Oxytocin Shown to Block Alcohol Withdrawal

In a small, randomized, double-blind clinical trial, intranasal oxytocin blocked the effects of alcohol withdrawal on a population presenting to a hospital-based detoxification unit. Results from the study were published in the March edition of Alcoholism: Clinical and Experimental Research and are the first to confirm results obtained in other studies using non-human subjects.

In the study, participants (n=11) were given either lorazepam and oxytocin (n=7), or lorazepam and placebo (n=4), over three days of inpatient detox. They were then administered several standardized alcohol withdrawal measurements (CIWA, AWSC, ACVAS, POMS) and compared the two groups. Across the board, patients who were administered intranasal oxytocin scored significantly lower on withdrawal measures, while reporting significantly less craving and significantly better mood.
While the limitations of the study (small size) are clear, these findings are impressive and will lead to further research. In recent years, oxytocin has shown promise in the treatment of multiple disorders. Certainly, this research will add another voice to the chorus of oxytocin advocates.

Ants, Corporations, Complexity, Emergence

Heard on NPR Morning Edition:

Ants, bees, and other colonizing insects have complex organizations similar in many respects to modern corporations. Each ant has a specialized function that varies by age. The young ones tend the queen, middle-aged ants do clean up duty, and the older more experienced ants go out foraging for food. "The queen is really the only one with a dead-end job: laying eggs." Ants can jump over the clean up straight to foraging, similar to overachieving corporate managers. I don't know if the ants have to suck up to whoever is the ant CEO (this actually didn't come up) or not. Actually, it doesn't appear there is a CEO, the colonies are self-organizing. The scientist discussing this was asked about whether ants retire and her answer was that "ant retirement is not pretty." There is a specialized function for some ants, namely corpse disposal.

So in many ways, ant colonies are similar to corporations, but in addition to the presumed lack of a CEO or Board, there are other differences as well. Ant communication is much more efficient than in corporations. The ants communicate through chemical and other means than spread throughout the colony. "There is no email in an ant colony." (Lucky them, and presumably no Facebook or Twitter or texting either.) Another difference is that that there are no ants who get 400-500% more of the goodies than the median ant, while average CEO:median worker pay ratio is something like that. (According to Payscale.com, the Wal-Mart CEO is paid greater than 1000% more than the median worker there.) And presumably, ants don't get memberships in country clubs as part of their executive pay package.

The scientific principles here are complexity and emergence, an extremely important property of self-organizing systems, such as humans and the human "colony."  If you want to learn more, there is a fun site where you can set up your own ant colony. Just don't try to be the CEO.

MW

Restricted Access to SUD Meds and the Lack of Informed Consent

by Ian McLoone

A recent study by Abraham, et al., published in the March Journal of Studies on Alcohol and Drugs, finds that patients receiving treatment at publicly-funded programs have significantly less access to potentially life-saving substance use disorder (SUD) medications like buprenorphine, disfulfiram, acamprosate, and naltrexone. Buried in the report, however, is the shocking statistic that a full 56.4% of the programs (publicly- or privately-funded) prescribed no medications whatsoever. Clearly, there are a whole lot of consumers not being informed of their full array of choices when it comes to managing their treatment.

The study analyzed nearly 600 treatment programs throughout the country - data originally part of the National Treatment Center Study – and looked for differences in physician access and SUD medication access. The authors found that 10.9% offered access to one medication, while 32.7% offered more than one medication. Fewer than 5% of programs offered access to all of the above medications.

The authors note that nearly 2/3 of all specialty SUD treatment programs in the US are publicly funded, relying on government block grants and state contracts for the money needed to provide treatment, while private funding tends to come from private insurance and self-paying patients.

When divided into publicly-funded and privately-funded categories, private programs were almost 15% more likely to have a physician on-staff and nearly 10% more likely to employ master’s-level counselors. And while publicly-funded treatment programs were almost 14% less likely to prescribe buprenorphine, only 32.5% of all programs offered the medication. Only 20.6% of programs offered disulfiram, 27% offered tablet naltrexone, 27% offered acamprosate, and a slim 13.1% of programs offered injectable naltrexone.

Among other findings, programs with a more professional workforce were positively correlated with the number of SUD medications offered, and programs with a physician on staff were more likely to offer higher numbers of SUD medications than programs with no access to physicians.

These findings beg the question: why are evidence-based practices so rare and why is this tolerated in addiction treatment but not in other professional treatments? (What if over half of American cardiologists prescribed no medications to their patients?) Sure, public programs offer fewer scientifically-supported therapies – but even people who are spending a fortune of their own money are often getting poor care. When patients are not informed of the full array of treatment options, the lack of informed consent becomes an ethical – and likely legal – issue.

I Challenge You to Find a Better Deal in Integrated Addiction & Psychiatric Treatment

First, my apologies for the drought in blogs lately. The last few weeks have been among the busiest in my life. Feels like internship all over again! Ian McLoone has been helping me with blog writing, and I haven't even had time to quickly look them over before publishing.

Busy is good to an extent, of course. The good news is that Alltyr is catching on, with very little marketing. Granted, being mentioned (with a very appreciated link) in Jane Brody's column, and the publication of Inside Rehab have propelled things along rather quickly, and to some extent it caught us off guard. But the new office in the 1st National Bank Bldg in St. Paul, MN is great. I love the building! Built in 1931, with lots of wonderful marble, and marvelous metalwork around the elevators. And, get this, planters with orchids all over the main level. In St. Paul, "the main level" is confusing. If you drive through downtown St. Paul, it looks like a kind of abandoned city on the street level. There's not much there except bus stops and the new light rail stops. Thing is, all the action occurs one story up, on the Skyway Level. Most buildings in downtown St. Paul and Minneapolis are connected to skyways. Skyways are connections between buildings 1 floor up from the street. So when I go to work there, I park in the heated garage in the building, leave my coat in the car, take the elevator to the skyway level. Here is where there are restaurants and delis, dry cleaning places, hair stylists, food courts, etc.

In addition to the office space, there are great amenities, including conference and training facilities at no extra charge and a modern workout facility, all included in the rent. And, we are in front of one of the new light rail stops, so it will be very easy to get here.

There are several suites on our current floor, which we are looking at for clinic expansion. My goal is to open a full -service SUD clinic in the fall of 2013. We are also talking to providers of sober housing. The idea is to create a comprehensive, state-of-the-art system of care that is based on 21st Century science, compassion and common sense.

We are also in discussions with local health plans, who are very interested in what we are doing. Remember, they are paying a lot for repeated useless residential and IOP rehabs. For example, a local nationally known provider charges about $30,000 for a 28-day residential rehab. I don't know what kind of discount the health plans get, but let's say they are paying $20,000 for it. Another prominent provider in the area charges $10,000 cash up front for a very pedestrian IOP with no housing. Alltyr's intensive services package, which includes a comprehensive evaluation by a physician (not a counselor), 10 1-hour psychotherapy and medication management visits, plus 25 30-minute therapy and medication visits over the course of a year, is only $4800, discounted from $5400 if purchased separately. Sober housing I'm going to estimate high at $1200 per month. So, for under $7,000, Alltyr Clinic will provide treatment services for a year plus 1 month supervised sober housing.  And with results that are guaranteed to be superior, because Alltyr's program includes completely integrated psychiatric treatment and uses all available treatment modalities.

I challenge you to find a better deal anywhere.

White House Announces Brain Mapping Initiative

Whew! Long drought! I was caught a bit off guard by the response to Jane Brody's column about Inside Rehab, which generated a lot of inquiries and new patients for Alltyr! All good things, plus opening the new office in downtown St. Paul and many other activities have left me a bit overwhelmed. Today's blog is written by Ian McLoone, a graduate student at the University of Minnesota Master of Professional Studies in Integrated Behavioral Health. Ian has been working with me learning about clinical work, as well as helping with Alltyr Clinic and other activities. He's going to be a regular contributor to Substance Matters.

MW

White House Announces Brain Mapping Initiative

President Obama announced on Tuesday plans to invest more than $100 million to develop and fund technology to map the human brain. The project, titled “Brain Research through Advancing Innovative Neurotechnologies”, or BRAIN Initiative, aims to improve our understanding of the human brain and, according to the White House, “uncover new ways to treat, prevent, and cure brain disorders like Alzheimer’s, schizophrenia, autism, epilepsy, and traumatic brain injury.”

Being hailed as the next Human Genome Project, the ambitious initiative will direct $50 million to the Defense Advanced Research Projects Agency (DARPA), $40 million to the National Institutes of Health (NIH), and another $20 million to the National Science Foundation (NSF). In addition, several private sector foundations and institutes have pledged significant contributions, each with specific goals in mind.

Cori Bargmann of Rockefeller University and William Newsome of Stanford University will lead the NIH working group. They will be tasked with creating specific plans, goals, a time frame, and cost estimates for the project moving forward. Of course this begs the question: what goals or plans would blog readers like to see addressed in this process? Is this initiative too ambitious, or not ambitious enough, given its size and scope? Leave your comments after the jump.

New Report Outlines Global Strategy to Reduce Harmful Drinking

New Report Recommends Public Health Focus on Harmful Drinking vs. Eliminating Consumption

Tuesday, February 26, 2013

International Center for Alcohol Policies (ICAP)  

Findings Run Counter to Current Public Health Approach, Discredit Traditional Perspectives

WASHINGTON, DC--(Marketwire) - The traditional public health perspective on alcohol and noncommunicable diseases is indicted in a new report from the International Center for Alcohol Policies (ICAP). "Alcohol misuse and global health: The case for an inclusive approach to harmful drinking" discredits the traditional public health perspective that focuses on a narrow group of stakeholders and ignores individual factors and social norms.

"Unfortunately, some widely-held public policy perspectives on reducing harmful drinking are based on questionable and misleading data," said ICAP President Marcus Grant. "This report draws on a wide pool of research to clarify misconceptions and propose a more effective model that involves a broader group of stakeholders and resources, including alcohol producers."

In the past decade, there is greater recognition of the impact of noncommunicable diseases (NCDs) in both developed and developing countries. Harmful alcohol consumption is a contributing lifestyle factor for several of the most widespread and harmful of these diseases, with alcohol misuse accounting for four percent of global disease burden.

The report notes that a reduction in heavy-drinking patterns will have a more significant impact on public health than limiting alcohol's physical and economic availability. Unlike tobacco use, which is harmful at any level, light to moderate drinking can have healthful benefits for some groups. There is little to be gained from stigmatizing what is, for many people, a normal behavior.

The WHO Global Strategy to Reduce the Harmful Use of Alcohol recognizes this distinction, and that including a wider array of stakeholders than historically have been engaged contributes to a more effective public health response. In an era of shrinking economies, the fight against such a critical public health issue cannot afford to exclude key influencers, such as alcohol producers, or the unique resources they can provide.

The focus of the public health community, policymakers, non-governmental organizations and yes, even producers, should be on mitigating the risk of unhealthy consumption patterns, rather than eliminating consumption altogether.

"Alcohol misuse and global health: The case for an inclusive approach to harmful drinking" is available:

http://icap.org/LinkClick.aspx?fileticket=C35rkfX54Mk%3d&tabid=159

The International Center for Alcohol Policies (ICAP; www.icap.org) is a not-for-profit organization supported by major international producers of beverage alcohol. Established in 1995, ICAP's mission is to promote understanding of the role of alcohol in society and to help reduce harmful drinking worldwide. ICAP's efforts to foster dialogue and partnerships in the alcohol policy field are shaped by its commitment to pragmatic and feasible solutions to reducing harm that can be tailored to local and cultural considerations and needs. ICAP has been recognized by the United Nations Economic and Social Council (UN ECOSOC) as a non-governmental organization in Special Consultative Status.

New Studies Confirm – and Contradict – Conventional Wisdom on Chronic Pain

New Studies Confirm – and Contradict – Conventional Wisdom on Chronic Pain

by Ian McLoone

- Chronic pain patients have long been told it’s all in their heads. Well, a team at McGill University just submitted more proof. The researchers, led by Prof. Laura Stone, found that injuries resulting in chronic pain are associated with epigenetic changes in the brains of mice which can be observed 6 months after the date of injury. These heritable changes, called DNA methylation, have far-reaching consequences across the entire genome and can impact behavior and well-being – but were also shown to be reversible. “The implications of epigenetic involvement in chronic pain are wide reaching and may alter the way we think about pain diagnosis, research and treatment,” the authors say. Future considerations for treatment will likely include behavioral and pharmacological interventions that focus on reversing DNA methylation in brain.

- Think all addicts make risky chronic pain patients? Think again. For decades, the conventional wisdom has told us that addicts and alcoholics are constitutionally incapable of managing chronic pain with the help of opioid pain relievers – no matter what their drug of choice had been. However, a recent study suggests that this isn’t necessarily the case, and that risk factors for opioid misuse are dynamic and complex.   

The study, published this January in the Drug and Alcohol Dependence journal, found that the trait most significantly associated with risk for prescription opioid misuse was “pain catastrophizing” and that, “current substance use disorder [SUD] status was not a significant predictor [of risk].” While it’s been shown elsewhere that simply being prescribed opioids constitutes a significant risk factor for abuse and misuse behaviors, this study seems to suggest that by screening for past or current SUD, we may be missing the point.

Dr. Carlton Erickson, PhD, director of the Addiction Science Research and Education Center, tells me it’s an issue that’s “currently being hugely debated across the nation…mainly [by] pain medicine physicians and addiction medicine physicians.” Much like Dr Willenbring, he stresses the importance of an integrated and comprehensive approach to working with such patients and suggests ensuring access to, “a team consisting of an addiction medicine specialist, pain management specialist [and] counselor…who can guide the treatment while minimizing the likelihood of” misuse. On a related note, there was news last year that chronic pain patients on opioid therapy can be successfully converted to buprenorphine. Specifically, patients on a morphine equivalent dose of 100-199 mgs seemed to fare better than those on higher doses.

- Does the color of your skin affect your chronic pain treatment? A new study suggests it does. Leslie R Hausmann, PhD, led a team of researchers from the VA Pittsburgh Healthcare System to investigate whether racial disparities existed in the follow-up and monitoring of patients who were prescribed opioid medications over a two-year period. In adjusted comparisons, they found black patients were less likely to have their pain documented than white patients, less likely to be referred to pain specialists, and more likely to be referred to a substance abuse assessment. Also, among those patients who had at least one drug test, black patients were subjected to more drug testing than their white counterparts. Among the report’s conclusions, the authors suggest that, “Addressing disparities in opioid monitoring and follow-up treatment practices may be a previously neglected route to reducing racial disparities in pain management.”

Ian McLoone is a graduate student at the University of Minnesota’s Integrated Behavioral Health program, a Graduate Research Assistant at the Minnesota Center for Mental Health, as well as a clinical intern at Alltyr, Inc.