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Friday, December 28, 2012
Some MaineCare Patients will still have Access to Methadone
Portland Press Herald
By WANDA CURTIS Kennebec Journal Correspondent
A task force developed criteria for continued MaineCare coverage of certain drug treatments.
Health officials say Mainers who need certain drugs to treat addiction won't be cut off entirely, despite legislation to cut off treatment for some.
MaineCare coverage for treatment with methadone and Suboxone is due to end Tuesday for those who have been covered for at least 24 months. A bill passed by the Legislature established the 24-month lifetime limit.
But a task force of medical providers, substance abuse treatment providers, government officials and patient advocates has developed criteria for continued MaineCare coverage of medically necessary methadone and Suboxone treatments.
That may avert what was predicted to become an unprecedented drug withdrawal crisis in January. Methadone and Suboxone are used to treat opiate addiction.
The medical director of MaineCare services, Kevin Flanigan, said the task force developed guidelines for continued coverage for people who need the treatment. He said Suboxone funding will end Jan. 1 for people who have reached the two-year limit -- the 24 months don't need to be consecutive -- only if medical providers are unable to get authorization to continue the treatment before the deadline.
Flanigan said the task force has identified specific behavior that may help indicate whether Suboxone treatment has been successful. He said people reviewing authorization applications will ask questions about clients such as:
- Have they been able to reunite with their families?
- Have they been able to return to work?
- Have they been able to engage in social or community or recreational activities again?
- Is there a spiritual component to their life that was absent before?
- Are they no longer having difficulties with the legal system?
- Are they in constructive activities their provider has asked them to participate in?
Sunday, May 27, 2012
Clinicians Say Giving Addicts Maintenance Methadone Serves Them and Society Best
By Christopher Williams, Sun Journal
Bangor Daily News May 27, 2012
When Zachary Tomaselli was sent to prison for sex crimes last month, he asked the judge to delay his sentence for a week.
The Lewiston man said he needed those seven days to wean himself off methadone, the drug he had been getting at a clinic to help him kick a prescription drug habit.
Thousands of addicts living “on the outside” visit Maine’s for-profit clinics for weeks, months and even years for their prescribed methadone doses. A large majority of those addicts are MaineCare clients, paying for methadone treatments with taxpayer dollars.
According to the Department of Health and Human Services, Maine spends about $9 million in state and federal funds every year to dose just over 3,100 MaineCare and Medicare clients every day. The state spends another $7 million a year to transport clients to methadone clinics.
That’s $5,140 per MaineCare patient per year.
Under the recently passed state budget, MaineCare clients are subject to a 24-month lifetime cap for methadone treatment. That cap is expected to save Maine more than $1.3 million a year.
According to Susan Sullivan, director of CAP Quality Care Clinic in Westbrook, patients there “are anxious and afraid of losing their treatment. Some are looking to be proactive and starting to taper themselves out because they don’t know what’s going to happen.”
If Tomaselli believed he could lick his drug habit in just a week, why wouldn’t — or shouldn’t — every drug addict do the same?
The answer, according to experts, is as complex as the subject of drug addiction itself.
Withdrawal is harsh reality
The good news for Tomaselli, experts say, is that he likely wasn’t in any danger of serious health risks had he decided to go cold turkey before trading his street clothes for jail garb.
The bad news — depending on how long he had been treated with methadone and at what dosage — is that his withdrawal might have been more grueling than his looming 3½-year prison sentence.
Dr. Michael E. Kelley, chief of psychiatry at St. Mary’s Regional Medical Center in Lewiston, said the effects of withdrawal from methadone are unique.
Because the medication is used as a maintenance narcotic for clients limited to a single dose each day, the drug typically stays in the body longer than other narcotics, he said.
“It is incredibly long-lasting,” he said.
That means withdrawal from that drug can linger for a week or longer. Sometimes up to a month.
Although not physically dangerous in an otherwise healthy adult, withdrawal can make you feel like you’re dying, Kelley said in an interview at the hospital, where he works as an addiction specialist, treating people with chemical dependency in residential and day programs.
“They can have a very miserable withdrawal,” he said.
It often includes severe flulike symptoms, including vomiting, diarrhea, sweating, chills and muscle cramps.
“But you won’t die,” Kelley said. The only possible medical risk is dehydration, he said.
The greater risk for narcotic addicts is relapse, experts say.
‘Jail isn’t a hospital’
While withdrawal from narcotics, including methadone, is usually safe, withdrawal from certain other drugs and alcohol can be dangerous, even fatal, according to medical experts.
Withdrawal from alcohol, benzodiazepines (tranquilizers) and barbiturates can be “very dangerous,” Kelley said.
Stopping those drugs too quickly can sometimes trigger seizures, heart arrhythmias and delirium tremens (in alcoholics), he said. The latter can be dangerous because those patients become disoriented and may inadvertently harm themselves.
Jails sometimes bring prisoners into the emergency room if they’re suspected of alcoholism or addiction to tranquilizers and show signs of withdrawal, Kelley said.
While the jail might let someone addicted to narcotics “tough it out,” they won’t take a chance on the other addictive populations, Kelley said.
“The jail’s not going to risk that,” he said. “The jail isn’t a hospital.”
When inmates come to St. Mary’s emergency department for medical clearance, hospital staff screens patients for drugs and toxic substances, checking their general health.
Doctors quiz the patients about drug use.
“Hopefully, they’ll be honest.” he said. But, too often they’re not. They fear their candor might get back to their probation officers. Although emergency room chats with doctors are confidential, inmates are on their guard generally and may not confide in the medical staff.
“Sometimes they lie to us,” Kelley said, “which is part of the scary thing.”
Doctors typically watch inmates suspected of drug or alcohol abuse for 12-16 hours, he said, but added, “There is no magic [time] line.” And there is no predicting a patient’s tolerance based on his or her history of drug or alcohol use.
No methadone for prisoners
At Maine’s correctional facilities, including its prisons, the state contracts its medical services with Corizon, a national company based in Tennessee. Three county jails in Maine, including Androscoggin County Jail in Auburn, also have contracts with Corizon.
The company has 150 health care professionals working at the state facilities. An additional 65 workers staff the three jails, according to Pat Nolan, a company spokesman.
Corizon would provide only written answers to questions posed by the Sun Journal for this story.
While it declined to detail how chemically dependent inmates are treated during intake at Maine’s prisons and jails, the company said it uses “standard, humane and medically approved detox protocols for these addictions.”
Inmates who attend methadone clinics prior to incarceration are not dispensed methadone at any of the correctional facilities where Corizon is under contract. Pregnant inmates using methadone are treated by an off-site OB-GYN doctor licensed in prescribing Buprenorphine, a semisynthetic opioid used to treat opiate-based drug addiction. After delivery, those inmates follow the standard detox protocols, Nolan said.
If an inmate were to come to jail or prison with a current prescription for Oxycontin or oxycodone, those drugs wouldn’t be dispensed, except in “very rare” cases, the company said.
Inmates with a medical marijuana certificate won’t be dispensed that drug at Maine’s prisons and jails, either, but substitutions could be considered on a case-by-case basis, the company said.
In all, roughly 90 percent of the inmates who enter Maine’s prisons and other correctional facilities have a history of addiction to one or more drugs (including narcotics, benzodiazepines or barbiturates) or alcohol.
Relapse rate is high
So, why don’t all methadone addicts spend a week weaning themselves from the drug like Tomaselli?
Some may try. But most will need more time. And a small percentage likely will need to stay on methadone until they die, experts say.
Sullivan, the director at CAP, where opioid addicts are treated with methadone, said the first goal is to stabilize clients on a suitable dose of medication.
Opioid addiction is a brain disease, she said, best treated with medication and psychosocial support. Clients who come to her clinic get both.
Like any addiction, “It’s a progressive disease,” she said. “The longer you use, the worse it gets and the more you use … so that treatment is based on the individual.”
Studies have found that patients with this chronic disease undergo a change in brain chemistry in which they are lacking free endorphins which, for many, means they likely will need medication throughout their lifetimes, she said.
The long-term goal of treatment is to improve a client’s ability to function at home, at a job and in the world.
Studies show it works.
Typically, relapse rates are 70-90 percent among those who leave methadone maintenance treatment, she said, even among those who taper to zero.
An alternative for opioid addicts to being on a maintenance program at a methadone clinic may be to seek street drugs, which can expose addicts to hepatitis C and HIV through shared and dirty needles, blood clots and possible overdose, among other health risks.
Some may try prescription shopping, a ploy medical professionals are increasingly more aware of and on which federal and state drug agencies have cracked down.
A patient on Sullivan’s caseload was in methadone treatment before he tapered his dosage to zero and left, she said.
“Within a year, he relapsed,” she said. “And then he came to this clinic and he’s been here about 9½ years and he’s tapering out, decreasing his medication so he can leave. To zero eventually. That’s his desire.”
By taking a gradual approach, that client is more likely to succeed, she said.
She said patients and staff at CAP are anxious about the new 24-month MaineCare cap. Under the new DHHS rule, that cap can be exceeded with prior MaineCare authorization.
However, Sullivan said, “We’re waiting for the criteria for prior authorization. We have no idea what that’s going to be.” Once that process is established, “that will probably be the determinant on who loses treatment,” she said.
In the 10 years her clinic has been open, Sullivan said the number of clients has averaged about 550 at any given time.
“We’ve had over 3,000 patients come and go,” she said. “And some stay.”
The MaineCare cap will have an adverse effect on methadone clinics across the state, Sullivan said. Nearly 70 percent of all clients are on MaineCare. And, under the MaineCare reimbursement cap, that patient load is likely to decrease if MaineCare-capped patients can’t pay out-of-pocket.
Fewer than 200 methadone patients pay for treatments with private insurance, which leaves about 1,000 patients without MaineCare or private insurance paying for their own treatments.
Although her clinic exists to treat addiction to narcotics, some people who became addicted started with a doctor’s prescription for pain, she said.
Pain and narcotic addiction “are not necessarily mutually exclusive,” she said.
“Even addicts get real pain,” St. Mary’s Dr. Kelley said. Those are the ones who are likely to stay on methadone or Suboxone (a partial narcotic, offered by St. Mary’s instead of methadone) the rest of their lives, he said.
The other group that would have to stay on clinical treatment includes those who are so addicted they likely would harm themselves otherwise through risky drug behavior. No rehab program, however proven and long-term, is going to work for them.
“There’s just that once-in-a-while person that everything’s failed, no matter what,” he said.
But studies he’s seen show that opioid addicts who attend methadone clinics are less likely to contract HIV or hepatitis C and less likely to be charged with crimes. They work more days and achieve higher levels of education.
“So it does reduce the harm, not only to them, but to society, in many ways [to maintain methadone treatments],” he said.
St. Mary’s approach to addiction is that 99.9 percent of addicts can be weaned off and can stay off drugs and alcohol — “all chemicals,” Kelley said.
“And that requires a hell of a lot more than just taking a pill,” he said. “It requires learning about yourself, doing what we call the recovery work … learning why I use, how I can cope with life without drugs.”
Addicts who have been using drugs to cope with life will have to relearn how to cope without them. “That’s how they dealt with every single emotion,” he said.
And some addicts who have been abusing drugs since their early teens will have to learn those coping skills for the first time.
“How many coping skills do you have at 13 years old?” Kelley said. “Once you start using drugs for everything, you don’t learn new coping skills because you don’t need to. You’ve got a coping skill. It’s right there in your pocket. And so, some of these people are starting from scratch.”
Link to Poll
Monday, January 23, 2012
United Insurance Company of America Pays $37,500 To Resolve EEOC Disability Discrimination Lawsuit
United Insurance Company of America Pays $37,500 To Resolve EEOC Disability Discrimination Lawsuit
Federal Information & News Dispatch, Inc.
1-23-12
United Insurance Company of America Pays $37,500 To Resolve EEOC Disability Discrimination LawsuitCompany Rescinded Job Offer to Recovering Drug Addict Because of His Disability, Agency ChargedRALEIGH, N.C. - United Insurance Company of America will pay $37,500 and furnish other relief to resolve a disability discrimination lawsuit filed by the U.S. Equal Employment Opportunity Commission (EEOC), the agency announced today.According to the EEOC's lawsuit, Craig Burns is a recovering drug addict who has been enrolled in a methadone treatment program since 2004. In January 2010, United Insurance offered Burns a position as an insurance agent in its Raleigh office, conditioned upon Burns' passing a drug test. After Burns' drug test showed the presence of methadone in his system, Burns submitted a letter to United Insurance from his treatment provider explaining that he was participating in supervised methadone treatment program and taking legally prescribed medication as part of the treatment. Upon receiving this information, United Insurance notified Burns that he was not eligible for hire and withdrew its offer of employment.Such alleged conduct violates the Americans with Disabilities Act (ADA), which protects employees and applicants from discrimination based on their disabilities. The EEOC filed suit in August 2011 in U.S. District Court for the Eastern District of North Carolina (Civil Action No. 5:11cv00430), after first attempting to reach a pre-litigation settlement through its conciliation process.In addition to monetary damages, the two-year consent decree resolving the suit requires United Insurance to conduct training on, among other things, an employer's obligation to conduct an individualized assessment in determining whether an employee or applicant is disabled under the ADA; appropriate methods of determining whether an employee or applicant poses a direct threat under the ADA; and the obligation to engage in an interactive process under the ADA when an employee or applicant requests a reasonable accommodation. United Insurance will also post a copy of its anti-discrimination policy at its headquarters in St. Louis."The ADA requires employers to make an individualized assessment of whether an individual can do the job rather than relying on fears or stereotypes," said Lynette A. Barnes, regional attorney for the EEOC's Charlotte District, which includes the Raleigh Area Office, where the original charge of discrimination was filed. "We are pleased that, in resolving this case, United Insurance is taking action to ensure that it fulfills its obligations under the ADA."
Federal Information & News Dispatch, Inc.
1-23-12
United Insurance Company of America Pays $37,500 To Resolve EEOC Disability Discrimination LawsuitCompany Rescinded Job Offer to Recovering Drug Addict Because of His Disability, Agency ChargedRALEIGH, N.C. - United Insurance Company of America will pay $37,500 and furnish other relief to resolve a disability discrimination lawsuit filed by the U.S. Equal Employment Opportunity Commission (EEOC), the agency announced today.According to the EEOC's lawsuit, Craig Burns is a recovering drug addict who has been enrolled in a methadone treatment program since 2004. In January 2010, United Insurance offered Burns a position as an insurance agent in its Raleigh office, conditioned upon Burns' passing a drug test. After Burns' drug test showed the presence of methadone in his system, Burns submitted a letter to United Insurance from his treatment provider explaining that he was participating in supervised methadone treatment program and taking legally prescribed medication as part of the treatment. Upon receiving this information, United Insurance notified Burns that he was not eligible for hire and withdrew its offer of employment.Such alleged conduct violates the Americans with Disabilities Act (ADA), which protects employees and applicants from discrimination based on their disabilities. The EEOC filed suit in August 2011 in U.S. District Court for the Eastern District of North Carolina (Civil Action No. 5:11cv00430), after first attempting to reach a pre-litigation settlement through its conciliation process.In addition to monetary damages, the two-year consent decree resolving the suit requires United Insurance to conduct training on, among other things, an employer's obligation to conduct an individualized assessment in determining whether an employee or applicant is disabled under the ADA; appropriate methods of determining whether an employee or applicant poses a direct threat under the ADA; and the obligation to engage in an interactive process under the ADA when an employee or applicant requests a reasonable accommodation. United Insurance will also post a copy of its anti-discrimination policy at its headquarters in St. Louis."The ADA requires employers to make an individualized assessment of whether an individual can do the job rather than relying on fears or stereotypes," said Lynette A. Barnes, regional attorney for the EEOC's Charlotte District, which includes the Raleigh Area Office, where the original charge of discrimination was filed. "We are pleased that, in resolving this case, United Insurance is taking action to ensure that it fulfills its obligations under the ADA."
Friday, August 26, 2011
ASAM Redefines Addiction as a Brain Disease
ASAM Redefines Addiction as a Brain Disease
Pain-topics.org
August 26, 2011 (Friday)
Addiction is a primary, chronic brain disease, not just bad behavior or bad choices, according to a new definition from the American Society of Addiction Medicine (ASAM). Pain practitioners need to understand the ramifications of addiction — especially involving Rx-opioid use — as a complicating factor in patient care. However, casual use of the term “addiction” or inaccurate diagnosis of the disorder is counterproductive for effective pain management and unjustly stigmatizing to patients.
According to ASAM in a news release, when people see compulsive and damaging behaviors in friends or family members — or public figures such as celebrities or politicians — they often focus only on the behaviors or substance use as the problem. However, these outward signs are actually manifestations of an underlying disease that involves various areas of the brain.
“At its core, addiction isn't just a social problem or a moral problem or a criminal problem. It's a brain problem whose behaviors manifest in all these other areas,” said Michael Miller, MD, past president of ASAM who oversaw the development of the new definition. “Many behaviors driven by addiction are real problems and sometimes criminal acts. But the disease is about brains, not drugs. It's about underlying neurology, not outward actions.”
The new definition resulted from an intensive, 4-year process with more than 80 experts actively working on it, including top addiction authorities, addiction medicine clinicians, and leading neuroscience researchers from across the country. The full Public Policy Statement on addiction also includes this short version of the definition:
“Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.” “Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.”
By defining addiction as a primary disease, ASAM stresses that it is not the result of other causes, such as emotional or psychiatric problems. Addiction also is recognized as a chronic disease — like cardiovascular disease or diabetes — that must be treated, managed, and monitored over a life-time.
Two decades of advancements in neurosciences convinced ASAM that addiction needed to be redefined by what is going on in the brain. Research shows that the disease of addiction affects neurotransmission and interactions within neural reward circuitry, leading to addictive behaviors that supplant healthy ones, while memories of previous experiences with food, sex, alcohol, and other drugs trigger craving and renewal of addictive behaviors.
Meanwhile, brain circuitry that governs impulse control and judgment also is altered in this disease, resulting in the dysfunctional pursuit of rewards such as alcohol and other drugs. This area of the brain is still developing during teen-age years, which may be why early exposure to alcohol and drugs is related to greater likelihood of addiction later in life.
“There is longstanding controversy over whether people with addiction have choice over anti-social and dangerous behaviors,” said Raju Hajela, MD, in the news release (he is past president of the Canadian Society of Addiction Medicine and was chair of the ASAM committee on the new definition). He further states, “the disease creates distortions in thinking, feelings and perceptions, which drive people to behave in ways that are not understandable to others around them. Simply put, addiction is not a choice. Addictive behaviors are a manifestation of the disease, not a cause.”
However, Hajela continues, “Choice still plays an important role in getting help. While the neurobiology of choice may not be fully understood, a person with addiction must make choices for a healthier life in order to enter treatment and recovery. Because there is no pill which alone can cure addiction, choosing recovery over unhealthy behaviors is necessary.”
COMMENTARY: The interface of pain, opioid analgesics, and addiction has been of great concern in the pain management field. Commonly, the term “addiction” has been loosely applied by practitioners, researchers, and the public, and this has frequently resulted in faulty diagnoses, unjust accusations, and stigmatization of patients.
Furthermore, there have been many studies in the field using definitions that inaccurately assess addiction among patients with pain prescribed opioid analgesics; consequently, more often than not, the prevalence of addiction has been inflated. Good quality studies, of which there have been few, suggest that de novo iatrogenic addiction in patients appropriately prescribed opioid analgesics for chronic pain is a relatively rare occurrence [see UPDATE here].
Will this reinterpretation of addiction from ASAM help to clarify the issues or add further confusion? In many respects, the definition is comprehensive but not entirely new thinking. In 2001, a trio of organizations — the American Academy of Pain Medicine, American Pain Society, and ASAM — released a consensus document, “Definitions Related to the Use of Opioids for the Treatment of Pain,” that defined addiction as follows:
“Addiction is a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.”
The new definition, from ASAM, notes that addiction is characterized by 5 features:
1. Inability to consistently Abstain;
2. Impairment in Behavioral control;
3. Craving, or increased “hunger” for drugs or rewarding experiences;
4. Diminished recognition of significant problems with one’s behaviors and interpersonal relationships; and
5. A dysfunctional Emotional response.
These are quite similar to features noted in the consensus statement of a decade ago, and ASAM emphasizes that the 5 “new” features are not diagnostic criteria for addiction. Rather, the diagnosis of addiction requires “a comprehensive biological, psychological, social and spiritual assessment by a trained and certified professional.” However, this raises some concerns about the new definition:
Finally, it is curious that ASAM released this extensive definition of addiction at this time, when the American Psychiatric Association (APA) is finalizing the 5th revision of their Diagnostic & Statistical Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Is this new ASAM definition intended to complement DSM-5, to supersede the APA’s work in defining addictive disorders, or as a standalone interpretation of the disorders by ASAM? Interestingly, other than a major section heading in DSM-5 titled “Substance Use and Addictive Disorders,” the APA continues to shun use of the term “addiction” as a descriptor, as they have in the past.
In any case, the new ASAM document is recommended reading for all healthcare providers who want an understanding of addiction and addictive behaviors.
American Society of Addiction Medicine ASAM
Pain-topics.org
August 26, 2011 (Friday)
Addiction is a primary, chronic brain disease, not just bad behavior or bad choices, according to a new definition from the American Society of Addiction Medicine (ASAM). Pain practitioners need to understand the ramifications of addiction — especially involving Rx-opioid use — as a complicating factor in patient care. However, casual use of the term “addiction” or inaccurate diagnosis of the disorder is counterproductive for effective pain management and unjustly stigmatizing to patients.
According to ASAM in a news release, when people see compulsive and damaging behaviors in friends or family members — or public figures such as celebrities or politicians — they often focus only on the behaviors or substance use as the problem. However, these outward signs are actually manifestations of an underlying disease that involves various areas of the brain.
“At its core, addiction isn't just a social problem or a moral problem or a criminal problem. It's a brain problem whose behaviors manifest in all these other areas,” said Michael Miller, MD, past president of ASAM who oversaw the development of the new definition. “Many behaviors driven by addiction are real problems and sometimes criminal acts. But the disease is about brains, not drugs. It's about underlying neurology, not outward actions.”
The new definition resulted from an intensive, 4-year process with more than 80 experts actively working on it, including top addiction authorities, addiction medicine clinicians, and leading neuroscience researchers from across the country. The full Public Policy Statement on addiction also includes this short version of the definition:
“Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.” “Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.”
By defining addiction as a primary disease, ASAM stresses that it is not the result of other causes, such as emotional or psychiatric problems. Addiction also is recognized as a chronic disease — like cardiovascular disease or diabetes — that must be treated, managed, and monitored over a life-time.
Two decades of advancements in neurosciences convinced ASAM that addiction needed to be redefined by what is going on in the brain. Research shows that the disease of addiction affects neurotransmission and interactions within neural reward circuitry, leading to addictive behaviors that supplant healthy ones, while memories of previous experiences with food, sex, alcohol, and other drugs trigger craving and renewal of addictive behaviors.
Meanwhile, brain circuitry that governs impulse control and judgment also is altered in this disease, resulting in the dysfunctional pursuit of rewards such as alcohol and other drugs. This area of the brain is still developing during teen-age years, which may be why early exposure to alcohol and drugs is related to greater likelihood of addiction later in life.
“There is longstanding controversy over whether people with addiction have choice over anti-social and dangerous behaviors,” said Raju Hajela, MD, in the news release (he is past president of the Canadian Society of Addiction Medicine and was chair of the ASAM committee on the new definition). He further states, “the disease creates distortions in thinking, feelings and perceptions, which drive people to behave in ways that are not understandable to others around them. Simply put, addiction is not a choice. Addictive behaviors are a manifestation of the disease, not a cause.”
However, Hajela continues, “Choice still plays an important role in getting help. While the neurobiology of choice may not be fully understood, a person with addiction must make choices for a healthier life in order to enter treatment and recovery. Because there is no pill which alone can cure addiction, choosing recovery over unhealthy behaviors is necessary.”
COMMENTARY: The interface of pain, opioid analgesics, and addiction has been of great concern in the pain management field. Commonly, the term “addiction” has been loosely applied by practitioners, researchers, and the public, and this has frequently resulted in faulty diagnoses, unjust accusations, and stigmatization of patients.
Furthermore, there have been many studies in the field using definitions that inaccurately assess addiction among patients with pain prescribed opioid analgesics; consequently, more often than not, the prevalence of addiction has been inflated. Good quality studies, of which there have been few, suggest that de novo iatrogenic addiction in patients appropriately prescribed opioid analgesics for chronic pain is a relatively rare occurrence [see UPDATE here].
Will this reinterpretation of addiction from ASAM help to clarify the issues or add further confusion? In many respects, the definition is comprehensive but not entirely new thinking. In 2001, a trio of organizations — the American Academy of Pain Medicine, American Pain Society, and ASAM — released a consensus document, “Definitions Related to the Use of Opioids for the Treatment of Pain,” that defined addiction as follows:
“Addiction is a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.”
The new definition, from ASAM, notes that addiction is characterized by 5 features:
1. Inability to consistently Abstain;
2. Impairment in Behavioral control;
3. Craving, or increased “hunger” for drugs or rewarding experiences;
4. Diminished recognition of significant problems with one’s behaviors and interpersonal relationships; and
5. A dysfunctional Emotional response.
These are quite similar to features noted in the consensus statement of a decade ago, and ASAM emphasizes that the 5 “new” features are not diagnostic criteria for addiction. Rather, the diagnosis of addiction requires “a comprehensive biological, psychological, social and spiritual assessment by a trained and certified professional.” However, this raises some concerns about the new definition:
- Who is a “trained and certified professional” qualified to make a bona fide diagnosis of addiction in a patient? Presumably, ASAM members are qualified; pain practitioners are not. However, chronic pain and instinctual human drives for pain relief may result in expression of any or all of the 5 features of addiction noted above, which can confound the diagnosis by someone inexperienced in both pain and addiction medicine.
- The ASAM document catalogs many of the interesting and important neurobiological structures and functions that have been discovered in research studies to play a role in addictive processes. However, this knowledge has not been translated into everyday clinical application for the diagnosis and treatment of addiction.
- ASAM further notes that “genetic factors account for about half of the likelihood that an individual will develop addiction,” and these are further influenced by environmental factors. This may be of some importance from prevention perspectives but, since a person’s genetic makeup cannot be remediated, it is unhelpful in the treatment of current addiction.
- The inclusion by ASAM of a spiritual dimension in their definition and the assessment of addiction, which is so prominent and important in 12-Step recovery groups, is controversial from a medical science standpoint. Delving into patients’ connections (or disconnects) with a “Higher Power” is generally outside the bounds of typical clinical practice.
Finally, it is curious that ASAM released this extensive definition of addiction at this time, when the American Psychiatric Association (APA) is finalizing the 5th revision of their Diagnostic & Statistical Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Is this new ASAM definition intended to complement DSM-5, to supersede the APA’s work in defining addictive disorders, or as a standalone interpretation of the disorders by ASAM? Interestingly, other than a major section heading in DSM-5 titled “Substance Use and Addictive Disorders,” the APA continues to shun use of the term “addiction” as a descriptor, as they have in the past.
In any case, the new ASAM document is recommended reading for all healthcare providers who want an understanding of addiction and addictive behaviors.
American Society of Addiction Medicine ASAM
Monday, July 19, 2010
Andrei Nesterenko MFA Spokesman Dept of Information and Press Russia
MINISTRY OF FOREIGN AFFAIRS OF THE RUSSIAN FEDERATION
DEPARTMENT OF INFORMATION AND PRESS
July 19, 2010
______________________________________
Replies by Russian MFA Spokesman Andrei Nesterenko to Media Questions regarding the appointment of Yuri V. Fedotov, to the post of Executive Director of the UN Office on Drugs and Crime
Q: What explains the choice candidate, Yury Fedotov, Russia's appointment as Executive Director of the UN Office on Drugs and Crime? Answer: When the question arose of replacing Ispoldirektora UNODC A. Costa (Italy), whose contract expires next month, the candidate of the current Russian Ambassador to Britain, Yuri V. Fedotov was proposed by us to UN Secretary General on a number of reasons. This is an experienced diplomat and an effective manager, who is deeply and fully owned by the United Nations issues. Prior to his appointment to London, he was Deputy Minister of Foreign Affairs, directly oversee the UN and UN organizations. Therefore, advancing Yury Fedotov on this post, we do not doubt that he will make a significant contribution to advancing the goals and challenges facing the UN in this direction.
Recall that Yury Fedotov was appointed to this position the UN Secretary General so that he - the choice is not only Russia, but Ban Ki-moon, too, which proves the objectivity of approach to this candidate. Question: What problem should be solved the new leader in office? A: As part of its powers Yury Fedotov headed one of the priority to the interests of the Russian Federation and, of course, the priority of the UN directions. After all, the UN Vienna plays an increasing role as a center for harmonizing international efforts in combating new challenges and threats of a criminal nature. In its terms of reference will include issues of international cooperation in combating the global threat of illegal drug distribution, including Afghanistan, corruption, cyber crime, laundering of proceeds from criminal activities, trafficking in persons, compliance with 16 international anti-terrorism treaties, etc. The role of the UN - the most to promote cooperation among States in these areas. Such activities include the provision of assistance (not only material) to those countries that need it, and find donors willing to provide such assistance, bilaterally or through the UN. Q: It is known that a group of representatives of the international network of harm reduction and organizations working on HIV / AIDS, addressed to UN Secretary General Ban Ki-moon with a letter in which he opposed the appointment of the representative of Russia to the presidency, citing the poor performance of the country in the fight AIDS. Do you shown concern justified? A: We believe this approach is totally unreasonable. It is no secret that there are influential and active forces interested in how to present the situation of HIV / AIDS in Russia as almost no catastrophic. But let's look at the facts. Yes, HIV / AIDS epidemic in our country as well as in most countries have not yet obtained reversed. However, there is every reason to hope that this will sooner or later we will achieve. One of the key elements of public policy in this area - the political will and awareness of the extent of the threat. As approved by the President of the Russian Federation in May 2009 National Security Strategy of 2020 the spread of HIV infection is recognized as one of the major threats to national security in health and health of the nation. The next most important factor - financing efforts. The turning point in this direction occurred in 2006, when the fight against HIV / AIDS has been allocated to twenty times more money than was allocated in previous years. And this trend continues unabated, and continues to grow. Many positive results are evident. To mention only one of them: last year, all HIV-infected people in need of treatment from the federal budget - and that 70,000 people - is receiving treatment. As you mentioned demarche, it seems, was dictated by the long-known desire of the international narkoliberalnogo lobby force in the same idea of the so-called substitution treatment or harm reduction offering under the guise of combating drug abuse and illicit drug use among high-risk groups to spread the "legal" drugs and devices for their use. The position of our country on this issue is well known. We reject this approach and our strong commitment to this line is in some circles irritation.
MINISTRY OF FOREIGN AFFAIRS OF THE RUSSIAN FEDERATION
DEPARTMENT OF INFORMATION AND PRESS
119200, Moscow G-200
Smolenskaya Square Hay., 32/34
tel.: (499) 244-4119
fax: (499) 244-4112
e-mail: mailto:dip@mid.ru
web-address: www.mid.ru
DEPARTMENT OF INFORMATION AND PRESS
July 19, 2010
______________________________________
Replies by Russian MFA Spokesman Andrei Nesterenko to Media Questions regarding the appointment of Yuri V. Fedotov, to the post of Executive Director of the UN Office on Drugs and Crime
Q: What explains the choice candidate, Yury Fedotov, Russia's appointment as Executive Director of the UN Office on Drugs and Crime? Answer: When the question arose of replacing Ispoldirektora UNODC A. Costa (Italy), whose contract expires next month, the candidate of the current Russian Ambassador to Britain, Yuri V. Fedotov was proposed by us to UN Secretary General on a number of reasons. This is an experienced diplomat and an effective manager, who is deeply and fully owned by the United Nations issues. Prior to his appointment to London, he was Deputy Minister of Foreign Affairs, directly oversee the UN and UN organizations. Therefore, advancing Yury Fedotov on this post, we do not doubt that he will make a significant contribution to advancing the goals and challenges facing the UN in this direction.
Recall that Yury Fedotov was appointed to this position the UN Secretary General so that he - the choice is not only Russia, but Ban Ki-moon, too, which proves the objectivity of approach to this candidate. Question: What problem should be solved the new leader in office? A: As part of its powers Yury Fedotov headed one of the priority to the interests of the Russian Federation and, of course, the priority of the UN directions. After all, the UN Vienna plays an increasing role as a center for harmonizing international efforts in combating new challenges and threats of a criminal nature. In its terms of reference will include issues of international cooperation in combating the global threat of illegal drug distribution, including Afghanistan, corruption, cyber crime, laundering of proceeds from criminal activities, trafficking in persons, compliance with 16 international anti-terrorism treaties, etc. The role of the UN - the most to promote cooperation among States in these areas. Such activities include the provision of assistance (not only material) to those countries that need it, and find donors willing to provide such assistance, bilaterally or through the UN. Q: It is known that a group of representatives of the international network of harm reduction and organizations working on HIV / AIDS, addressed to UN Secretary General Ban Ki-moon with a letter in which he opposed the appointment of the representative of Russia to the presidency, citing the poor performance of the country in the fight AIDS. Do you shown concern justified? A: We believe this approach is totally unreasonable. It is no secret that there are influential and active forces interested in how to present the situation of HIV / AIDS in Russia as almost no catastrophic. But let's look at the facts. Yes, HIV / AIDS epidemic in our country as well as in most countries have not yet obtained reversed. However, there is every reason to hope that this will sooner or later we will achieve. One of the key elements of public policy in this area - the political will and awareness of the extent of the threat. As approved by the President of the Russian Federation in May 2009 National Security Strategy of 2020 the spread of HIV infection is recognized as one of the major threats to national security in health and health of the nation. The next most important factor - financing efforts. The turning point in this direction occurred in 2006, when the fight against HIV / AIDS has been allocated to twenty times more money than was allocated in previous years. And this trend continues unabated, and continues to grow. Many positive results are evident. To mention only one of them: last year, all HIV-infected people in need of treatment from the federal budget - and that 70,000 people - is receiving treatment. As you mentioned demarche, it seems, was dictated by the long-known desire of the international narkoliberalnogo lobby force in the same idea of the so-called substitution treatment or harm reduction offering under the guise of combating drug abuse and illicit drug use among high-risk groups to spread the "legal" drugs and devices for their use. The position of our country on this issue is well known. We reject this approach and our strong commitment to this line is in some circles irritation.
MINISTRY OF FOREIGN AFFAIRS OF THE RUSSIAN FEDERATION
DEPARTMENT OF INFORMATION AND PRESS
119200, Moscow G-200
Smolenskaya Square Hay., 32/34
tel.: (499) 244-4119
fax: (499) 244-4112
e-mail: mailto:dip@mid.ru
web-address: www.mid.ru
Tuesday, December 09, 2008
Painkillers Linked to Increase in Overdose Deaths.
Painkillers Linked to Increase in Overdose Deaths.
More popularity, availability of these medications may be reason, study suggests.
Steven Reinberg
HealthDay News, December 9, 2008
TUESDAY, Dec. 9 (HealthDay News) -- Deaths from overdoses of prescription drugs, primarily pain relievers, appear to be on the rise throughout the United States, new research suggests. West Virginia, in particular, has seen a large increase in such unintentional deaths, say government researchers, who have uncovered patterns of "doctor shopping" for drugs and overdosing on medications not used as prescribed. "We found that two-thirds of these deaths involved prescription drugs that had not been prescribed to the individuals who died," said the lead researcher, Dr. Aron J. Hall, an epidemic intelligence service officer for the U.S. Centers for Disease Control and Prevention. In addition, one in five had "doctor shopped," looking for physicians to prescribe pain medications, particularly opioids like methadone, hydrocodone and oxycodone, Hall said. "This epidemic of prescription drug overdose involves a substantial amount of substance abuse, and it affects not just West Virginia, but particularly rural areas of the country," Hall said. "It's been a problem throughout the country. Our study focused on West Virginia as the tip of the iceberg." Hall's group thinks that doctors and pharmacists have a critical role in preventing the misuse of these drugs. "It is essential that they counsel patients not only about the risk of overdose to themselves, but about the risks to those with whom they might share their drugs," he said. In addition, Hall advises doctors to use prescription monitoring programs, which can tell them if patients are getting drugs from other doctors. The report is published in the Dec. 10 issue of the Journal of the American Medical Association. For the study, Hall's team looked at deaths from unintentional overdoses in West Virginia in 2006. From 1999 to 2004, deaths from unintentional poisoning in the state increased 550 percent, the greatest increase for any state in the country. To determine the size of the problem in West Virginia, the researchers collected data from medical examiners, prescription drug-monitoring programs, and opiate treatment program records. In 2006, 295 West Virginians died from unintentional overdoses of pain killers, Hall's group found. Of these, 67.1 percent were men and 91.9 percent were between the ages of 18 and 54. Most on those who died (63.1 percent) used painkillers, but did not have a prescription for them. And 21.5 percent had prescriptions for these drugs from at least five doctors in the year before their death, the researchers found. Women were more likely to doctor shop than men (30.9 percent vs. 16.7 percent), and younger people used painkillers for non-medical purposes more than their older counterparts did, according to the report. In 79.3 percent of the deaths, people had used several medications. Opioids were the most common drugs used, accounting for 93.2 percent of the deaths. Of these deaths, only 44.4 percent of the victims had any evidence of having a prescription for these drugs, Hall's group noted. Methadone was the most common drug linked to fatal overdoses, accounting for 40 percent of the deaths. People who died from a methadone overdose were less likely to have a prescription for the drug than people who overdosed on hydrocodone or oxycodone, the researchers found. In 1997, two reports called for better management of chronic pain and encouraged the use of opioid pain medications. Since that time, the sales of these painkillers has gone up dramatically as have overdoses, deaths and recreational use linked to these drugs, Hall said. Dr. Adam Bisaga, an associate professor of clinical psychiatry in the division on substance abuse at Columbia University College of Physicians and Surgeons in New York City, thinks that improved guidelines for appropriate prescribing, along with training to detect substance use disorders in patients, might reduce the unintended consequences seen in this study. "This finding is not surprising. Opiates are generally very safe if used appropriately, but opiate abuse/dependence is an illness with high mortality rates," Bisaga said. "So the issue is not with the medication, but rather the detection and treatment of those who abuse and become addicted to opiates." In addition, there is a need to expand access to addiction treatment, particularly in high-risk populations, Bisaga said. "I strongly believe that present results could be directly used to justify implementing changes in practice and treatment to promptly reverse this worrisome trend that is likely to be occurring throughout the country, not just in one state," Bisaga said.
More information
For more on prescription drug abuse, visit the U.S. National Institute on Drug Abuse. Link to Article.
More popularity, availability of these medications may be reason, study suggests.
Steven Reinberg
HealthDay News, December 9, 2008
TUESDAY, Dec. 9 (HealthDay News) -- Deaths from overdoses of prescription drugs, primarily pain relievers, appear to be on the rise throughout the United States, new research suggests. West Virginia, in particular, has seen a large increase in such unintentional deaths, say government researchers, who have uncovered patterns of "doctor shopping" for drugs and overdosing on medications not used as prescribed. "We found that two-thirds of these deaths involved prescription drugs that had not been prescribed to the individuals who died," said the lead researcher, Dr. Aron J. Hall, an epidemic intelligence service officer for the U.S. Centers for Disease Control and Prevention. In addition, one in five had "doctor shopped," looking for physicians to prescribe pain medications, particularly opioids like methadone, hydrocodone and oxycodone, Hall said. "This epidemic of prescription drug overdose involves a substantial amount of substance abuse, and it affects not just West Virginia, but particularly rural areas of the country," Hall said. "It's been a problem throughout the country. Our study focused on West Virginia as the tip of the iceberg." Hall's group thinks that doctors and pharmacists have a critical role in preventing the misuse of these drugs. "It is essential that they counsel patients not only about the risk of overdose to themselves, but about the risks to those with whom they might share their drugs," he said. In addition, Hall advises doctors to use prescription monitoring programs, which can tell them if patients are getting drugs from other doctors. The report is published in the Dec. 10 issue of the Journal of the American Medical Association. For the study, Hall's team looked at deaths from unintentional overdoses in West Virginia in 2006. From 1999 to 2004, deaths from unintentional poisoning in the state increased 550 percent, the greatest increase for any state in the country. To determine the size of the problem in West Virginia, the researchers collected data from medical examiners, prescription drug-monitoring programs, and opiate treatment program records. In 2006, 295 West Virginians died from unintentional overdoses of pain killers, Hall's group found. Of these, 67.1 percent were men and 91.9 percent were between the ages of 18 and 54. Most on those who died (63.1 percent) used painkillers, but did not have a prescription for them. And 21.5 percent had prescriptions for these drugs from at least five doctors in the year before their death, the researchers found. Women were more likely to doctor shop than men (30.9 percent vs. 16.7 percent), and younger people used painkillers for non-medical purposes more than their older counterparts did, according to the report. In 79.3 percent of the deaths, people had used several medications. Opioids were the most common drugs used, accounting for 93.2 percent of the deaths. Of these deaths, only 44.4 percent of the victims had any evidence of having a prescription for these drugs, Hall's group noted. Methadone was the most common drug linked to fatal overdoses, accounting for 40 percent of the deaths. People who died from a methadone overdose were less likely to have a prescription for the drug than people who overdosed on hydrocodone or oxycodone, the researchers found. In 1997, two reports called for better management of chronic pain and encouraged the use of opioid pain medications. Since that time, the sales of these painkillers has gone up dramatically as have overdoses, deaths and recreational use linked to these drugs, Hall said. Dr. Adam Bisaga, an associate professor of clinical psychiatry in the division on substance abuse at Columbia University College of Physicians and Surgeons in New York City, thinks that improved guidelines for appropriate prescribing, along with training to detect substance use disorders in patients, might reduce the unintended consequences seen in this study. "This finding is not surprising. Opiates are generally very safe if used appropriately, but opiate abuse/dependence is an illness with high mortality rates," Bisaga said. "So the issue is not with the medication, but rather the detection and treatment of those who abuse and become addicted to opiates." In addition, there is a need to expand access to addiction treatment, particularly in high-risk populations, Bisaga said. "I strongly believe that present results could be directly used to justify implementing changes in practice and treatment to promptly reverse this worrisome trend that is likely to be occurring throughout the country, not just in one state," Bisaga said.
More information
For more on prescription drug abuse, visit the U.S. National Institute on Drug Abuse. Link to Article.
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