Ruth Fox Course Tackles Sex Addiction Issues

The 2011 “Ruth Fox Course for Physicians” addressed nine topics Thursday, with an emphasis on sex addiction and sexual disorders.

Topics addressed included adolescent sexuality, integrating addiction treatment into primary care, paraphernalia and forensic issues in sexual addiction, spirituality in addiction, health information technology, treatment of sexual addictions, drugs and hypersexuality and an annual literature review.

Stanley E. Gitlow, M.D., FASAM, a former ASAM president, opened the course by reflecting on the life and work of Dr. Fox before other speakers delivered their presentations.

Sex Often Tied to Substance Abuse in Young Adults
When it comes to sex, teenage boys and girls are very different, with boys ready in an instant while girls are not so easily aroused. Bridging that gap are drugs and alcohol, which was discussed in “Adolescent and Young Adult Sexuality: The Relationship to Substance Abuse and Dependence.”

“The population that has the greatest percentage of sexually transmitted diseases is the 15- to 19-year-old age span, more so than any other five-year age span,” said Anthony Dekker, D.O., FASAM, director of addiction medicine, Ft. Belvoir Community Hospital U.S. Army, Ft. Belvoir, Va. “The 20- to 24-year-olds and 25- to 29-year-olds have more sex more often than adolescents, but teenagers have a higher rate of sexually transmitted disease. So, the question is, ‘How can they have less sex and more disease?’

“One of the reasons is that most teenagers, when they are having sex, have impairment with alcohol or other drugs of abuse.”

Many of those experiences are tied to use of alcohol, marijuana, or other drugs of abuse, Dr. Dekker said.

“Doctors need to interview in a non-pejorative way about sexual histories when they are talking to substance-abusing adolescents or young adults,” he said. “There is also a need to emphasize the need for screening, contraceptive care, and treatment of sexually transmitted diseases.

Treating Addiction Issues in Primary Care
Health care reform makes primary care the hub in the wheel of patient care, emphasizing the patient-centered medical home approach that will initiate treatment for many diseases and illnesses, including addiction. The coordination of addiction care in this environment was addressed in “Getting Addiction Treatment into Primary Care.”

“Health care reform wants to improve care and save money. If we are willing to address substance abuse disorders in primary care, we can accomplish that easily,” said Norman Wetterau, M.D., FASAM, ASAM liaison to the patient-centered primary care cooperative. “The patient-centered medical home emphasizes that we individualize treatment and educate, motivate, and connect them to other groups.”

Primary care physicians can screen for tobacco, alcohol, and drug abuse, but the addiction community needs be involved in building systems to help educate the entire primary care team — nurses, nurse practitioners, physician assistants, and office staff — in this process, he said.

“If a doctor does not have systems that work, it won’t get done,” said Dr. Wetterau, who practices at Tri-County Family Practice, Nunda, N.Y. “If we are willing to empower the patient and use rest of staff to do some of the work, it can be much more effective. The patient-centered medical home emphasizes the team and involving the patient.”

Some of this can involve teaching patients about websites such as QuitNet and Rethinking Drinking for those who want to stop smoking or drinking, he said. The primary care staff can follow up with telephone calls or emails to check on a patient’s progress.

This all sounds feasible on paper, but Dr. Wetterau gave Ruth Fox attendees an exercise to help them carry out the plan. Attendees were asked to complete practice surveys about how they deal with patients who have tobacco, alcohol, and drug issues, and to write down ideas from the sessions about how they might change their practices.

“I want them to go back to their office staffs and go over it with them,” he said. “You can leave this conference with all the ideas in the world, but it won’t get done unless we can get people on board.”

If addiction physicians are not directly involved in primary care practices, they can serve as consultants for cases where their expertise is needed.

“Smoking, drinking, drug abuse, and prescription drug abuse are what primary care will handle, and refer other things out,” Dr. Wetterau said. “We want them to do screening, prevention screening, and brief interventions before the problems become more serious.”

Sexual Addiction Treatment: A Familiar Model
The treatment of sexual addiction may follow the paths of drug and alcohol treatments from past decades as counseling and medical therapy increasingly replace incarceration.

“Primary care providers with training in addiction, and other addiction-certified physicians can play a larger roll in the screening, evaluation, and management of paraphilias and sexual addictions. They will have to, because the criminal justice system will offload the responsibilities to the medical community in a model that resembles alcohol and drug abuse chronicled in the last 50 years,” said William R. Morrone, D.O., M.S., who presented “Paraphilias, Paraphernalia and Forensic Issues in Sexual Addiction.”

Driving addiction treatment down this familiar path is the permanent shortage of psychiatrists and the recognition that it is less expensive to prevent people from progressing toward sexual addiction than to jail them later, he said.

“We are at the beginning of that trend in addiction and in sex crimes, a trend we are going to see in the next decade. Stakeholders are going to expect that progressive governing policy can medicalize this diagnosis and treat people,” said Dr. Morrone, the assistant program director of family medicine at Synergy Medical Education Alliance and an assistant clinical professor in the departments of family medicine, psychiatry and pediatrics at Central Michigan University College of Medicine.

The medicalization of deviance is a policy of the Department of Justice that dates to the 1980s, when funding moved from law enforcement to medical and health care, he said. The complication is that epidemiology is difficult and no medicines have been developed to treat sexual addiction. The best medical option is to use pharmaceuticals and treat with off-label uses.

The result is a potential public health threat to communities and an even greater need for primary care providers with training in addiction.

“It’s not a joke we should snicker about. Everybody should be concerned for community health and safety because it is a problem that affects safety in our communities. There is help for everybody,” Dr. Morrone said, adding that the pressure will fall on primary care. “If you don’t treat it yourself (because you are uncomfortable with treatment), refer people out for specialty care. In the past, too many medical providers would say ‘I don’t do that, there is nothing to do, and I don’t know where to send them. I don’t want any medical providers to say that.”

Spirituality a Strong Anchor in Battling Addiction
Patients need to call on their inner strength to overcome addiction, but they also need help from outside sources in the form of spirituality, which was discussed in “Spirituality in Addiction Treatment.”

“Spirituality is an attempt to make contact with a transcendent object. Whether it is a person or whether it is our concept of God, it is to a higher power, something greater than ourselves. By doing that, patients get a sense of fellowship, a sense of relaxation, a sense of safety, a sense of peace in this communication with a higher power,” said John P. Scanlon, D.O., assistant professor of family medicine and addiction medicine, Pikeville College School of Osteopathic Medicine, Pikeville, Ky.

No matter what the addiction is, the principles of spirituality in addiction treatment are the same, he said, adding that spirituality is different from religion.

Religion is probably man’s attempt to package spirituality,” Dr. Scanlon said. “Where spirituality and religion have a lot of things in common, there are aspects of the two that are quite different. Religion tends to be structured. You generally have to have a professional leader, like a rabbi, priest, or minister. Spiritual feelings we have are not necessarily bound by a sacred textbook or something other than our spectrum of feelings.”

An important part of evoking spirituality is for patients to learn relaxation techniques, such as closing their eyes and using deep breathing, music and the spoken voice. Using relaxation techniques before psychotherapy helps patients explore their past and the deeper meaning of their feelings, he said.

“The big spiritual technique is the bonding, the feeling of fellowship between the people participating in group therapy or the bond that occurs between the physician and the patient by using relaxation techniques or suggestions, using points of departure to take the patient to previous events in his life. By using relaxation techniques to prepare the patient for this, we can evoke feelings of relaxation and safety that will provide more effectiveness in our other therapeutic ventures,” Dr. Scanlon said.

Examine Consequences in Treating Hypersexual Disorder
Sexual addiction can be defined in many ways by many people, but the key in recognizing and treating hypersexual disorder is to examine the patient’s quality of life, said James C. Montgomery, M.D., who presented “Comprehensive Evaluation and Treatment of Sexual Addictions.”

“The big key is that sexual addiction is less about understanding behavior and the initial diagnosis than it is about the identifying consequences,” said Dr. Montgomery, medical director, Sante Center for Healing, Argyle, Texas. “Has the patient lost significant things like relationships, jobs, and money? Has he or she put energy into controlling behaviors? Have they tried to quit? How many times has the control or quitting only led to resumption of the same behavior? Does it come back with a vengeance? How much time and energy does it take from their lives?

“You need to look at the consequences and implications of the behavior.”

Diagnosing hypersexual disorder is difficult because it is a broad issue that is not clearly defined, but involves sexually out-of-control behavior, Dr. Montgomery said. A key is to use a diagnosis template to list and categorize behaviors. For example, the behaviors in any patient may range from anonymous, safe behaviors, such as phone sex, Internet chats and cybersex, to soliciting prostitutes and engaging in dangerous acts that require pursuit and seduction, or violent sex.

Primary care addictionists can use templates to recognize and support patients with hypersexual disorder, but ultimately should refer these patients to specialists for treatment, he said.

“It is probably too involved and intimate for primary care,” Dr. Montgomery said.

The ultimate goal is to help patients get back on the road to improving their quality of life.

“Sexual addiction recovery is not about abstaining from sex, even though celibacy and abstinence are really key parts of early recovery,” he said. “Recovery is about quality of life, quality of relationships and that internal — almost spiritual — path they lost in addiction.”

Addiction Physicians Face Health IT Challenges
An important part of the health care reform law is incentives for physicians and institutions to add electronic health record (EHR) systems to their practices. However, addiction medicine physicians face challenges different from other physicians because of the confidentiality concerns of patients.

Physicians who want to take advantage of incentives offered through the EHR incentive programs must choose between either the Medicare or Medicaid programs, said H. Westley Clark, M.D., J.D., M.P.H., FASAM, director of the Center for Substance Abuse Treatment, Substance Abuse Mental Health Services Administration, U.S. Department of Health and Human Services. Dr. Clark discussed the incentive programs and other challenges for addiction physicians in “Health Information Technology.”

Many addiction medicine physicians have mixed practices, and addiction medicine is only a part of their practices. To be eligible under Medicaid, addiction medicine physicians must meet the patient volume criteria, he said.

In addition, several entities where addiction medicine physicians often practice are not eligible, including community mental health centers, substance abuse treatment programs and recovery programs.
With EHR comes increased access to health records, which raises the question of how to ensure patient confidentiality and trust, Dr. Clark said. To achieve any level of systemic durability and success, electronic exchange efforts must establish trust relationships with all participants, including patients, so the applicability of 42 CFR Part 2 needs to be addressed.

Ultimately, the solution lies in finding common ground that involves engaging patients in the importance of health information exchange, education efforts, and tight restrictions on data access, including stringent penalties for misuse, he said.

Sexually Addicted Find Inappropriate Use for Drugs
Health care professionals need to be aware of the variety of drugs and the variety of uses their patients may have discovered to further their stimulation and therefore advance sexual compulsivity, which were issues addressed during “Drugs and Hypersexuality.”

“There are some drugs used to facilitate sexual behavior and then there are different drugs of abuse used to heighten sexual sensation,” said Darrin R. Mangiacarne, D.O., an addictionologist at Pine Grove Behavioral Health and Addiction Services, Hattiesburg, Miss.

Dr. Mangiacarne discussed how some drugs — legal and illegal — are used by those engaged in hypersexual behavior, and addressed myths and misconceptions.

Dopaminergic drugs often used for restless leg syndrome have the side effect of increasing sexual drive. Additionally, testosterone is used by those who are sexually addicted to decrease the lag time between erections.

“It is not uncommon for these patients to try to masturbate multiple times per day,” Dr. Mangiacarne said. “If you are treating young, otherwise healthy males and they are complaining about erectile dysfunction, that is a red flag.”

It is important to be aware of these off-label uses of drugs because they can be dangerous, Dr. Mangiacarne said.

Literature: The Year in Review
The good news is that the literature about addiction disorders is growing, and the bad news is that the literature is growing, making it difficult to keep up with all the available information.

Stephen A. Wyatt, D.O., filled the role of consultant-librarian for addiction professionals — a role he said he thoroughly enjoyed — preparing for the Ruth Fox Annual Literature Review. Dr. Wyatt is an addiction psychiatrist at Middlesex Hospital, Middleton, Conn., who focused on 10 articles during his presentation.

“I tried to look at all the literature, including journals outside those specific to addiction medicine,” he said. “I looked at a variety of areas of addiction medicine, including pharmacology, education, adolescence and various drugs of abuse.

“Addiction medicine affects all areas of medicine. As a specialty it is relatively young. What struck me is that things we have known for a while and ways we have been practicing are starting to be further refined in the current literature. We are starting to become to a truly specialized area of medicine.”

Articles reviewed ranged from new research to important reviews culled from peer-reviewed journals in a variety of medical specialties, all focused on improving the practice of addiction medicine.

“Many of articles are things we have known about, and they may be conventional wisdom, but maybe the conventional wisdom has been switched a little bit or has been refined.” Dr. Wyatt said. “We can begin to practice in a much more defined way as knowledge in our field continues to grow.”