expect, and problems that these medications are very effective at stopping would return—illness, crime, child neglect.

“It was all done for purely fiscal reasons. There wasn’t a clinical basis for believing it was a bad treatment. Rather, it was explicitly looked at as a cost-savings.”

ASAM, through the PATF, has gathered support from a broad range of public and private sector groups. Groups supporting the ASAM effort include the National Institute on Drug Abuse, the Substance Abuse and Mental Health Services Administration, the Office of National Drug Control Policy, and pharmaceutical and insurance companies, Dr. Kraus said.

The PATF is using this support to build a case against, and reverse, the trend toward treatment limitations. The PATF’s efforts also will help to identify good models of access that can be shared with public and private payers.

“We thought we needed to put forward an effort to find the information that is lacking, to really examine the problem,” Dr Kraus said. “We also recognized there wasn’t any comprehensive review of the literature on the treatment efficacy or on the cost benefits of these treatments.

“We are hoping that after this is done and analyzed that we will have proved our point, and then we will bring it out to our sister organizations and the public. After we show there is efficacy and that this is something that needs to be directed, we need to convince policymakers and payers of the efficacy of going forward to use these medications and to understand how certain payers are providing good examples of access to assure optimal patient care.”

Dr. Publicker said the effort to save money now would cost more in the long run.

“The amount of money they were predicting they would save is decimal dust, like $800,000 for the 2013 fiscal year [in Maine],” he said. “The cost in terms of human lives is enormous. We know that every dollar invested in effective addiction treatment returns $7 in savings. They were interested in pharmacy savings, but disregarded the longer term consequences of expansion of illnesses like HIV and hepatitis C, the loss of jobs, the increase in the crime rate, childhood abuse, and neglect. Those were all not considered.

“ASAM is the voice for our patients. Largely, our patients are voiceless because of stigma and the need to protect confidentiality with a disease that is regarded as stigmatized. Our patients, by and large, don’t speak for themselves, so ASAM has to be their voice.”

Coming Soon: The ASAM Criteria Software

The ASAM criteria has been helping health care professionals make decisions about the care of patients with addictive disorders for more than 20 years. The forthcoming edition, The ASAM Criteria, has more than 300 pages and covers decision points related to admission, level of care, continued stay, and discharge. Now for the first time, ASAM will be releasing a software application-focused version of the ASAM criteria that will provide a standardized way for treatment assessment.

The development of the software is being led by David Gastfriend, MD, Newton, Mass., who is an addiction psychiatrist. Dr. Gastfriend will present the new software at Workshop 5, “The Open Source ASAM Criteria Software,” three times today, at 10 am, 2 pm, and 4:30 pm in Williford B on the third floor of the Hilton Chicago.

About 6 million patients enter more than 13,000 U.S. addiction treatment programs each year, but many are placed into programs that are not appropriate for their needs. Studies have found that patients referred to a lower level of care than recommended for alcohol dependence drank twice as often after treatment as those who were properly matched, and they used nearly twice as many hospital bed-days per year, he said.

The ASAM Criteria Software, which has been in development for more than a decade, prompts interviewers to ask patients a series of questions and enter data into the program. It also provides interpretation and options while guiding the interviewer through the level of care placement process. By using the software and The ASAM Criteria book together, addiction medicine specialists can really understand how to implement the criteria fully.

Dr. Gastfriend said the software uses a quantitative algebraic algorithm to produce reliable recommendations about a patient’s care needs. The ASAM Criteria book is a foundational guide to implementing this software

“The computer decides how to branch into different areas, and then the depth of each area, to explore a patient’s needs with a high degree of specificity,” he said of the software, which has been tested for three years in Norway. “There are roughly 6,000 decision points. No two patients will experience the same interview.”

The hands-on, interactive workshops will allow physicians to experience the software by watching videos of patient interviews, assessing those patients, and entering data into the program.

“This is a chance to shop the software and give feedback,” Dr. Gastfriend said.

And that feedback is needed, he said. Attendees will be asked to provide their opinions on the software, including its usefulness, how it could be improved, and what needs to be developed next.

“This is just the beginning,” Dr. Gastfriend said.

The session also will provide details on ASAM’s plans for disseminating the software, training, and certifying programs. The software is expected to become the standard of care for patients in need of addiction treatment evaluation, placement, and re-evaluation. So who should attend the session?

“People who work in systems with the capacity to introduce clinical decision-support software in their daily operations,” Dr. Gastfriend said.

Two Researchers Honored for Their Work

Two researchers will be honored during today’s ASAM Awards Luncheon for their work on projects that examined the number of babies diagnosed with neonatal abstinence syndrome and the amount of overlap between medical toxicology training and addiction medicine training.

The luncheon will be from noon to 2 pm in the Grand Ballroom on the second floor of the Hilton Chicago. Kay Roussos-Ross, MD, is the recipient of the Young Investigator Award and Timothy Wiegand, MD, FACMT, will receive the Medical-Scientific Program Committee Award.

Dr. Roussos-Ross is an Assistant Professor in OB-GYN and Psychiatry at the University of Florida Shands Hospital, Gainesville. Her paper, “Increasing Trends in Neo-Natal Abstinence Syndrome, What Is the Cost?” studied the number of babies diagnosed with neonatal abstinence syndrome (NAS) at the hospital after she noticed the number of patients using opiates during her OB-GYN residency.

“I became interested after noticing an increasing epidemic of opiate use in Florida, including among pregnant women,” she said. “We were seeing more and more neonates diagnosed with NAS in the NICU. I was interested in investigating the trend of NAS in our newborns, to determine if it was in line with the increasing epidemic of opiate use. I was also interested in examining the length of hospital stay of the affected neonates.”

The study also looked at the costs of keeping babies who were exposed to opiates during pregnancy and ended up having a diagnosis of NAS after delivery, Dr. Roussos-Ross said.

“We also wanted to look at the costs associated with caring for affected neonates, to show that perhaps spending money preemptively to provide treatment in substance programs for affected pregnant women might curtail costs of caring for affected neonates in the current, or in future, pregnancies,” she said.

Dr. Roussos-Ross noted that the OBGYN department at the University of Florida initiated protocols in 2011 for its clinics regarding opiate use in pregnancy.

“We are interested to see, with protocols in place, whether there is a difference in our incidence of NAS or if it continues to increase,” Dr. Roussos-Ross said. “We will continue to study this.”

Dr. Wiegand is Director of the Toxicology and Toxicology Consult Service and Associate Clinical Professor of Emergency Medicine at the University of Rochester Medical Center. “Addiction Training During Medical Toxicology Fellowship” received the highest rating for its scientific merit among abstracts submitted for presentation at the conference.

Dr. Wiegand worked with Joel Moore, MD, a University of Rochester Medical Center emergency medicine resident to survey fellowship directors at the 27 medical toxicology programs in the United States.

“We were interested in the extent of overlap medical toxicology fellowship training had with addiction medicine training and in looking at specific opportunities that medical toxicologists had to focus on content in addiction medicine. In particular we wanted to look at the overall hours and clinical experience with regard to whether the fellowship training in and of itself would allow them to be eligible to sit for ABAM credentialing,” he said in discussing the objectives of the survey.

The toxicology fellowship directors were asked about the content of their core curricula and opportunities to earn hours to become certified in addiction medicine, Dr. Wiegand said. Sixty-six percent of the directors responded.

“We found that toxicology fellowship training allows for a significant and diverse experience in addictions training with exposure to many patients with drug overdose and withdrawal syndromes,” he said. “Most fellowships allowed for opportunities involving research, surveillance, and prevention in addiction-related areas.

“The training seemed to have overlap with addiction medicine core components, but the directors had difficulty defining specifically where they spend their hours in addiction training. They said the fellows were exposed to addiction medicine training on a daily basis. We realized there are a lot of opportunities, but there is much better opportunity to define these opportunities.”

There are about 500 board-certified medical toxicologists in the United States. The American College of Medical Toxicology (ACMT) has defined six practice pathways in toxicology for development in terms of preparing models and opportunities for careers and practice, and addiction medicine is one of the pathways.

“We need to define the core curriculum in addiction medicine a little better because there clearly are opportunities,” Dr. Wiegand said. “ACMT is working on developing the training material and infrastructure in terms of exposure to addictions training during fellowship as well as in continuing education to better define the addiction medicine practice pathway in medical toxicology with the goal of creating a robust practice pathway model.”

ASAM Members Elect New Officers

(From left) ASAM President Stuart Gitlow, MD, MPH, MBA, FAPA; Penny Ziegler, MD, FASAM; and President-Elect Jeffrey Goldsmith, MD, FASAM; enjoy a moment together after Friday's Members Annual Business Meeting.

(From left) ASAM President Stuart Gitlow, MD, MPH, MBA, FAPA; Penny Ziegler, MD, FASAM; and President-Elect Jeffrey Goldsmith, MD, FASAM; enjoy a moment together after Friday’s Members Annual Business Meeting.

ASAM members elected new officers to the Executive Board and approved the addition of a vice president’s position to the society during the ASAM Members Annual Business Meeting and Breakfast Friday.

The new officers will be Jeffrey Goldsmith, President-Elect, MD, FASAM, of the Veterans Administration Post-Traumatic Stress Clinic, Cincinnati. The new Secretary will be Margaret Jarvis, MD, FASAM, Medical Director at Marworth, Waverly, Pa. Lori Karan, MD, FACP, FASAM, will serve a second term as Treasurer. She is Medical Director at the Department of Public Safety, Hawaii, and Professor at the John A. Burns School of Medicine.

The members also voted to amend Article V of the ASAM constitution to add the vice president position.

Also during the meeting, ASAM President Stuart Gitlow, MD, MPH, MBA, FAPA, appealed to members to join the American Medical Association so the society can maintain its seat in the AMA House of Delegates. The AMA requires its member organizations to have 20 percent of its members join the AMA to keep a seat in the House of Delegates.

“We have 15 percent of those in the room who are members, and we need 20 percent,” Dr. Gitlow said. “I realize the bar is high. We are asking you to pay $420 to join the AMA. It is important for us and our ability to stand up and be recognized by the house of medicine and be part of that voice.”

Board of Directors Meeting

Wednesday, the ASAM Board of Directors met. The Board adopted the updated ASAM criteria as a clinical document consistent with ASAM’s policy, mission, and branding warranting collective support of the organization. It directed the ASAM Criteria Review Committee to continue to function. The board also approved:

  • A policy statement on pharmacological therapies for opioid use disorder.
  • A plan to permit non-physicians to join ASAM as Associate members. These Associate members will not be voting members or eligible to hold office.
  • Development of an Opioid Use Disorder Pharmacotherapy Practice Guideline as the next phase of the Patient Advocacy Task Force.