Is Florida Turning a Corner?

According to a brand new study, published online this week in the journal, Pharmacoepidemiology and Drug Safety, Florida's recent legislative actions to 1.) strengthen the state's prescription drug monitoring program, and 2.) toughen the regulation of the state's pain clinics, seem to be having the desired effect: drug diversion has been dropping steadily since 2011. In addition, according to the state's commission of medical examiners, prescription opioid overdose deaths are dropping too. Here's the abstract from the article and a figure of the models of longitudinal change, according to each drug: 

Reductions in prescription opioid diversion following recent legislative interventions in Florida

Surratt, et al., 2013

Purpose
Florida has been at the center of the nation's ongoing prescription opioid epidemic, with largely unregulated pain clinics and lax prescribing oversight cited as significant contributors to the opioid problem in the state.

Methods
In an effort to mitigate prescription opioid abuse and diversion in Florida, legislative interventions were implemented during 2010 and 2011, which included two primary elements: (i) comprehensive legislation to better regulate the operation of pain clinics; and (ii) a statewide prescription drug monitoring program to promote safer prescribing practices. Using systematic longitudinal data collected on a quarterly basis from law enforcement agencies across Florida, this report examined changes in prescription opioid diversion rates following implementation of these regulatory initiatives. Quarterly diversion rates for buprenorphine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone, and tramadol were calculated, and subsequently, hierarchical linear models were fit to test for differences in diversion rates over the 15 quarter period of interest.

Results
Significant declines in diversion rates were observed for oxycodone, methadone, and morphine; hydrocodone displayed a marginally significant decline.

Conclusions
This study documented reductions in statewide opioid diversion rates following implementation of Florida's pain clinic and prescription drug monitoring program legislative interventions. Although these initial findings appear promising, continued surveillance of diversion is clearly warranted. Copyright © 2013 John Wiley & Sons, Ltd.

Poor and Non-Whites Less Likely to Receive Opioid for Pain in ERs

Race and Socioeconomic Status Affect Emergency Department Opioid Prescribing for Pain

Prior research suggests that factors besides pain—such as patient race and ethnicity—affect opioid prescribing for pain, but those studies have often not adjusted for socioeconomic status (SES). In this study, investigators examined the association between race, ethnicity, and neighborhood SES on prescription of an opioid during an emergency department (ED) visit for moderate or severe pain in the National Hospital Ambulatory Care Survey. During 4 years there were over 183 million visits and opioids were prescribed during 50,264 of them.

• Compared with patients living in areas with the highest SES, patients living in areas with the lowest SES were less likely to receive opioids (39% versus 49% when neighborhood poverty was >20%; 41% versus 47% when median income was <$33,000; and 43% versus 46% when <13 a="" bachelor="" degree="" held="" li="" s="">
• Black (39% versus 46% for white) and Hispanic (40% versus 45% for non-Hispanic) patients were less likely to receive opioids.
• All differences were significant in analyses adjusted for race, ethnicity, SES, sex, pain severity, injury, hospital type, past ED visits, and geography.

Comments:

This study adjusted for neighborhood rather than individual SES. Nonetheless, it does provide support for the hypothesis that race, ethnicity, and SES impact opioid receipt for pain. Clinicians should be aware that this may happen, and researchers should attend to discovering why, with an eye toward eliminating any inappropriate disparities.Richard Saitz MD, MPH

Reference:

Joynt M, Train MK, Robbins BW, et al. The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States. J Gen Intern Med. 2013 [Epub ahead of print]. PMID: 23797920.

If You Build It, They Will Drink

If there were lingering doubts about the effect of alcohol availability on alcohol consumption, a host of new studies seem to lead the reader to the same conclusion: that increases in availability are correlated to increases in consumption. In other words: if you build it (bar, liquor store, etc), we will drink. What's more, in many cases, it's not just drinking that will happen. So-called alcohol outlet density has been linked to interpersonal and intimate partner violence, adolescent consumption and beliefs about alcohol, and even alcohol-attributable deaths. On the other hand, raising the minimum prices or implementing taxes on alcohol sales seems to go a long way in reducing these potential harms.

The journal, Addiction, has published several of these studies online in the past few weeks. Gruenewald and colleagues analyzed survey data from 50 California cities with populations between 50,000 - 500,000. They found "greater on-premise outlet densities were related to greater drinking frequencies and volumes, and use of on-premise drinking places" (like bars and restaurants).  The researchers concluded that, in addition to characteristics of the individual drinkers (e.g. "impulsivity, risky driving), alcohol availability is correlated with consumption and related problems.

Also in-press at Addiction, Paschall and colleagues analyzed the same sample, but instead focused on adolescent drinking. Some 1478 California youths, aged 13-17, responded to survey questions about past-year alcohol consumption, perceived availability, and questions related to underage enforcement and parental views toward drinking. The answers to these questions were then compared against alcohol outlet (bar) density, public policy, law enforcement activity and city demographics. The authors found that adolescent behaviors and attitudes were significantly affected by their environments. For example, past-year alcohol use was positively correlated to bar density and inversely correlated to "the comprehensiveness and stringency of local alcohol policies". In addition, higher rates of adult drinking were associated with greater increases of past-year adolescent drinking over the three-year study period.

Over in Alcohol and Alcoholism, Grubesic and colleagues studied the association between outlet density in Philadelphia and violent crime. Once again, the researchers found consistent association between the two. Here is a pair of maps, the first showing assault density, the second showing outlet density:

Contrary to the popular belief, no association was found between assault density and "transportation nodes and risky retailers". However, alcohol expenditures and general commercial activity were "positively and significantly" associated with assault density. 

The connection between intimate partner violence (IPV) and alcohol outlet density seems to be well established. In 2012, Conradi and colleagues reported that the density of bars in California was positively associated with IPV-related emergency department visits between 2005-2008. Then, earlier this year, Waller and colleagues found alcohol outlet density to be positively correlated to male-to-female physical - but not sexual - IPV among a national sample. Finally, in March, Zhao and colleagues showed that alcohol outlet density was associated with an increase in alcohol-attributable deaths in British Columbia between 2002-2009. In fact, they calculated that a 10% increase in private liquor stores was associated with a 2.45%, 2.36% and 1.99% increase in acute, chronic and total alcohol-associated (AA) mortality rates.

Interestingly, the single policy that seemed to have the biggest impact in turning these numbers around: raising the minimum price for alcohol. A 10% increase in the minimum price was associated with a 31.72% reduction in "wholly AA deaths". Pretty big numbers. As Dr W observed recently, "raising taxes on alcohol would do more for public health than all the treatment in the world." 

What do you think?

MMT and 12-Step Groups: Stigma Persists

In his latest contribution to the academic literature, William L. White and colleagues turn their focus on 12-Step participation among patients in methadone maintenance treatment (MMT). Rates of self-reported Narcotics Anonymous (NA) and Alcoholics Anonymous (AA) attendance were very high; however, participants frequently reported that their MMT status prevented them from taking part in many of the "key ingredients" of the groups that most members take for granted. When asked about the experience, nearly half of all respondents who had attended NA or AA reported that they had "received negative comments about methadone use" and nearly "a quarter (24.4%) reported having had a serious problem within NA or AA related to their status as a methadone patient."

The following table from the report details the "frequency with which respondents faced particular challenges":

Table 4: NA and AA Responses to MMT Patient Status                                NA            AA

Response to MM Patient Status:                                                                         (n=228)     (n=142)

Received negative comments about methadone use                                                43.0%     45.1%

Were pressured to reduce the dose of methadone                                                  21.9%     23.2%

Were pressured to stop taking methadone                                                             32.9%     34.5%

Were denied the right to speak at a meeting because of being
in methadone treatment                                                                                         14.5%      14.1%

Were denied the right to become a sponsor because of being                                  8.8%        9.9%
in methadone treatment


White and colleagues implemented this small study at not-for-profit opioid treatment program (OTP) in the Northeastern US. A total of 322 respondents answered a 53-question survey about their participation in recovery support groups. Of the 322, 259 (80.4%) reported a primary affiliation with a recovery support group. Of these, 88.8% reported it to be in some way a 12-Step group. Importantly, 66% of respondents reported past-year NA/AA participation, with 88-89% reporting the group was "helpful".

Despite these figures, the authors found MMT patients had low rates of participation in the "key ingredients" that seem to be critical influencers of long-term recovery outcomes: having a home group (50%), having a sponsor (26%), sponsoring others (13%), attending 12-Step social events (23%), and active step work (21%).

Anecdotally, we see a lot of patients at Alltyr who have a hard time finding a place in the local 12-Step scene. We even began compiling a list of medication-friendly meetings in the Twin Cities as we learned about them, but the stigma associated with maintenance is still prevalent. Could it be that we are on the verge of another breakthrough in medication acceptance? After all, there was a time when you weren't considered "sober" if you were on antidepressant or antipsychotic medications (but now, as Dr W likes to say, you're more likely to be referred to the psychiatrist by your sponsor than by anyone else). We would be interested to hear reader stories about this experience - or opinions on the topic. Are things changing - or not?

See the full paper by White, et al., here: http://www.williamwhitepapers.com/pr/2013%20Co-participation%20in%2012-Step%20Groups%20and%20Methadone%20Maintenance.pdf

12-Step Familiarity vs 12-Step Facilitation

A pair of studies were published last month to little fanfare and which seem to be contradictory in nature. Both papers involve 12-step programs and focus on the role of the counselor in delivering Twelve-Step Facilitation (TSF), a SAMHSA-recognized evidence-based practice. Published in the American Journal of Drug and Alcohol Abuse, the studies come to the following conclusions: Therapist familiarity and personal experience with twelve-step programs (TSPs) improves their credibility among clients and, in turn, therapeutic alliance; yet therapists who viewed TSPs favorably and who described themselves as being in recovery tended to do a poorer job at maintaining fidelity and adherence to TSF in a large, multi-site trial.

In the first paper, researchers at the State University of New York administered surveys to clients and counselors at a host of treatment programs in and around Albany. Clients (n=180) rated counselors on their perceived familiarity with  TSPs, the amount of time in-session devoted to discussion of TSPs, and the credibility of each counselor, as rated in a 12-point questionnaire. In addition, counselors (n=30) answered a demographic questionnaire, reporting such information as education level, recovery status, and months of experience in the field. As hypothesized, counselors who were perceived to be in recovery and more personally-familiar with TSPs received higher ratings of credibility from their clients, presumably resulting in better therapeutic alliances and, therefore, better outcomes.

In the second paper, researchers in Oregon and California sought to determine the characteristics associated with fidelity and TSF adherence among therapists participating in a large trial of the EBP. Notably, the authors found that 1) "Therapists reporting more positive attitudes toward 12-step groups had lower adherence ratings;" 2) "Being in recovery was associated with lower fidelity in univariate tests, but higher adherence in multivariate analysis;" and 3), "Fidelity was higher for therapists reporting self-efficacy in basic counseling skills" (as well as for therapists with a graduate degree) "and lower for self-efficacy in addiction-specific counseling skills." 

The "juxtaposition" of the two outcomes, as Yale's Steve Martino puts it, leads the reader to believe that the ideal therapist in this setting can't possibly exist, or ar the very least is exceedingly rare. Someone who is very familiar with 12-step principles is likely to report a positive attitude toward them, and counselors in recovery are likely to rate themselves as possessing strong addiction-specific counseling skills. So, what is the moral to the story, if one exists? Where do we focus workforce development energy with mixed messages like these? It would be interesting to hear from readers who fall on either side (or both sides) of this issue...

Sunday Alcohol Blue Laws: Keeping consumption in-check?

In a brand new paper by SUNY economist Bans Yoruk, the author analyzes alcohol consumption rates in five states which recently repealed laws banning the sale of alcohol on Sundays. The findings, published online this month in the journal Addiction, show that in three of the five states, per capita alcohol consumption rose significantly in the years following the repeals. Beer seems to be the type of alcohol responsible for most of the increase across the states, with wine and spirits seeing small, if any, changes in demand.

The five states studied were Delaware, which repealed its law against Sunday alcohol sales in 2003, as did Massachusetts and Pennsylvania; Rhode Island, which repealed in 2004; and New Mexico, where the law was changed in 1995. The three states whose per capita consumption increased were Delaware (from 4% pre-repeal to 4.7% post-repeal), Pennsylvania (4% to 4.6%), and New Mexico (6.5% to 7.1%). The increase in Rhode Island was “small and statistically insignificant,” and there was no change in Massachusetts. (Interestingly, the demand for beer seemed to drive the up-tick in sales – all three states where the overall demand rose saw beer consumption increase by about a full percentage point.) The five states were then compared to control states, like our beautiful Minnesota, where alcohol Blue Laws remain in effect. 

Here's the graph from the paper:

Professor Yoruk's analysis falls on the heels of another study which tracked the effects of, among other variables, perceived alcohol availability and bar density on adolescent alcohol consumption. Paschall, et al. found such environmental factors contributed significantly to higher rates of past-year alcohol use. Could it be that an archaic and puritanical relic could actually be saving some lives? Will be interesting to see what readers think about the issue…

Sources:

        Paschall, M. J., Lipperman‐Kreda, S., & Grube, J. W. (2013). Effects of the Local Alcohol Environment on Adolescents’ Drinking Behaviors and Beliefs.Addiction.

        Yörük, B. K. (2013). Legalization of Sunday alcohol sales and alcohol consumption in the United States. Addiction.

Advice for Consumers of Addiction Services

In the November issue of the prestigious journal Health Affairs, Anne Fletcher's book Inside Rehab got a very favorable review. Yours truly was highlighted with this paragraph from the review:

"Certainly the most useful part of the book is the advice provided by Mark Willenbring, former director of the Division of Treatment and Recovery Research at the National Institute on Alcohol Abuse and Alcoholism. He recommends that those seeking treatment should see themselves as customers and seek the best treatment that will work for them. They should get a comprehensive evaluation from someone not financially invested in a specific treatment program, demand nothing less than master’s degree–prepared therapists, and make sure the program treats any co-occurring issues. They should also not go through the same treatment protocols over and over again when it is obvious that they aren't working."

Thanks to Anne of course, and also to the reviewer, Rick Mathis (Richard_Mathis@bcbst.com), a a health
researcher at the BlueCross BlueShield of Tennessee Health Institute.

MW

New Findings in Medication-Assisted Treatment

Some interesting new studies are showing promising results for patients all over the world:

Turns out, Quality of Life improvements aren't just for the wealthy:
Quality of Life (QoL) scores significantly improved in ALL four domains (psychological, physical, social and environmental) of the WHO QoL scale in patients in low and middle income countries, according to the authors of a systematic review of 13 studies involving over 1800 participants. The findings, published online last week in the Journal of Drug and Alcohol Dependence, show that despite the apparent lack of resources in these countries, opiate replacement therapy with methadone or buprenorphine can be an effective treatment tool - with scores increasing along with the length of time at followup - and offering outcomes comparable to those seen in high income countries.
You can read the abstract of the study by Feelemeyer, et al., here: http://www.sciencedirect.com/science/article/pii/S0376871613004225

The methadone of methamphetamine?:
In encouraging news for stimulant users, a small study has shown methylphenidate (Ritalin) to both improve symptoms and reduce use episodes, in a cohort of criminal justice-involved stimulant users with co-occurring ADHD. Similar findings have been published supporting mixed-amphetamine salts (Adderall) plus topiramate (Topamax) for the treatment of cocaine dependence, and more recently topiramate by itself. The authors of the small study note the high prevalence of ADHD among stimulant users in the criminal justice population and in their research used dosages that were high enough to be therapeutically effective for patients with a history of substance use disorders (a flaw, they argue, in previous studies of this kind). Could it be that we are getting closer to an accepted agonist maintenance treatment for stimulant use disorders? Read the results of the Swedish study by Konstenius, et al., published online this month in the journal Addiction:
http://onlinelibrary.wiley.com/doi/10.1111/add.12369/abstract

Groups could improve access to AUD medications:
And finally, in a new study in the Journal of Substance Abuse Treatment, researchers have shown that group pharmacotherapy is an effective intervention for patients on medication-assisted treatment of alcohol use disorders. The authors provide a brief description of this novel approach and their experiences implementing the program. They note that, for many clinicians, providing ongoing monitoring of these effective medications can create a barrier to implementation. What the team found however, was that a "medication group" was not only feasible, but it actually increased their patients' access to meds like disulfiram (Antabuse), naltrexone and acamprosate (Campral). Read the abstract from the report by Dr Shannon Robinson and a team at San Diego's VA Health Care System here: http://www.sciencedirect.com/science/article/pii/S0740547213001347

Overcoming Addictions, a web-based application, & SMART Recovery: Outcomes of a randomized clinical trial

This week's entry comes from Dr Reid K Hester, PhD. He is Director of the Research Division at Behavior Therapy Associates, LLC, where they have been conducting some exciting new research using a web-based application, Overcoming Addictions. Thank you, Dr Hester, for the guest post:

Overcoming Addictions, a web-based application, & SMART Recovery: Outcomes of a 

randomized clinical trial

My research staff and I recently published the early outcomes of a new web app, Overcoming Addictions in the Journal of Medical Internet Research (http://www.jmir.org/2013/7/e134). Overcoming Addictions (OA, www.overcomingaddictions.net) is an abstinence-oriented, cognitive behavioral program based on the protocol of SMART Recovery. SMART Recovery (www.smartrecovery.org) is an organization that has adapted empirically supported treatment strategies for use in a mutual help framework with in-person meetings, online meetings, a forum and other resources.

A firm believer of “In God we trust, everyone else has to show their data,” we evaluated the effectiveness of OA and SMART Recovery (SR) with problem drinkers in a randomized clinical trial. We recruited 189 heavy problem drinkers primarily through SMART Recovery’s web site and their online and in-person meetings. We randomly assigned them to: (1) OA alone, (2) OA+ attend SMART Recovery meetings (OA +SR), or to (3) attend SMART Recovery meetings (SR) only. Outcome measures included self-reported percent days abstinent, mean drinks per day when they did drink , and alcohol/drug related consequences. We also interviewed significant others to corroborate the participant’s self-report.

We predicted that: (1) All groups would reduce their drinking and alcohol/drug related consequences at follow-up compared to their baseline levels; (2) the OA groups would reduce their drinking and alcohol/drug related consequences more than the control group (SR).

There were several striking features of our participants. First, 60% of them were female. While this is consistent with the clinical trials of our other web applications like the Drinker’s Check-up (www.drinkerscheckup.com) and Moderate Drinking (www.moderatedrinking.com), it is significantly more than what one would predict given the prevalence of problem drinking in women versus men (35 vs. 65% respectively) in the epidemiological data. Second, this was a highly educated group with an average of 16 years of education. Third, while these folks were not seeking formal treatment, they had a level of alcohol problems comparable to the outpatient arm of Project MATCH.

At the 3 month follow-up both the intent-to-treat analyses and the actual use analyses showed highly significant improvement from baseline to follow-ups.  Mean within-subject effect sizes were large (d > .8) overall. There were, however, no significant differences between groups. Participants in all groups significantly increased their percent days abstinent from 44% to 72% (P<.001), decreased their mean drinks per drinking day from 8.0 to 4.6 (P<.001), and decreased their alcohol/drug-related problems (P<.001) by about 50%. These are clinically meaningful improvements in outcomes.

These outcomes indicate that both our Overcoming Addictions web app and attending SMART Recovery meetings and using their resources online (www.smartrecovery.org) were effective in helping people recover from their problem drinking.

These graphs reflect outcomes of the actual use analyses.

Advice for Mental Health Clinicians

A clinician recently sent me this email:

Dr. Willenbring,

I read an article in the New York Times from early this year discussing Effective Addiction Treatment that in part highlighted your comments and Alltyr's mission to be a 21st century model for addictions treatment.

As a therapist in an outpatient practice not specializing in addictions treatment--but who nevertheless encounters co-morbidity with substance abuse on a pretty regular basis--it can be confusing to know how to approach the psychosocial aspects of treatment. I believe in a multimodal approach for chronic forms of addiction but there are tons of options out there for my part in that process:  motivational enhancement therapy, cognitive-behavioral, contingency management interventions/motivational incentives, the matrix model, 12-step, DBT, family behavior therapy, interpersonal neurobiology, etc. There is so much out there it's dizzying, and I feel overwhelmed. There are some that seem more indicated for alcohol, others that seem better for stimulants, another for opioids. I've worked for agencies that are sold on one particular treatment for every type of substance abuser, and others that turn their therapists loose to use whatever they think best.

I want to use the best, empirically validated approaches and everyone seems to have an opinion on what that is. Where would you recommend I start, particularly for treatment options?

Here's my reply:

Hi Jxxxx,

It is indeed a confusing landscape out there, both for non-specialist clinicians and for patients and families. 

A good place to start is with the ASAM textbook on treatment of addictive disorders. It's coming out with a new edition (or it has just come out). Also, the American Psychiatric Association textbook is pretty good as an overall summary of evidence-based practice.

On an individual clinician level though it can be confusing. Here are some thoughts:

First, there is no ONE RIGHT WAY to overcome addictions. There are many different pathways. Our job is to help each person find his or her own best way.

Second, a skilled clinician is usually effective no matter the specific technique, as long as the clinician is focused on the patient, not the technique or path. Focus on general skills, such as empathy, reflective listening, unconditional positive regard, and instilling hope. There is no evidence that a specific technique is more effective than another, except in specific circumstances. The relationship is more important.

Third, be patient oriented. Take them where they are. Find out what they want, help them clarify their goals and how to reach them. Help them learn skills to achieve their goals, while also gently helping them realize that the ideal goal (use without consequences) is out of reach.

Finally, be patient and let them teach you about their disorder and its nature. Recovery is a two-steps-forward, one-step backward process. Trying and failing is a necessary step for most people, and the important thing is to accept that, learn from each step back, and then look forward. Persistence is the key. 

A couple of other things.

Never use the words denial, codependency, or enabling. Don't threaten, cajole or berate. Don't share your own experience unless it is (very) clearly in the best interests of the patient (it usually isn't). 

Never question their motivation to get better. I've never met an addict who liked being addicted. They all want to feel better, but sometimes it takes awhile to figure what the way forward is. 

Accept that you can't help everyone. Why should we be able to universally help everyone with a complex human affliction? Be humble, but hopeful and available. Never blame the patient/client for the failure of our treatments, which are modestly effective at best. People die of this disease, and too often we can't stop it or know how to help them. People die from all sorts of illnesses. It's no different to die of a dysregulation in our brain than in our heart, immune system or pancreas. We need to get over ourselves a little bit. We don't need to blame the person with the disease in order to protect ourselves from our inability to stop it. 

And keep working, and trying, and stay hopeful and alive and open hearted. That does the most of all.

Thanks for writing,

MW

Recovery Happens.

An analysis of an impressive and wide-sweeping study arrived in my email box this morning, via the wonderful folks at Drug and Alcohol Findings in the UK. For the study, recovery advocate William L White reviewed 415 scientific studies of recovery outcomes from clinically- and culturally-diverse populations, looking at research performed over the past century. Among the highlights, the author concludes from all of this data that recovery happens - at far greater rates than conventional wisdom would have us believe. In fact,  "Recovery is not an aberration achieved by a small and morally enlightened minority of addicted people. If there is a natural developmental momentum within the course of [these] problems, it is toward remission and recovery."

Some very hopeful words to start your day.

Below are some additional highlights. You can access the article here:  http://findings.org.uk/count/downloads/download.php?file=White_WL_24.txt and find great resources for treatment research and interventions here: http://findings.org.uk/index.php (the drug and alcohol matrices are a treasure trove of important research).

1 How many people are in recovery from substance use disorders in the United States? This was answered by extrapolating national estimates from the major governmental surveys of the course of alcohol and other drug use and related problems and from a 2010 recovery survey conducted by the Public Health Management Corporation in Philadelphia and six surrounding counties. Based on this analysis, the proportion of adults in the general US population in remission from substance use disorders ranges from 5.3% to 15.3%. These rates produce a conservative estimate of more than 25 million adults in remission from significant alcohol or drug problems in the United States and possibly up to 40 million.

2 What percentage of those who develop alcohol or drug problems eventually achieve remission/recovery? Of adults surveyed in the general population who once met lifetime criteria for substance use disorders, an average of 49.9% (53.9% in studies conducted since 2000) no longer meet those criteria. In community studies (ie, not sampling treatment populations only) reporting both remission rates and abstinence rates for substance use disorders, an average of 43.5% of people who have ever had these disorders achieved remission, but only 17.9% did so through complete abstinence.

3 What is the rate of remission/recovery for people whose problems are severe enough to warrant professional treatment? Across 276 substance use treatment follow-up studies of adult clinical samples, the average remission/recovery rate was 47.6% (50.3% in studies published since 2000). In studies with sample sizes of 300 or more and follow-up periods of five or more years – used as proxy for greater methodological sophistication – average remission/recovery rates were 46.4% and 46.3%, respectively. In the 50 adult clinical studies reporting both remission and abstinence rates, the average remission rate was 52.1%, and the average abstinence rate was 30.3%.This 21.8% difference appears to reflect the proportion in post-treatment follow-up studies who are using alcohol and/or other drugs asymptomatically or are experiencing problems not severe enough to meet diagnostic criteria for substance use disorders.

4 Does the rate of remission/recovery for adolescents following specialised treatment differ from that of adults? Yes. This analysis compares 276 adult substance use treatment outcome studies conducted between 1868 and 2011 with 60 adolescent substance use treatment outcome studies between 1979 and 2011. The average recovery/remission rate following specialty treatment for adolescents was 42% (35% for studies since 2000), compared to 47.6% for adults (50.3% for studies since 2000). Interpretation of this finding should be tempered by the greater number of adult studies and their larger sample sizes and much longer follow-up periods. While the high percentage of adolescents who report some alcohol or drug use in the months following treatment is discouraging, longer-term studies confirm post-treatment increases in abstinence, reductions in use, and gains in global health among treated adolescents. There is cause for optimism regarding adolescents' long-term prospects for recovery from substance use disorders.

5 How can local communities establish baseline remission/recovery prevalence data? To evaluate community-wide strategies by tracking changes in recovery prevalence over time, local communities can integrate recovery prevalence questions into regular community health surveys. A model for potential replication is the integration of recovery prevalence questions into the bi-annual community health survey conducted in Philadelphia and surrounding counties. Such baseline data are being used there and could be used in other communities to guide recovery-focused systems-transformation efforts and to evaluate planned interventions in particular geographical areas (eg, evaluating service needs by postcode/planning areas and matching treatment/recovery support resources to areas where problem severity is highest and recovery capital lowest).

Adolescent Cannabis Use: A Self-Fulfilling Prophecy

In an interesting study recently made available in Addictive Behaviors, researchers found that parents’ beliefs about their children’s cannabis use could predict whether they began using one year later. It turns out, parents’ predictions, while highly variable and often wrong, could work in their favor – or against them, depending on the response: kids were more likely to begin smoking cannabis if their parents had wrongly assumed they already were. What’s more, kids were more likely to cease smoking if their parents had wrongly assumed they didn't smoke. Turns out, the Self-Fulfilling Prophecy is alive and well in our nation’s high schools.

Data for the study was analyzed from the National Survey of Parents and Youth (N=3131). In the survey, youth (ages 12-17) were asked about past-year marijuana use (T1). In addition, one parent of each respondent was asked about what they thought was their child’s past-year use. One year later (T2), investigators followed up with the same questions.

Researchers found that youth who were abstinent at T1 were significantly more likely to be smoking by T2 if their parents wrongly believed them to be. On the other hand, youth who were smoking at T1 were more likely to stop smoking by T2 if their parents wrongly believed that they hadn't been smoking. Interestingly, children who were using at T1 tended to increase their use by T2 if their parents had originally expressed belief that they were using marijuana at T1.

While the authors caution that "these results don't counsel a Pollyanna-like approach to child rearing," the do argue that the influence a parent can have on their children can be both "profound" and delivered in a host of subtle ways. "The lesson also counsels considerably greater communication between parents and their children about drug use," They write. Just be careful before jumping to any conclusions.

Is MMT Counseling Replaceable Too?

By now, we've all heard about the recent studies challenging the conventional wisdom on counseling in buprenorphine treatment. Now comes news about a new approach for methadone maintenance treatment, too - this one an even scarier prospect for fellow counselors. Authors of an in-press article in the Journal of Substance Abuse Treatment substituted 1/2 of the traditional counseling in an MMT clinic for a web-based behavioral intervention called the "Therapeutic Education System" (TES). The results showed significantly better outcomes (measured as % weeks of opioid abstinence) in the group randomized to reduced standard treatment plus TES, compared to the group who received only standard treatment.
Figure 2 from the study:


As demand for technology-based interventions grows, it's likely we'll continue to see treatment adjuncts like this one more and more often. What I'd like to know is how data like this will be viewed by the chorus of experts advocating for a change to the current MMT-Clinic system? Seems to me it would be welcome news.

Source: http://www.journalofsubstanceabusetreatment.com/article/S0740-5472(13)00200-6/abstract

Law Enforcement Views Opioid Overdose Training Favorably

As first responders, law enforcement officers are one of the most common groups of people to witness an opioid overdose. However, no one has ever asked the officers how they would view a training program to equip them to handle this type of situation - until now. A study out of Drug and Alcohol Dependence  indicates that many officers would welcome drug overdose prevention training and, in particular, naloxone/Narcan administration. It seems this study is welcome news to the growing chorus of overdose prevention advocates. As the body of evidence showing these efforts to be effective continues to grow, the importance of involving law enforcement in the discussion is obvious.

The abstract via Science Direct:

Abstract

Background

Law enforcement is often the first to respond to medical emergencies in the community, including overdose. Due to the nature of their job, officers have also witnessed first-hand the changing demographic of drug users and devastating effects on their community associated with the epidemic of nonmedical prescription opioid use in the United States. Despite this seminal role, little data exist on law enforcement attitudes toward overdose prevention and response.

Methods

We conducted key informant interviews as part of a 12-week Rapid Assessment and Response (RAR) process that aimed to better understand and prevent nonmedical prescription opioid use and overdose deaths in locations in Connecticut and Rhode Island experiencing overdose “outbreaks.” Interviews with 13 law enforcement officials across three study sites were analyzed to uncover themes on overdose prevention and naloxone.

Results

Findings indicated support for law enforcement involvement in overdose prevention. Hesitancy around naloxone administration by laypersons was evident. Interview themes highlighted officers’ feelings of futility and frustration with their current overdose response options, the lack of accessible local drug treatment, the cycle of addiction, and the pervasiveness of easily accessible prescription opioid medications in their communities. Overdose prevention and response, which for some officers included law enforcement-administered naloxone, were viewed as components of community policing and good police-community relations.

Conclusion

Emerging trends, such as existing law enforcement medical interventions and Good Samaritan Laws, suggest the need for broader law enforcement engagement around this pressing public health crisis, even in suburban and small town locations, to promote public safety.

Relapse Prevention Strategies and Anti-Relapse Medications

A recent commenter asked these questions:

Anonymous has left a new comment on your post "Is Maintenance the Best Therapy for Opioid Addicti...": 

Dr. Willenbring,

Would you agree that a person in recovery should have a solid relapse prevention plan in place regardless of the recovery path they choose. For example a person could choose abstinence-based recovery (AA/NA, CBT, counseling, etc.), Medication Management, or a combination of those, in whatever multitude of variations. Isn't it still imperative that they stay away from their former lifestyle as much as possible?

-Stay away from the places you obtained your drug of choice?
-Stay away from the places you used your drug of choice?
-Stay away from the people that provided your drug of choice?
-Stay away from the people you used with?

What are your thoughts regarding these and other common relapse prevention measures with regard any treatment/recovery option available? 

The simplest answer is that yes, a relapse prevention plan is essential to recovery from any SUD. The examples this reader gives are common-sense strategies designed to reduce exposure to cues that might trigger urges, craving, preoccupation and, most importantly, opportunity. An old saying in AA is, "If you hang around a barber shop long enough, sooner or later you're going to get a haircut." I like the CBT approach of "Recognize, Avoid, Cope." First, do what you can to Recognize higher-risk situations, such as a social event that involves drinking (for someone with alcohol use disorder,) or where you are likely to be stressed or sleep-deprived (you have to work long hours for some reason, or a close family member is seriously ill.) For many people, a trip out of town to a work meeting, or, often worse, their spouse is going to be out of town (when the cat's away...) are high risk. Recognizing allows you to plan your strategy to reduce your risk of a recurrence. 

Second, Avoid the high-risk situation if you can. If a social event is going to involve a lot of drinking or drug use, and it's an optional event, skip it. Why put yourself in that situation? Why stress about it? Besides, one of the first things most people realize is that being sober while the other people are intoxicated isn't any fun. Although they (and you, in the past) may think that they're witty, charming and sexy, the reality is anything but. Typically, intoxicated people are dull and sometimes obnoxious. Unfortunately, avoiding intoxicated people too often means that you have to develop new friends, and you may have to endure some lonely times as that develops. Community support groups such as AA can help by providing you with a built-in social system to bridge that gap, but there are many other opportunities: book clubs, hiking clubs, bicycling organizations, volunteering, spiritual or religious activities, among many others. Be creative!

Finally, if you can't avoid the higher risk situation, develop strategies to Cope with it before you get there. Take a supportive friend, or identify another non-user within the group. Plan an early exit if possible. Practice drink/drug refusal skills. Take an anti-relapse medication (ARM). Remember, no one has any right to know your personal business, including whether you decide to use intoxicants or not. Have one or two stock phrases that 1) don't give a lot of information but don't lie, and 2) don't invite further questions. For example: "Hey, what's up? What's with you not drinking any more? Too stuck up for your bros? Let my buy you a drink, come on!" "No thanks. I just don't like the way I feel when I drink," or "You know, these days it pays to stay sharp, and I get too fuzzy headed if I drink." I'm sure you can come up with others. If the other person persists, you might retort, "Does my not drinking make you uncomfortable? What's the problem?"

One more thing, though, is that I think it's time to give up the false "abstinence-based recovery" vs. "medication-assisted treatment" dichotomy. It's a remnant of 1955. Is someone taking insulin for diabetes on "medication-assisted therapy" versus someone who tries to manage it by lifestyle changes alone? Is someone taking an antipsychotic or mood stabilizer "not abstinent?" My patients struggle at least as much with having to take medications for arthritis, MS, or depression as they do with taking anti-relapse medications. How about ARMs like naltrexone, or disulfiram (Antabuse), or topiramate (Topamax)? If you take those, are you "abstinent?" What if, by trying to "be abstinent," you are a miserable wretch with a high relapse risk, while if you take a medication such as buprenorphine (Suboxone), you are a happy, productive person with a low relapse risk? Why is "being abstinent" automatically thought to be superior, better, and to reflect more positively on you? Is it because we "should" be able to "do it ourselves?" Is it because "God should be enough?" Is it because it shows we are stronger, morally superior, more capable? Why "should" we be "able to recover without medications"? Who says? On what basis? This one idea kills more people with SUDs than almost any other, and I mean that quite literally. Get over it. The brain is flesh and blood. It gets dysregulated just like any other organ and sometimes it is incapable of healing or fixing itself. Sometimes it needs help with medication, as well as social support, psychotherapy, spirituality, exercise, and other non-medication supports and treatments. So what? 

New Report Sheds Light on Adolescent Substance Use

In a new report by the Center for Behavioral Health Statistics and Quality (CBHSQ), a public health data wing of SAMHSA, we are shown the rates of adolescent substance use through the lens of an "average day". While the overall use of substances declined from 2008 - the previous time this data was compiled -, rates for treatment-seeking have remained stable and the numbers are still quite shocking.

Among the highlights (emphasis mine):  
According to combined 2010 and 2011 NSDUH data, in the past year, nearly 7 million adolescents aged 12 to 17 drank alcohol, nearly 5 million used an illicit drug, and 3 million smoked cigarettes.

In addition, on an average day during the past year, adolescents aged 12 to 17 used the following substances:
• 881,684 smoked cigarettes;
• 646,702 used marijuana;
• 457,672 drank alcohol;
• 38,540 used inhalants;
• 21,775 used hallucinogens;
• 6,747 used cocaine; and
• 5,602 used heroin.

The combined 2010 and 2011 NSDUH data indicate that:
• adolescents who used alcohol in the past month drank an average of 4.3 drinks per day on the days they drank, and
• adolescents who smoked cigarettes in the past month smoked an average of 3.9 cigarettes per day on the days they smoked.
Number of Adolescents Aged 12 to 17 Who Used Cigarettes, Alcohol, or Illicit Drugs for the First Time on an Average Day: 2010 and 2011 NSDUHs:

Source: 2010 and 2011 SAMHSA National Surveys on Drug Use and Health (NSDUHs).

Treatment Data -
TEDS reported that there were 132,850 admissions for adolescents aged 12 to 17 to substance abuse treatment programs in 2010 (TEDS data come primarily from facilities that receive some public funding). TEDS indicates that, on a typical day in 2010, adolescent admissions to treatment reported the following primary substances of abuse:

Source: http://www.samhsa.gov/data/2K13/CBHSQ128/sr128-typical-day-adolescents-2013.htm

The report also notes that in 2011 there were over 280,000 drug-related ED visits by adolescents, and on a typical day, alcohol - alone, or in combination with another drug - is most likely to be involved.

You can see the full report here.

Street-Obtained Buprenorphine: Drug of Abuse, or Proof of Limited Access?

In a recent article from the journal Addictive Behaviors, researchers discovered that buprenorphine was rarely, if ever, used by IV drug users to get high. In fact, the vast majority of people who reported acquiring the medication from an illicit source did so with the expressed purpose of avoiding withdrawal symptoms. This seems to contradict the common misconception that heroin users "get high" on Suboxone, therefore we should promote abstinence-based treatment. To the contrary, studies like this one could be interpreted as evidence there is not enough access to these medications - if there were, people wouldn't be forced to seek the drugs from street dealers or friends.
Interested to hear your take on the subject.

Below is a table from study. You can read the abstract here: http://www.sciencedirect.com/science/article/pii/S0306460313002232

Table 2. Knowledge and Use of Buprenorphine among 602 Injection Drug Users in Baltimore, Maryland.

	Buprenorphine N (%)	Suboxone N (%)	Subutex N (%)	Buprenex N (%)	Any N (%)
Ever heard of drug	537 (89)	355 (59)	52 (9)	68 (11)	541 (90)
Seen sold on street	430 (71)	232 (39)	13 (2)	18 (3)	446 (74)
Ever used	246 (41)	112 (19)	12 (2)	9 (1)	273 (45)
Usual sourcea Doctor Friend Street	124 (50) 32 (13) 55 (22)	71 (63) 8 (7) 18 (16)	9 (75) 1 (8) 1 (8)	6 (67) 2 (22) 0	152 (56) 35 (13) 64 (23)
Used last 3 months	73 (12)	50 (8)	4 (1)	1 (< 1)	95 (16)
Used last 30 days	47 (8)	35 (6)	3 (< 1)	1 (< 1)	69 (11)
year 1stused (median)	2005	2006	2006	2003	2005
Ever used to get high	26 (4)	10 (2)	2 (< 1)	1 (< 1)	30 (5)
Usual sourcea Doctor Friend Street	1 (4) 10 (38) 15 (58)	2 (20) 3 (30) 5 (50)	0 1 (50) 1 (50)	0 0 1 (100)	2 (7) 12 (40) 18 (60)
Used to get high in last 3 months	14 (2)	7 (1)	1 (< 1)	0	15 (2)
Used to get high in last 30 days	5 (1)	3 (< 1)	1 (< 1)	0	8 (1)
Used to get high more than once	20 (3)	8 (1)	1 (< 1)	1 (< 1)	23 (4)

Totals may not add to 100 because of missing, don’t know, and refused responses; Individuals may be represented more than once in the “Any” column if they reported on more than one drug.

a

Proportion of the usual source of drug is among those who had reported ever using/ever using to get high

Citation:

Genberg, B. et al. (2013). Prevalence and correlates of street-obtained buprenorphine use among current and former injectors in Baltimore, Maryland. Addictive Behaviors.