Tuesday, February 26, 2013

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:

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.

Thursday, February 21, 2013

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.

NIH Warns Of Major Drawbacks With Sequester

NIH Warns Of Major Drawbacks With Sequester

Feb 20, 2013

BETHESDA, Md. (WUSA9) -- The looming sequester may dramatically slow medical research.

Officials at the National Institutes of Health warn the budget cuts they face if the sequester is implemented will be devastating to new research.

NIH faces a possible 1.5 billion dollar cut, which would mean a 5 percent cut across the board for every program.

National Institutes of Health Director, Dr. Francis Collins, M.D., Ph.D. says, "Cuts will spell slower progress against our most common diseases, such as alzheimer's, cancer, AIDS, diabetes, and heart disease."

Dr. Collins says cuts may also mean a delay in creating the next vaccine for influenza.

Senator Barbara A. Mikulski (D-Md.) toured NIH Wednesday afternoon.  She warns of the direct impact the research cuts may have in her home state.

Sen. Mikulski says, "It will be an impact on 15-thousand Marylanders, who work either at NIH or who benefit from the research funding at other Maryland institutions, whether it is Johns Hopkins, the University of Maryland and nearby institutes."

The Chairwoman of the Senate Appropriations Committee warns if action is not taken soon, we will be hurting ourselves as a nation.

Sen. Mikulski says, "We talk a lot about threats to the United States, we fear foreign predators and terrorism.  We fear foreign competition, 'oh, what are the chinese doing?', but what we are about to inflict upon us is a self-inflicted wound."

The deadline to end the federal fiscal standoff to avoid the sequester cuts is March 1st.

Smoke Free Laws Reduce Hospitalizations & Deaths

In a recent meta-analysis, Tan and Glanz compared rates of hospitalization and death due to cardiovascular disease, stroke and respiratory across communities with different levels of smoke-free laws (Tan, C. E., & Glantz, S. A. (2012). Association between smoke-free legislation and hospitalizations for cardiac, cerebrovascular, and respiratory diseases. Circulation126(18), 2177-2183.) They combined the results of 43 studies that examined rates a median of 30 months before enactment of the laws and then compared them to rates over a median of 24 months after enactment. The results are shown in the graph below. Relative risk refers to the likelihood of an event. A RR < 1 indicates that an event is less likely compared to baseline (before enactment.) As is evident from the graph, there is a consistent and significant reduction in hospitalization and death rates for these diseases as a result of smoke free laws, and the more extensive the restrictions (restaurants and bars as well as other workplaces) the larger the effect. 

Source: BASIS, Feb 2013

Tuesday, February 19, 2013

What's Wrong With Addiction Treatment in America?

Since Jane Brody quoted me in her column in the New York Times, I've been inundated with calls, emails and other inquiries. Here are some themes, impressions and stories that help illustrate the gaps and barriers to receiving up to date, consumer-friendly, addiction treatment.

1. "He's been through treatment program after treatment program. None of them worked! And we still don't really feel he's had a good evaluation or any continuity of treatment."

This has been a very consistent experience reported by families of someone with an addictive disorder. There is a profound sense of being out there alone, in sharp contrast to having a relative with colon cancer. There is a great sense of fragmentation of care, as well as inconsistent opinions and recommendations. Because "programs" are arbitrarily time-limited, they have no ongoing responsibility of the care of their patients, unlike other medical specialities. How would you like it if your oncologist only saw you for 8 weeks, and then treatment ended? And once "the program" has ended, there is no care, no one to help you manage an out-of-control situation. And it's worse when "the program" is in a distant location. What is learned in an artificial, low-stress environment and now access to alcohol or drugs does not translate well when you get back home. The stacks of bills, the crying baby, the leaking roof, and the liquor store around the corner make it pretty difficult. Addiction is best treated like other disorders, with people living in their own communities, learning how to stay sober there, with everything that's going on.

2. "I (or my loved one) is in (or about to begin) a treatment program for drug X. But they don't seem to have the kind of treatments you talk about. Where can I get that kind of treatment?"

Many people I talk to are trying to figure out what type of treatment or treatment facility is going to be best for their particular problem. And they don't know where to get reliable information. Much of the information, practices and pronouncements are not supported by scientific studies, but that doesn't stop treatment programs from asserting them anyway. So the marketplace is confusing, not unlike walking through a market with each vendor hawking her wares. Testimonials and outrageous claims abound! Literally fantastic outcomes are assured! That's right! Step right up and submit your payment now! You won't be sorry! We promised 100% success if you do exactly as we tell you and you really want to succeed!

(So if you fail... well...it's your fault. Sorry.)

We need an ethic of professionalism in addiction treatment that at least reduces that type of selling of services. We need to embrace an ethic of adhering to scientific findings, and changing our beliefs when the facts change. We need to foster the humility to care, even though our treatments are only partially effective, and in some cases totally ineffective. We can't abandon our patients because we cannot change the course of their illness. Do you really think they want to die? They don't! But they and we are helpless in the face of their brain dysregulation. As is true with so many human ailments: cancer, heart disease, stroke, diabetes, depression, arthritis, multiple sclerosis. As our understanding of these diseases advances, through scientific research, our tools for preventing and treating them will improve. But it will cost a lot and take a long time. But our only hope is to support it. Research on addictions and their treatment.

Friday, February 8, 2013


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Thursday, February 7, 2013

The Need for Something New in Addiction Treatment

It will come as no surprise to regular readers of this blog that there is a need for new approaches to treating addictions. In particular, people with substance use disorders (SUDs) and their families need access to current, scientifically based practice and greater consumer choice of treatment modalities. Today, I've been receiving a resounding validation of this fact from the response to Jane Brody's column for the New York Times three days ago. In the last two days, I've received almost 30 calls from all parts of the US from people who are interested, if not desperate, for something new, either for themselves or for a relative who is suffering from this disease. One person called me from China!

The main focus of Jane's column was a terrific new book by Anne Fletcher titled Inside Rehab. It's already #1 on the Amazon best-seller list for alcoholism recovery books, and it's been receiving widespread coverage that is overwhelmingly positive. And this is before it's actually available to the public! (Full disclosure: I was one of many experts in the field whom Anne used as resources for her book, and since she also lives in MN, we have become friends.) Jane, with whom I had previously talked with when I was at NIH, called to talk about the book and the state of the treatment field today, and this conversation figured fairly prominently in the column.

Of course, I'm grateful for the coverage of my efforts to change the treatment system and of Alltyr, but I'm saddened by the similarity of the stories I hear time and again. Mostly, it's about going through rehab over and over, almost all of them 12-step oriented, cookie-cutter programs that show films, give lectures, send clients to 12-step groups and use low-quality group  counseling. Clients of these programs are told that the program always works if they accept it, that they must not be motivated or willing, or that they are in denial, and so forth. Families often report nearly bankrupting themselves paying for expensive residential rehab programs that don't work. In too many cases, 12-step abstinence based treatment is used for opioid addiction even though all the evidence shows it doesn't work. Almost always, these are stories about repeated episodes of time-limited low quality treatment without continuity over time, attention to co-existing psychiatric and medical disorders, or meaningful family involvement. There is very little consumer choice or even information about the various options that have been shown to work. Little has changed from when I was at NIH, and frequently gave talks and interviews that were covered in the media. I would always receive calls and emails there asking how to find evidence-based treatment.

At the same time, I am heartened by this latest demonstration of how pressing the need is, how many people are desperately wanting something new. And it inspires me anew to keep pressing forward on a mission that at times feels overwhelming, where there are so many barriers and where progress is often difficult to see. The palpable pain and suffering I hear remind me why I'm doing this. And I know I am not alone, and as more people join the effort the momentum will continue to build.


Tuesday, February 5, 2013

Why SBIRT Is Dead in the Water

In the latest issue of Health Affairs, Grace Lin et al. describe an effort to introduce decision-making aids to facilitate shared decision-making regarding back pain and colo-rectal cancer screening. Essentially, nothing changed, in spite of making the aids easily accessible, conducting training sessions, and so on. What's important is the authors' conclusion that "The results of focus groups, ethnographic field notes, and surveys suggest that major structural and cultural changes in health care practice and policy are necessary to achieve the levels of use of decision aids and shared decision making in routine practice envisioned in current policy."

Their experience mirrors my own in trying for over 20 years to get substance use addressed in primary care. Most recently, I have two separate but relate experiences here in Minnesota where I essentially ran up against a brick wall. Why? First, primary care doctors are besieged by quality improvement initiatives aimed at reducing variability of practice and improving outcomes for depression, diabetes, heart failure, back pain, asthma, hypertension and many others. These are typically mandated from the top of health care organizations (remember that most primary care physicians are now employees of a large health care organization (HCO.) By attempting to implement not only SBIRT but treatment of alcohol dependence in primary care (I call it Screening, Evaluation and Treatment, or SET, but another term could be SBIRT+) by asking physicians to voluntarily take it on was a non-starter. Typical comments were "It's a good idea but we can't take on anything more right now," or "We're having enough trouble trying to get this clinic's operations running smoothly, and until we do, it wouldn't work." 

A second factor is one of priorities. I have argued for years that universal SBIRT is not cost-effective, but should be more targeted. Related to this is a crucial question: since visit length is not going to increase, what do you want the doctor to stop doing so they can do these new things, like shared decision-making and SBIRT+?  In other words, in a typical visit, the patient has certain expectations about why they are there and what they want, and most patients have multiple chronic diseases like obesity, arthritis, hypertension and diabetes. Oh, and of course they smoke. So, do you want the doctor to not address the patient's presenting complaint (e.g., arthritis pain, insomnia), or not address their hypertensive control so they have the time to spend on shared decision-making for back pain, or to conduct SBIRT+? How do you think patients would feel about this? This applies especially to SBIRT, because it is attempting to identify a problem they patient is unaware of and not concerned about. "Doctor, I came here because my right knee is all swollen and painful, and you want to take 2 out of the 8 minutes you spend with me asking me about drinking!?"

So have come to a similar conclusion: until the medical home concept is fully implemented, with team care that includes a focus on health behaviors of all types, SBIRT or SET are DOA. My most recent attempt has been to start with something that has the attention of every primary care doctor: pain management. I'm providing training to all the primary care doctors in Allina Health in management of chronic pain, and the response so far has been overwhelmingly positive. I'm hoping that by getting to know so many primary care physicians in this HCO, they will be more receptive to introducing SET. However, it has also become clear that the only way this will occur is if the top leadership of the organization decides that SET is important enough to get it into the queue of quality improvement projects, and thus mandate its implementation. 

Primary care, even with the medical home, is not going to be all things to all people, and choices are going to have to be made about what is important enough to include and what might ideally be included but which doesn't make the cut because it is not cost-effective or clinically significant enough.

Besides, if we were serious about addressing the heavy disease burden associated with heavy drinking, we would triple the taxes on alcoholic beverages. That would have a greater public health impact than implementing SBIRT in every primary care practice in the country. 


Here's the abstract:

An Effort To Spread Decision Aids In Five California Primary Care Practices Yielded Low Distribution, Highlighting Hurdles

  1. Dominick L. Frosch7,*
+Author Affiliations
  1. 1Grace A. Lin is an assistant professor in the Division of General Internal Medicine and at the Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco.
  2. 2Meghan Halley is an assistant research anthropologist in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute, in California.
  3. 3Katharine A.S. Rendle is a research associate in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute.
  4. 4Caroline Tietbohl is a research assistant in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute.
  5. 5Suepattra G. May is an assistant research anthropologist in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute.
  6. 6Laurel Trujillo is medical director of quality at the Palo Alto Foundation Medical Group and chair of the Quality Improvement Steering Committee, both at the Palo Alto Medical Foundation, in Los Altos, California.
  7. 7Dominick L. Frosch (dominick.frosch@moore.org) is an associate adjunct professor in the Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California, Los Angeles.
  1. *Corresponding author


Despite the proven efficacy of decision aids as interventions for increasing patient engagement and facilitating shared decision making, they are not used routinely in clinical care. Findings from a project designed to achieve such integration, conducted at five primary care practices in 2010–12, document low rates of distribution of decision aids to eligible patients due for colorectal cancer screening (9.3 percent) and experiencing back pain (10.7 percent). There were also no lasting increases in distribution rates in response to training sessions and other promotional activities for physicians and clinic staff. The results of focus groups, ethnographic field notes, and surveys suggest that major structural and cultural changes in health care practice and policy are necessary to achieve the levels of use of decision aids and shared decision making in routine practice envisioned in current policy. Among these changes are ongoing incentives for use, physician training, and a team-based practice model in which all care team members bear formal responsibility for the use of decision aids in routine primary care.