Who is Failing Whom? Moving Towards Person-Centered Addiction Treatment

By Sarah E. Wakeman, MD, FASAM
August 11, 2017

It is not enough to simply say addiction is an illness. If we truly believe this, then we must ensure our language and approach mirror how we care for patients with other illnesses.

The need for treatment modification is a hallmark of disease management, particularly for complex, chronic illnesses like diabetes or HIV. We expect that for many patients a typical treatment course will include periods of remission and recurrence with associated adjustments in medication or other interventions. We even have a term for treatment for the most severe cases of refractory disease; we call it “salvage therapy.” For cancer, salvage therapy refers to “Treatment that is given after the cancer has not responded to other treatments.”1 Note that the lack of response is focused on the disease, appropriately, and not the patient. Continue reading “Who is Failing Whom? Moving Towards Person-Centered Addiction Treatment”

Are Supervised Injection Facilities an Answer to Saving Lives in the Opioid Epidemic?

By Ajay K. Singh, MBBS, FRCP, MBA
March 28, 2017

I would recommend a perspective article by Sarah Wakeman in the New England Journal of Medicine as a “must read” for health care professionals wondering what still remains to be done in the dealing with the opioid epidemic. However, Dr. Wakeman’s view is not necessarily widely shared and might explain why the supervised injection facility (or site) idea hasn’t been widely adopted in the US.

In her article, Wakeman talks poignantly about the value of supervised injection facilities in saving lives. Says Wakeman, Continue reading “Are Supervised Injection Facilities an Answer to Saving Lives in the Opioid Epidemic?”

Marijuana Use: The National Academy Report

*OPINIONS EXPRESSED BY OUR GUEST AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.

By Ajay K. Singh, MBBS, FRCP, MBA
Tuesday, January 24, 2017

The use of marijuana for medical treatment is legal in 28 states and the District of Columbia (DC). And recreational marijuana (or pot) has been legalized in eight of those states and DC.

Marijuana is derived from the dried leaves, flowers, stems, and seeds from the hemp plant, Cannabis sativa. Delta-9-tetrahydrocannabinol (Delta-9-THC) is the primary psychoactive ingredient in marijuana.

The January 12, 2017 publication of the report, “The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research” by the blue ribbon National Academies of Sciences, Engineering and Medicine in Washington, D.C. provides some important information on the risks and benefits of marijuana.

The report is available online and is very well worth a read. Highlights (excerpted) include:

Therapeutic Effects

  • In adults with chemotherapy-induced nausea and vomiting, oral cannabinoids are effective antiemetics.
  • In adults with chronic pain, patients who were treated with cannabis or cannabinoids are more likely to experience a clinically significant reduction in pain symptoms.
  • In adults with multiple sclerosis (MS)-related spasticity, short-term use of oral cannabinoids improves patient-reported spasticity symptoms.
  • For these conditions, the effects of cannabinoids are modest; for all other conditions evaluated, there is inadequate information to assess their effects.

Cancer

  • The evidence suggests that smoking cannabis does not increase the risk for certain cancers (i.e., lung, head, and neck) in adults.
  • There is modest evidence that cannabis use is associated with one subtype of testicular cancer.
  • There is minimal evidence that parental cannabis use during pregnancy is associated with greater cancer risk in offspring.

Psychosocial

  • Recent cannabis use impairs the performance in cognitive domains of learning, memory, and attention. Recent use may be defined as cannabis use within 24 hours of evaluation.
  • A limited number of studies suggest that there are impairments in cognitive domains of learning, memory, and attention in individuals who have stopped smoking cannabis.
  • Cannabis use during adolescence is related to impairments in subsequent academic achievement and education, employment and income, and social relationships and social roles.

Mental Health

  • Cannabis use is likely to increase the risk of developing schizophrenia and other psychoses; the higher the use the greater the risk.
  • In individuals with schizophrenia and other psychoses, a history of cannabis use may be linked to better performance on learning and memory tasks.
  • Cannabis use does not appear to increase the likelihood of developing depression, anxiety, and posttraumatic stress disorder.
  • For individuals diagnosed with bipolar disorders, near daily cannabis use may be linked to greater symptoms of bipolar disorder than non-users.
  • Heavy cannabis users are more likely to report thoughts of suicide than non-users.

The 16-member National Academy committee comes to the following conclusion, “There is conclusive or substantial evidence that cannabis or cannabinoids are effective:

  • For the treatment for chronic pain in adults (cannabis)
  • Antiemetic’s in the treatment of chemotherapy-induced nausea and vomiting (oral cannabinoids)
  • For improving patient-reported multiple sclerosis spasticity symptoms (oral cannabinoids)

[Develop your skills in clinical research for CME credit st HMS Global Academy.]

Ajay Singh, MBBS, FRCP

Dr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.

*OPINIONS EXPRESSED BY OUR AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.

 

Oliceridine and The Opioid Epidemic: Getting Long-Term Users off Opioids


By Ajay K. Singh, MBBS, FRCP, MBA
Tuesday, January 17, 2017

The 2014 National Survey on Drug Use and Health estimates that approximately two million Americans are addicted to prescription opioids. Over the past 20 years, prescription opioids have led to over 165,000 deaths in the US. In 2015 alone, more than 15,000 people died from overdoses involving prescription drugs.

The recently published Washington Post/Kaiser Family Foundation Survey, explored the factors that led individuals to become long-term users of prescription opioids. The report is important because it provides explanations for why long-term addiction to opoiod painkillers is so difficult to manage.

Some details about the survey…

Telephone interviews of 809 randomly selected adults age 18 years and older, or a household member, were conducted in the fall of 2016. Long-term users were defined as individuals who had taken prescription painkillers for two months or more at some time during the prior two years. They excluded individuals who had taken painkillers for either cancer or terminal illness.  About one-third were telephone surveys of landlines and two-thirds of cell phones.

The report revealed that:

  • Most chronic users were started on opioids via a prescription from a doctor.
  • Indications for opioid drugs included, chronic pain (44%), pain post-surgery (25%) or pain following an accident or injury (25%). Only 3% stated that they started opioids for recreational reasons, but subsequently about 1 in 5 said they were also using painkillers “for fun or to get high.”
  • Most chronic users had debilitating disability or chronic disease (70%).
  • About 57% of chronic users stated that opioids made their quality of life better. 92% indicated that the major reason for taking the painkillers was to reduce physical pain.
  • Doctors discussed the possibility of addiction or dependence only 65% of the time when users began painkillers.
  • Doctors discussed “other ways to manage pain besides these painkillers” only 62% of the time.
  • Most of those surveyed blamed themselves and the doctors who prescribed the drugs, but also stated that the drug manufacturers and the government should take blame.
  • The majority of users (≈80%) recommended greater education directed at doctors and medical students about treating pain. They also recommended more research and greater access to addiction treatment programs.

[HMS CME Online will launch a free CME opioid course in the spring.]

So what’s the bottom-line?

First, it will be hard to get individuals off opioid painkillers if they perceive that they need them. As  Emily Guskin writes in the Washington Post,  “At the center of the nation’s opioid crisis is a simple fact: Large numbers of Americans experience serious pain, and the vast majority of those who have used strong painkillers for a long period say they work.”

Second, doctors need to do a better job of discussing with patients the risks of addiction and alternatives to opioids. As a December 16 editorial in the Washington Post states, “a key condition…is for doctors to become much more careful in the way they distribute these powerful pills, which are still widely prescribed for noncancer pain, notwithstanding what is now a mountain of evidence, accumulating for years, that the drugs are far more addictive than manufacturers once led physicians and patients to believe.”

The Post editorial concludes: “If progress is to be made … American medicine must redouble its commitment to sound prescribing practices.” Clearly, there is a view at least among the media that education for doctors and other clinicians is still needed about whom to treat for pain and for how long.

And, third, better and more effective painkillers are necessary. In a December 22, 2016 article in ScienceNews, Bethany Brookshire reviews the hunt for a safer opioid painkiller, and in a  January 13, 2017 Smithsonian magazine article, John Kelvey discusses the clinical development of the only alternative to morphine, Oliceridine. A powerful rapidly acting and nonaddictive painkiller is desperately needed, and it seems like a candidate is on the horizon.


The Opioid Use Disorder Education Program

The Opioid Use Disorder Education Program (OUDEP) is now available from HMS Global Academy. OUDEP is comprised of 3 free online CE/CME courses produced by Harvard Medical School (HMS) with scientific contributions from The National Institute on Drug Abuse (NIDA). These courses are intended for nurses, nurse practitioners, physician assistants, physicians, and other health care providers collaborating to treat patients with substance use disorders.


Ajay Singh, MBBS, FRCPDr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.

*OPINIONS EXPRESSED BY OUR AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.

Doctors as Drug Dealers?

 

By Ajay K. Singh, MBBS, FRCP, MBA
December 27, 2016

In a December 16, 2016 interview with NPR’s Terry Gross, Dr. Anna Lembke, author of a book titled Drug Dealer, MD, talks about the role of doctors in the opioid use disorder.

Dr. Lembke claims that in the 1980s doctors were sold the idea that there was an evidence basis for opioids as effective treatment for chronic pain. She says this idea was propagated by “big medicine” that was “in cahoots with big pharma”. Continue reading “Doctors as Drug Dealers?”

Substance Use Disorder: The Surgeon General’s Report

By Ajay Singh, MBBS, FRCP
November 21, 2016

A quote from Chris Prentiss’s book1, The Alcoholism and Addiction Cure is an appropriate backdrop to the publication this past week on The Surgeon General’s Report on Alcohol, Drugs, and Health.

Writes Prentiss about addiction: “It’s the causes, not the dependent person, that must be corrected. That’s why I see the United States’ War on Drugs as being fought in an unrealistic manner. This war is focused on fighting drug dealers and the use of drugs here and abroad, when the effort should be primarily aimed at treating and curing the causes that compel people to reach for drugs.”

Surgeon General Vice-Admiral Dr. Murthy asks the question: “How we respond to this crisis is a moral test for America.”

In my view the Surgeon General’s Report is a “tipping point” in changing our knowledge and perception about substance abuse.

Time and again the report states “addiction is a health condition, not a moral ailing or character flaw

The full report2 and executive summary3 are available online.

Some Highlights:

  • More than 27 million people in the US reported using illegal drugs or abusing prescription drugs in 2015.
  • There are over 20 million people in the country with substance use disorders, which is approximately the same number of people with diabetes, and 1.5 times the number of people with all cancers combined.
  • Only 1 in 10 people with substance abuse disorders are receiving treatment.
  • In 2014, over 43,000 people died from drug overdose, more than in any previous year on record.
  • Substance abuse must be identified in general health settings, including primary, psychiatry, and emergency care.
  • Effective screening will help create individual treatment plans.
  • Treatment is critical and effective.
  • More than 25 million individuals with a previous substance use disorder are in remission and living healthy, productive lives.
  • Increasing access to medicine—methadone, buprenorphine, and naltrexone—is crucial to fighting the opioid crisis.
  • Substance abuse treatment is not just the work of individual specialists. A mix of caregivers should treat it—social workers, recovery specialists, and nutritionists—just as they do with diabetes or cancer. 

Post-script

The word “malarkey” came to mind after reading an opinion piece4 by Dr. Manny Alvarez’s about the Surgeon General’s Report. The full definition of the word “malarkey” in the Merriam-Webster dictionary is  “insincere or foolish talk”.


The Opioid Use Disorder Education Program

The Opioid Use Disorder Education Program (OUDEP) is now available from HMS Global Academy. OUDEP is comprised of 3 free online CE/CME courses produced by Harvard Medical School (HMS) with scientific contributions from The National Institute on Drug Abuse (NIDA). These courses are intended for nurses, nurse practitioners, physician assistants, physicians, and other health care providers collaborating to treat patients with substance use disorders.


References

1Chris Prentiss C: The Alcoholism and Addiction Cure: A Holistic Approach to Total Recovery ISBN 0943015448 Published October 1st 2005 by Power Press (first published January 1st 2005)

2Department of Health and Human Services, Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS, November 2016.

3Executive Summary

4Alvarez M: Dr. Manny: Surgeon General Murthy leaves legacy of too little, too late.  Accessed Nov 20, 2016

Ajay Singh, MBBS, FRCP

Dr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.

*OPINIONS EXPRESSED BY OUR AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.