tag:blogger.com,1999:blog-61549231218573893732024-03-13T12:14:47.266-05:00Substance MattersThe internet's voice for professional, scientifically-based treatment of alcohol and other substance use disorders.Mark Willenbring, MDhttp://www.blogger.com/profile/10556707753571367243noreply@blogger.comBlogger205125tag:blogger.com,1999:blog-6154923121857389373.post-24382513277508807612019-03-07T08:02:00.001-06:002019-03-07T08:02:41.164-06:00Deaths of Despair at Highest Levels Ever!From the Well Being Trust:<br />
<br />
<div class="danger-zone">
<span class="big-cap-wrap"><span class="big-cap">F</span></span>ar
too many Americans are dying from preventable causes, and each time we
make progress it seems like new problems appear. Take the case of opioid
overdoses. As we are beginning to get a handle on misuse of
prescription opioids, fentanyl and synthetic opioids have come to the
fore. Two decades ago, they were linked to fewer than 1,000 deaths each
year. In 2017, fentanyl and synthetic opioids killed more than 28,000
Americans.</div>
<div class="danger-zone">
The emphasis on opioids is appropriate, but too
narrow. The underlying conditions that often lead to drug misuse can
also lead to alcohol misuse, loneliness, and despair. Even as America is
experiencing surging rates of drug misuse, the nation is also
witnessing an unprecedented rate of suicide deaths, which rose 6 percent
between 2016 and 2017, and with alarming increases among children and
adolescents.</div>
<div class="danger-zone">
Overall, more than 150,000 Americans — the most
ever — died from alcohol and drug-induced fatalities and suicide in
2017. <span style="background-color: yellow;">That’s more than twice as many as in 1999, according to a <a href="http://wellbeingtrust.org/wp-content/uploads/2019/03/FINAL-WBT-TFAH-2019-PainNationUpdateBrief-.pdf" rel="noopener" target="_blank">new analysis</a> released on Tuesday by our organizations, Well Being Trust and Trust for America’s Health.</span></div>
<div class="danger-zone">
To truly tackle complex, deeply rooted societal
problems like these, we need to transform fragmented and disjointed
community systems. Deaths from substance misuse and suicide are symptoms
of broader problems. If we treat only the symptoms, more and more
people will be at risk and die needlessly.</div>
<aside class="read-more standard"><div class="read-more-text">
<div class="read-more-label">
<a href="https://www.statnews.com/2017/11/28/resilience-deaths-despair-opioids-suicide/">
Related:
</a>
</div>
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<a data-post-id="300901" href="https://www.statnews.com/2017/11/28/resilience-deaths-despair-opioids-suicide/">
A national resilience strategy can help prevent deaths from despair </a>
</div>
</div>
</aside>To address the underlying causes, we need a comprehensive
approach that includes increasing funding and support for programs that
reduce risk factors for despair and promote resilience in children,
families, and communities. Exposure to trauma and adverse life
experiences at young ages <a href="https://www.samhsa.gov/capt/sites/default/files/resources/aces-behavioral-health-problems.pdf" rel="noopener" target="_blank">increases the potential</a>
for substance misuse and suicide. Programs that reduce community
violence; address poverty and discrimination; create safe, supportive
schools and quality learning experiences; and promote access to secure
housing and employment opportunities can decrease adverse experiences
and build resilience.<br />
For example, the <a href="https://www.nursefamilypartnership.org/" rel="noopener" target="_blank">Nurse-Family Partnership</a>
works with young, low-income women who are pregnant for the first time.
A public health nurse meets with the mother from pregnancy until the
child turns 2, establishing a trusted relationship with both. The home
visits connect first-time mothers with the care and support they need to
ensure a healthy pregnancy and birth. The model has been shown to have
dramatic benefits to society. For instance, when Medicaid pays for
Nurse-Family Partnership services, the federal government gets a <a href="https://www.nursefamilypartnership.org/wp-content/uploads/2017/07/NFP_Benefit_Cost.pdf" rel="noopener" target="_blank">54 percent return on its investment</a>.<br />
Along that line, the nation should expand substance misuse prevention
and mental health programs in schools by increasing the number of
schools that get training for, can screen for, and can respond to
childhood trauma. Schools should also be supported in scaling up
evidence-based life- and coping-skills programs like the <a href="http://www.goodbehaviorgame.org/" rel="noopener" target="_blank">Good Behavior Game</a>, and increasing the availability of culturally appropriate mental health and other services.<br />
Schools should also work with other community agencies to assist the
families of the children who have experienced trauma. Successful school <a href="https://www.samhsa.gov/sites/default/files/cost-benefits-prevention.pdf" rel="noopener" target="_blank">substance misuse prevention programs</a>
return $3.80 to $34 for every $1 invested; social-emotional learning
programs provide an $11 for $1 return; and school violence prevention
programs (including suicide) have a $15 to $81 return.<br />
The nation will see results only if it addresses the need for a
multigenerational response that includes substance use disorder
treatment for parents and additional support for all caregivers while
also expanding resources for the foster care system.<br />
Model programs have been effective in helping mothers achieve
sobriety, reducing state custody placement of children by half and
producing a strong return on investment. <a href="https://cdn2.hubspot.net/hubfs/4132958/bfe1ed_3fee1ac1253f429f99496f2079d0a205.pdf" rel="noopener" target="_blank">Sobriety Treatment and Recovery Teams</a>
(START), for example, is a Kentucky-based program for families with
parental substance use disorders and issues of child abuse and/or
neglect. It helps parents achieve sobriety and, when possible, keeps
children safely with their parents. Mothers who participated in START
achieved sobriety at nearly twice the rate of those not in the program
and children in START families were half as likely to be placed in state
custody. For every dollar spent on START, Kentucky avoided spending
$2.22 on foster care.Mark Willenbring, MDhttp://www.blogger.com/profile/10556707753571367243noreply@blogger.com0tag:blogger.com,1999:blog-6154923121857389373.post-86214614685140096202019-03-07T07:55:00.002-06:002019-03-07T07:55:39.137-06:00Doctors: CDC Guidelines Are Hurting Pain PatientsFrom the Washington Post, March 6, 2019:<br />
<br />
<h1>
Health-care providers say CDC’s opioid guidelines are harming pain patients</h1>
<div class="byline">
By <a href="https://www.washingtonpost.com/people/lenny-bernstein/">Lenny Bernstein</a></div>
<div class="date">
March 6, 2019 at 8:20 PM</div>
<div class="text">
More
than 300 health-care experts told the Centers for Disease Control and
Prevention Wednesday that the agency’s landmark guidelines for the use
of opioids against chronic pain are harming patients who suffer from
long-term pain and benefit from the prescription narcotics.</div>
<div class="text">
The health-care providers, including three
former U.S. drug czars, said the CDC recommendation of a daily numerical
threshold for opioid use has led insurers to refuse reimbursement,
pharmacies to erect obstacles to obtaining drugs and risks for doctors
who want to give out more.</div>
<div class="text">
“Taken in combination,
these actions have led many health care providers to perceive a
significant category of vulnerable patients as institutional and
professional liabilities to be contained or eliminated, rather than as
people needing care,” they said in a letter to the agency.</div>
<div class="text">
They said patients have endured unnecessary pain, turned to illegal drugs and even committed suicide.</div>
<div class="text">
The
role of opioids for chronic pain has been one of the most contested
aspects of the nationwide crackdown on narcotic prescribing. <a href="https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fmmwr%2Fvolumes%2F65%2Frr%2Frr6501e1er.htm">The CDC guidelines, issued in 2016,</a> assert there is little evidence for the use of opioids against pain beyond 12 weeks.</div>
<div class="text">
But
many patients have claimed that long-term use of the drugs is all that
stands between them and unrelenting pain, and that they can take the
medication without becoming dependent or addicted. The accumulation of
that anecdotal evidence led to the experts, who call themselves Health
Professionals for Patients in Pain, to write to the CDC.</div>
<div class="text">
The CDC did not respond to a request for comment Wednesday.</div>
<div class="text">
The National Institutes of Health is studying the issue as part of its <a href="https://www.nih.gov/research-training/medical-research-initiatives/heal-initiative">Helping to End Addiction Long-term Initiative </a>and
last week the Food and Drug Administration ordered drug companies to
examine whether opioids are effective against chronic pain.</div>
<div class="text">
In the meantime, the number of opioid prescriptions issued annually has fallen sharply, from a <a href="https://www.cdc.gov/drugoverdose/maps/rxrate-maps.html">peak of more than 255 million in 2012 to 191 million in 2017,</a> according to the CDC. Many states have enacted limits on opioid prescribing.</div>
<div class="text">
Still, 47,600 people died of opioid overdoses in 2017, <a href="https://www.washingtonpost.com/national/health-science/us-life-expectancy-declines-again-a-dismal-trend-not-seen-since-world-war-i/2018/11/28/ae58bc8c-f28c-11e8-bc79-68604ed88993_story.html?utm_term=.56c4e82c0d43">more than 17,000 of them from legal painkillers </a>such as oxycodone, hydrocodone and methadone.</div>
<div class="text">
The
CDC guidelines suggest 90 milligrams of morphine or their equivalent as
a daily ceiling for opioid use against pain. But the letter said
insurers, regulators and others have used the figure “as both a
professional standard and a threshold for professional suspicion.”</div>
<div class="text">
The
group called on the CDC to investigate the damage that the limit may be
doing to patients and to clarify the guidelines, especially in regard
to discontinuing patients’ opioid use.</div>
<div class="text">
</div>
Mark Willenbring, MDhttp://www.blogger.com/profile/10556707753571367243noreply@blogger.com0tag:blogger.com,1999:blog-6154923121857389373.post-91446198345065678962019-02-13T09:20:00.001-06:002019-02-13T09:20:34.019-06:00New USPTF Guidelines on Prevention of Perinatal Depression<span style="font-size: small;">The US Prevention Task Force has issued a new guideline for prevention of perinatal depression, and it's surprising how easy it is. A few sessions of CBT or interpersonal therapy, usually initiated in the second trimester, significantly reduced the incidence of perinatal depression. The Task Force went on to stated that it had moderate confidence that if this were widely implemented, it could provide a substantial public benefit. It's important the this was done preventively, before depression was established. It should be done in high risk groups: women with a history of depression, subsyndromal symptoms of depression, and women in certain groups. These include low socio-economic status, adolescent or single parenthood, recent partner violence, elevated levels of anxiety or a history of negative life events. Insufficient or mixed evidence was found for other potential interventions, including exercise, dietary supplements, pharmacotherapy, and health systems interventions. The group concluded that physicians should provide counseling or refer pregnant women in these high-risk groups for counseling.</span>Mark Willenbring, MDhttp://www.blogger.com/profile/10556707753571367243noreply@blogger.com0tag:blogger.com,1999:blog-6154923121857389373.post-82017529738101079622019-01-22T14:35:00.001-06:002019-02-03T12:53:09.389-06:00Small Study Suggests That Naltrexone Blockade Dose Not Block Ketamine Response<br />
A small study at Yale demonstrated that treatment with naltrexone, an opioid-blocking agent used to treat alcohol use disorder, does not interfere with an antidepressant response to ketamine. Yoon, et al. followed 5 subjects being treated with naltrexone as they received ketamine infusions for depression. Three of five subjects showed remission, and 5/5 showed response. (See figure for details.)<br />
<br />
This study contradicts an earlier one that showed no ketamine response for people under naltrexone blockage. More to come, I'm sure.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiPRGTu5MPNdoMWorJoTR_V2KWrfiTHpHTVjapXT5ipr4Yzkq-50oceS4U_GV5HN4Ha6xH1d-MDYfnWXsqMbx2ZE-1u7q1H3uhrI4wMyfACBzUPNvJMaodAa3xFTVw15SrJk2zX7qj8hyphenhyphenE/s1600/m_yld180009f1.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="475" data-original-width="810" height="374" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiPRGTu5MPNdoMWorJoTR_V2KWrfiTHpHTVjapXT5ipr4Yzkq-50oceS4U_GV5HN4Ha6xH1d-MDYfnWXsqMbx2ZE-1u7q1H3uhrI4wMyfACBzUPNvJMaodAa3xFTVw15SrJk2zX7qj8hyphenhyphenE/s640/m_yld180009f1.png" width="640" /></a></div>
<br />Mark Willenbring, MDhttp://www.blogger.com/profile/10556707753571367243noreply@blogger.com0tag:blogger.com,1999:blog-6154923121857389373.post-64456796361468645152019-01-22T14:19:00.001-06:002019-01-22T14:19:06.303-06:00Recent data on opioids from the CDC<br />
<br />
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<b>Study Shows Urban-Rural Split on Opioid Prescribing Rates; Putting the Numbers to Fentanyl Deaths in NYC</b><o:p></o:p></div>
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A new study just released from the CDC confirmed findings
that opioid prescriptions were nearly twice as likely to occur among rural residents,
compared to central metro areas. (García MC, Heilig CM, Lee SH, et al. Opioid
Prescribing Rates in Nonmetropolitan and Metropolitan Counties Among Primary
Care Providers Using an Electronic Health Record System — United States,
2014–2017. MMWR Morb Mortal Wkly Rep 2019;68:25–30. DOI: <a href="http://dx.doi.org/10.15585/mmwr.mm6802a1" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; orphans: 2; text-align: start; widows: 2; word-spacing: 0px;" target="_self"><span style="color: windowtext; text-decoration: none; text-underline: none;">http://dx.doi.org/10.15585/mmwr.mm6802a1</span></a><span style="-webkit-text-stroke-width: 0px; float: none; font-variant-caps: normal; font-variant-ligatures: normal; orphans: 2; text-align: start; text-decoration-color: initial; text-decoration-style: initial; widows: 2; word-spacing: 0px;">.</span>) <span style="mso-spacerun: yes;"> </span>The study analyzed data from the AthenaHealth electronic
medical record system. This cloud based EMR is used by about 100,000 providers
serving 86 million patients. De-identified data were used for the study.<o:p></o:p></div>
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<div class="MsoNormal">
The first take-home message is that there is a lot of opioid
prescriptions flying out of rural providers’ offices. <b>At the last data point in
2017, about 9% of patients in non-core and micropolitan areas, whereas only 5% received
a prescription in central metropolitan areas. </b><o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
A second major finding was that the percentage of patients
in metro areas remained remarkably stable, at 5%, whereas in rural areas, it
got as high as 10.3%, before starting to drop since 2016. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<o:p></o:p></div>
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The authors correctly point out that there are many possible
reasons for such a finding. However, the split between rural and urban areas is
solid.</div>
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<br /></div>
<div class="MsoNormal">
In another article from the same issue (Colon-Berezin C,
Nolan ML, Blachman-Forshay J, Paone D. Overdose Deaths Involving Fentanyl and
Fentanyl Analogs — New York City, 2000–2017. MMWR Morb Mortal Wkly Rep
2019;68:37–40. DOI: <a href="http://dx.doi.org/10.15585/mmwr.mm6802a3" style="-webkit-text-stroke-width: 0px; font-variant-caps: normal; font-variant-ligatures: normal; orphans: 2; text-align: start; widows: 2; word-spacing: 0px;" target="_self"><span style="color: windowtext; text-decoration: none; text-underline: none;">http://dx.doi.org/10.15585/mmwr.mm6802a3</span></a><span style="-webkit-text-stroke-width: 0px; float: none; font-variant-caps: normal; font-variant-ligatures: normal; orphans: 2; text-align: start; text-decoration-color: initial; text-decoration-style: initial; widows: 2; word-spacing: 0px;">,) deaths from
fentanyl overdose increased dramatically.<b> In 2012, about 2% of deaths involved
fentanyl, but by 2017, fentanyl involvement was present in 57% of overdose
deaths in New York City. </b><o:p></o:p></span></div>
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<br /></div>
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<o:p>The CDC's Morbidity and Mortality Weekly is available to all <a href="https://www.cdc.gov/mmwr/index.html" target="_blank"><i>here</i></a>. </o:p></div>
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Mark Willenbring, MDhttp://www.blogger.com/profile/10556707753571367243noreply@blogger.com0tag:blogger.com,1999:blog-6154923121857389373.post-55436847836944709442018-07-20T16:59:00.003-05:002018-07-20T16:59:30.293-05:00Good New About American Teens!<div class="MsoNormal" style="background-color: white; color: #212121; font-family: sans-serif;">
HealthDay<u></u><u></u></div>
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More U.S. Teens Shunning Drugs, Alcohol<u></u><u></u></div>
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By Alan Mozes<u></u><u></u></div>
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HealthDay Reporter<u></u><u></u></div>
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THURSDAY, July 19, 2018 (HealthDay News) -- Over the last four decades, more American teenagers have decided to say no to drugs and alcohol, a new report shows.<u></u><u></u></div>
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"There has been a steady increase in the proportion of students graduating high school who report never having tried alcohol, marijuana, tobacco or any other drugs," said study author Dr. Sharon Levy. She directs the adolescent substance use and addiction program at Boston Children's Hospital.<u></u><u></u></div>
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For example, while about 5 percent of high school seniors had embraced abstinence in 1976, that figure had risen to 25 percent in 2014, according to the most recent poll of nearly 12,000 students.<u></u><u></u></div>
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Surveys conducted among 8th and 10th graders between 1991 and 2014 unearthed a similar trend, with abstinence jumping from roughly 10 percent to almost 40 percent among the former, and from 25 percent to more than 60 percent among the latter.<u></u><u></u></div>
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There was also a jump in total abstinence during the month leading up to each survey, rising from just over 20 percent among high school seniors in 1976 to more than 50 percent by 2014. Among 8th graders, that jump was from about 50 to about 65 percent, while among 10th graders month-long abstinence rose from about 65 to roughly 85 percent, the findings showed.<u></u><u></u></div>
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Levy said the downward trends didn't catch her off-guard, even if "the findings may surprise people because we constantly hear bad news about drug use and the opioid epidemic."<u></u><u></u></div>
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She explained that both drinking and smoking -- the number one and number three most common substance use habits -- have been sliding in popularity across the board for a while now, even though pot use has held steady.<u></u><u></u></div>
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But why? That remains "the million dollar question," said Levy, "and for sure it doesn't have one simple answer."<u></u><u></u></div>
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Overall, she credited public health efforts for giving rise to a new cultural climate that encourages teens to shun substance use because it's dangerous and unhealthy, rather than because it's immoral or forbidden.<u></u><u></u></div>
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Dr. Eric Sigel, an adolescent medicine specialist at Children's Hospital Colorado in Aurora, said the results of those efforts are "encouraging."<u></u><u></u></div>
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Sigel, who was not part of the study team, attributed the trend to successful grassroots campaigns such as Mothers Against Drunk Driving (MADD), the increased availability of mental health and substance use programs, better parental role-modeling and an emphasis on the harsh health risks posed, particularly by cigarettes.<u></u><u></u></div>
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Still, Levy warned that the good news "is quite precarious."<u></u><u></u></div>
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For example, "while fewer teens overall are using substances, those who do face a landscape of more dangerous substances [like opioids] compared to their parents' generation," Levy said.<u></u><u></u></div>
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Investigators also found that white and Hispanic teens were less likely to choose abstinence, compared with their black peers. And because girls are more likely than boys to "misuse" prescription drugs -- particularly pain medications -- they were also less likely to be fully abstinent, despite less frequent alcohol, marijuana and tobacco use.<u></u><u></u></div>
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"This is a good reminder that parents, primary care providers and other trusted adults should be talking to kids about avoiding prescription medications, knowing how addictive they can be," Levy said.<u></u><u></u></div>
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What's more, she stressed that "there are always lurking threats to our progress." In particular, Levy pointed to the soaring popularity of e-cigarettes and the steadfast appeal of marijuana, both of which are increasingly perceived as safe.<u></u><u></u></div>
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Those threats were also highlighted by Sigel.<u></u><u></u></div>
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"Society has not as yet focused those [education] efforts on marijuana being detrimental to youth," he said. "Nor have we had the opportunity to combat the whole vaping/electronic use of tobacco products."<u></u><u></u></div>
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Both habits are on the rise, Sigel said, a "foreboding" development that "could influence these [abstinence] trends for years to come."<u></u><u></u></div>
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The study findings were published online July 19 in the journal Pediatrics. <a data-saferedirecturl="https://www.google.com/url?q=http://pediatrics.aappublications.org/content/early/2018/07/17/peds.2017-3498&source=gmail&ust=1532210086931000&usg=AFQjCNHVVDQP6Q5mDIjc0OQcW_CK0Ax2Jw" href="http://pediatrics.aappublications.org/content/early/2018/07/17/peds.2017-3498" style="color: #7e57c2; position: relative; z-index: 0;" target="_blank">http://pediatrics.<wbr></wbr>aappublications.org/content/<wbr></wbr>early/2018/07/17/peds.2017-<wbr></wbr>3498</a><u></u><u></u></div>
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More information<u></u><u></u></div>
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<br /></div>
<div class="MsoNormal" style="background-color: white; color: #212121; font-family: sans-serif;">
There's more on substance use and teens at the U.S. National Institute on Drug Abuse.<u></u><u></u></div>
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<br /></div>
<div class="MsoNormal" style="background-color: white; color: #212121; font-family: sans-serif;">
SOURCES: Sharon Levy, M.D., MPH, director, adolescent substance use and addiction program, division of developmental medicine, Boston Children's Hospital; Eric Sigel, M.D., adolescent medicine specialist, Children's Hospital Colorado, Aurora; July 19, 2018, Pediatrics, online</div>
Mark Willenbring, MDhttp://www.blogger.com/profile/10556707753571367243noreply@blogger.com0tag:blogger.com,1999:blog-6154923121857389373.post-4035593097092032412018-06-15T14:27:00.003-05:002018-06-15T14:27:51.922-05:00Opening in Los Angeles!Opening in California!<br />
<br />
I’m pleased to announce the opening of Alltyr Addiction and Mental Health Services in Los Angeles, CA! In order to establish a footprint there, we’ve rented an office at 10886 Wilshire Blvd, Los Angeles, CA 90024. It’s on the corner of Wilshire and Westwood, near UCLA.<br />
<br />
I’ll be coming out for the first time next week. I’ll be arriving Thursday night, and I’ll be in the office all day Friday and possibly Sat AM. Phone number is the same. I’ll be out monthly at first, and do the rest via telehealth. As business picks up, I’ll be coming out more often and/or for longer time periods.<br />
<br />
I’m really looking forward to bringing Alltyr’s brand of 21st Century addiction and mental health treatment to California! <br />
<div>
<br /></div>
<div>
Mark</div>
Mark Willenbring, MDhttp://www.blogger.com/profile/10556707753571367243noreply@blogger.com0tag:blogger.com,1999:blog-6154923121857389373.post-80293254937830325082018-03-21T12:13:00.002-05:002018-03-21T12:13:17.886-05:00More Evidence Chantix May Reduce Heavy Drinking(*)<div>
<a href="https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2665215?redirect=true" target="_blank">A newly published study</a> suggests varenicline (Chantix) may have role in the treatment of co-occurring alcohol use disorder and smoking. Results from the Phase 2, randomized placebo-controlled trial, published in last month's JAMA Psychiatry, showed a reduction in the percentage of heavy drinking days among some of its participants. These results, however, came with a big asterisk: the improvements were only seen among the men enrolled in the study, while the women in the placebo group showed more improvement than those in the medication group.<br />
<br />
Chantix has been FDA-approved for smoking cessation since 2006. As a partial nicotinic acetylcholine receptor agonist, it has been called the "Suboxone of nicotine addiction." As researchers gained insights into the converging role this receptor system plays in both smoking and alcohol reward, the idea that it could have value in alcohol use disorder (AUD) treatment gained momentum. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3914416/" target="_blank">Preclinical studies in 2007, 2009, and 2011</a> showed some promising results, indicating rodents taking the medicine drank less alcohol than those who weren't. This led to several small human trials of Chantix for heavy drinking, though with mixed results. The February study was the first to show such divergent results between the two genders, and it is unclear why men fared so much better than the women enrolled in the study.<br />
<br />
Nevertheless, these results contribute a little more data to the search for new addiction medications and suggest prescribers may want to consider Chantix for their male patients who both smoke and drink heavily. Here at Alltyr Clinic, we have seen some of our AUD patients respond quite well to Chantix. Since our clinicians routinely screen our patients who smoke for their desire to quit, it has been a logical option to consider as a firstline treatment. Despite the less-than-blockbuster results of this study, we are glad to hear about any new research on potential medication options.</div>
<div>
<br /></div>
<div>
See the study here:<br />
<a href="https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2665215?redirect=true">https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2665215?redirect=true</a><br />
<br />
And the earlier trial can be seen here:<br />
<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3914416/" target="_blank">https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3914416/ </a></div>
Anonymoushttp://www.blogger.com/profile/02083530358646742701noreply@blogger.com0tag:blogger.com,1999:blog-6154923121857389373.post-16636951459162633492018-03-02T17:17:00.001-06:002018-03-02T17:17:31.775-06:00Researchers: Supervised Methadone and Buprenorphine Dosing Adds Little Therapeutic BenefitMethadone, the full agonist synthetic opioid, is one of the most tightly regulated medications on the planet - at least, that is, when it's being used to treat opioid addiction. Here in Minnesota, no fewer than 5 regulatory bodies oversee the clinics that provide methadone maintenance treatment (MMT). One of the core federal requirements of "opiate treatment programs" is daily supervised dosing, requiring patients to come daily to the clinic to receive their dose, observed by trained nursing staff for at least the first 3 months. After that, patients earn <i>one </i>additional day of "take-home" doses at a time until they've earned 1 week (after the 8th month of treatment), then 2 weeks (after the first year in treatment), and finally 4 weeks of take-home doses (after 2 years of sustained participation in the program). The rationale for these highly restrictive federal rules, ostensibly, has been that it will protect patient safety, decrease diversion, and will improve outcomes among MMT patients.<br />
<br />
A recent review of the literature throws these assumptions into question. The review, analyzed and shared by the folks at <a href="http://findings.org.uk/PHP/dl.php?file=Saulle_R_1.txt&s=eb" target="_blank">Drug and Alcohol Findings</a>, found "<b>no evidence that supervising consumption meant patients were better safeguarded or that the treatment more effectively reduced illegal drug use.</b>" Instead, these policies tend to be quite costly to programs and burdensome to patients. They reinforce negative stereotypes about MMT patients and have prevented people from seeking potentially lifesaving treatment. <br />
<br />
Here at Alltyr Clinic, we routinely hear from patients that the ability to receive a monthly prescription of Suboxone has meant they could keep their job or maintain their role within the family. With all the national attention being given to the recent spike in overdose statistics, maybe it's time the feds re-visit these burdensome regulations and increase access to the highly effective treatments. <br />
<br />From the Findings UK article:<div>
<br /><b><span style="font-size: large;">Supervised dosing with a long-acting opioid medication in the management of opioid dependence</span></b><br /><a href="http://findings.org.uk/PHP/dl.php?file=Saulle_R_1.txt&s=eb&sf=sfnos" target="_blank">http://findings.org.uk/PHP/dl.php?file=Saulle_R_1.txt&s=eb&sf=sfnos</a></div>
<div>
<br /></div>
<div>
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Key points<br /><span class="smalltext textNoSpaceTop" style="font-size: 8pt; line-height: 10.5pt; margin-top: 0px;">From summary and commentary</span></h2>
<div style="color: #333333; font-family: verdana, arial, sans-serif; font-size: 9pt; margin-bottom: 8px;">
Guidelines recommend making opioid-dependent patients take their methadone or other opioid substitutes at the clinic or pharmacy to safeguard the patient and prevent medication being ‘diverted’ to other people.</div>
<div style="color: #333333; font-family: verdana, arial, sans-serif; font-size: 9pt; margin-bottom: 8px;">
Randomised trials and studies study which monitored patients in routine treatment afforded no evidence that supervising consumption meant patients were better safeguarded or that the treatment more effectively reduced illegal drug use.</div>
<div style="color: #333333; font-family: verdana, arial, sans-serif; font-size: 9pt; margin-bottom: 8px;">
However, introduction of supervision to UK treatment services was associated with fewer methadone-related overdose deaths.</div>
<div style="color: #333333; font-family: verdana, arial, sans-serif; font-size: 9pt; margin-bottom: 8px;">
Findings and expert opinion support initial supervised consumption and its relaxation on an individual basis, depending on assessment of the patient.</div>
</div>
Anonymoushttp://www.blogger.com/profile/02083530358646742701noreply@blogger.com0tag:blogger.com,1999:blog-6154923121857389373.post-15221205275126141632018-02-28T11:46:00.000-06:002018-02-28T11:55:34.931-06:00The Language We Use in Addiction Treatment<br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The language we use related to alcohol and drug use
disorders is often stigmatizing and misguided. Alltyr’s mission is to transform
addiction treatment in America. Changing language is a necessary step in that process.<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal" style="text-align: center;">
<u>Here’s is Alltyr’s guide to addiction language for the 21<sup>st</sup>
Century.</u><o:p></o:p></div>
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<table border="1" cellpadding="0" cellspacing="0" class="MsoTableGrid" style="border-collapse: collapse; border: none; mso-border-alt: solid windowtext .5pt; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-yfti-tbllook: 1184;">
<tbody>
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<td style="border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 211.25pt;" valign="top" width="282"><div align="center" class="MsoNormal" style="text-align: center;">
<b style="mso-bidi-font-weight: normal;">Instead of saying:<o:p></o:p></b></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 3.75in;" valign="top" width="360"><div align="center" class="MsoNormal" style="text-align: center;">
<b style="mso-bidi-font-weight: normal;">Say:<o:p></o:p></b></div>
</td>
</tr>
<tr style="mso-yfti-irow: 1;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 211.25pt;" valign="top" width="282"><div class="MsoNormal" style="line-height: 150%;">
alcoholic <o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 3.75in;" valign="top" width="360"><div class="MsoNormal" style="line-height: 150%;">
person with an alcohol use
disorder (AUD)<u><o:p></o:p></u></div>
</td>
</tr>
<tr style="mso-yfti-irow: 2;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 211.25pt;" valign="top" width="282"><div class="MsoNormal" style="line-height: 150%;">
addict <o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 3.75in;" valign="top" width="360"><div class="MsoNormal" style="line-height: 150%;">
person with a substance use
disorder (SUD)<o:p></o:p></div>
</td>
</tr>
<tr style="mso-yfti-irow: 3;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 211.25pt;" valign="top" width="282"><div class="MsoNormal" style="line-height: 150%;">
alcohol /drug abuse <o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 3.75in;" valign="top" width="360"><div class="MsoNormal" style="line-height: 150%;">
risky use, heavy drinking, risky
drinking<o:p></o:p></div>
</td>
</tr>
<tr style="mso-yfti-irow: 4;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 211.25pt;" valign="top" width="282"><div class="MsoNormal" style="line-height: 150%;">
sober<o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 3.75in;" valign="top" width="360"><div class="MsoNormal" style="line-height: 150%;">
abstaining, in remission<o:p></o:p></div>
</td>
</tr>
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<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 211.25pt;" valign="top" width="282"><div class="MsoNormal" style="line-height: 150%;">
betrayer, liar, cheat, thief,
selfish<o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 3.75in;" valign="top" width="360"><div class="MsoNormal" style="line-height: 150%;">
addicted person, sick, ill<o:p></o:p></div>
</td>
</tr>
<tr style="mso-yfti-irow: 6;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 211.25pt;" valign="top" width="282"><div class="MsoNormal" style="line-height: 150%;">
enabler<o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 3.75in;" valign="top" width="360"><div class="MsoNormal" style="line-height: 150%;">
loved one <span style="mso-spacerun: yes;"> </span><o:p></o:p></div>
</td>
</tr>
<tr style="height: 10.75pt; mso-yfti-irow: 7;">
<td style="border-top: none; border: solid windowtext 1.0pt; height: 10.75pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 211.25pt;" valign="top" width="282"><div class="MsoNormal" style="line-height: 150%;">
enabling<o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 10.75pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 3.75in;" valign="top" width="360"><div class="MsoNormal" style="line-height: 150%;">
unhelpful or unskillful behavior<o:p></o:p></div>
</td>
</tr>
<tr style="mso-yfti-irow: 8;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 211.25pt;" valign="top" width="282"><div class="MsoNormal" style="line-height: 150%;">
tough love<o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 3.75in;" valign="top" width="360"><div class="MsoNormal" style="line-height: 150%;">
self-care, setting reasonable limits
and expectations<o:p></o:p></div>
</td>
</tr>
<tr style="mso-yfti-irow: 9;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 211.25pt;" valign="top" width="282"><div class="MsoNormal" style="line-height: 150%;">
unmotivated, denial<o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 3.75in;" valign="top" width="360"><div class="MsoNormal">
ambivalent about change, non-adherent, not yet able to overcome
barriers to change, demoralized<o:p></o:p></div>
</td>
</tr>
<tr style="mso-yfti-irow: 10;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 211.25pt;" valign="top" width="282"><div class="MsoNormal" style="line-height: 150%;">
dry drunk<o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 3.75in;" valign="top" width="360"><div class="MsoNormal" style="line-height: 150%;">
irritable, moody, troubled,
erratic, struggling<o:p></o:p></div>
</td>
</tr>
<tr style="mso-yfti-irow: 11;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 211.25pt;" valign="top" width="282"><div class="MsoNormal" style="line-height: 150%;">
slip, lapse, relapse<o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 3.75in;" valign="top" width="360"><div class="MsoNormal" style="line-height: 150%;">
use episode, recurrence, set-back<o:p></o:p></div>
</td>
</tr>
<tr style="mso-yfti-irow: 12;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 211.25pt;" valign="top" width="282"><div class="MsoNormal" style="line-height: 150%;">
recovery (abstinence + spiritual
growth)<o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 3.75in;" valign="top" width="360"><div class="MsoNormal" style="line-height: 150%;">
remission (absence of illness
once present)<o:p></o:p></div>
</td>
</tr>
<tr style="mso-yfti-irow: 13;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 211.25pt;" valign="top" width="282"><div class="MsoNormal" style="line-height: 150%;">
relapse<o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 3.75in;" valign="top" width="360"><div class="MsoNormal" style="line-height: 150%;">
recurrence, set-back<o:p></o:p></div>
</td>
</tr>
<tr style="mso-yfti-irow: 14;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 211.25pt;" valign="top" width="282"><div class="MsoNormal" style="line-height: 150%;">
relapse prevention<o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 3.75in;" valign="top" width="360"><div class="MsoNormal" style="line-height: 150%;">
recovery skills training<o:p></o:p></div>
</td>
</tr>
<tr style="mso-yfti-irow: 15;">
<td style="border-top: none; border: solid windowtext 1.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 211.25pt;" valign="top" width="282"><div class="MsoNormal" style="line-height: 150%;">
treatment program<o:p></o:p></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 3.75in;" valign="top" width="360"><div class="MsoNormal" style="line-height: 150%;">
rehab<o:p></o:p></div>
</td>
</tr>
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Treatment (meaning rehab)<o:p></o:p></div>
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treatment (includes all levels of care)<o:p></o:p></div>
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MAT (medication assisted
treatment)<o:p></o:p></div>
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treatment, pharmacotherapy,
anti-relapse meds<o:p></o:p></div>
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compliance <o:p></o:p></div>
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adherence <o:p></o:p></div>
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non-compliant<o:p></o:p></div>
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non-adherent <o:p></o:p></div>
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harm reduction<o:p></o:p></div>
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treatment, chronic care management, partial response<o:p></o:p></div>
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<b>Want to learn more about The Alltyr Model of Care</b><span style="font-family: "times new roman" , serif;"><b>™? Visit our website</b>: <a href="http://www.alltyr.com/">www.alltyr.com</a> </span></div>
Mark Willenbring, MDhttp://www.blogger.com/profile/10556707753571367243noreply@blogger.com0tag:blogger.com,1999:blog-6154923121857389373.post-26382998286631474302018-01-11T10:25:00.002-06:002018-01-11T10:25:54.671-06:00Substance Matters Blog is Back!Hi Everyone,<br />
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The blog is back! In 2014, I stopped blogging because I was too busy to keep it interesting. With growth and other recent changes, we'll be starting to post again. A link to the blog is always available on <a href="http://www.alltyr.com/">www.Alltyr.com</a>, so you don't have to worry about bookmarking this URL.<br />
<br />
A lot has changed since 2014. <a href="http://www.alltyr.com/" target="_blank">Alltyr Clinic</a> has grown, and development of the Alltyr Model of Care<span style="font-family: "Calibri",sans-serif; font-size: 12pt; line-height: 107%; margin: 0px;">™</span> is complete. We are still located in downtown St. Paul, MN, but plan to expand into the west metro Twin Cities area. We are also looking at expansion in other states. The most likely new location is the Los Angeles area. Ian McLoone, who came aboard very early, helped me with the blog before, and will be posting as well.<br />
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I'm looking forward to continuing to do everything possible to disrupt the current corrupt and antiquated rehab system, and replace it with accessible, affordable, attractive and effective professional treatment.<br />
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Thanks for reading. Please comment on the posts. <br />
<br />
And visit <a href="http://www.alltyr.com/">www.Alltyr.com</a> to learn more about how far Alltyr Clinic has come!Mark Willenbring, MDhttp://www.blogger.com/profile/10556707753571367243noreply@blogger.com0tag:blogger.com,1999:blog-6154923121857389373.post-85142780204358198982014-09-17T08:11:00.001-05:002014-09-17T08:12:39.964-05:00The Myth of "Cross-Addiction" DebunkedFor decades, the conventional wisdom and clinical lore in rehab facilities and recovery communities has warned against the risks of so-called "cross-addiction". "Be careful," they say, "you're at-risk of picking up a new addiction now that you've kicked one habit." Heroin addicts are warned against developing an addiction to alcohol, and cocaine addicts are warned against developing an addiction to opiates, Cross-addiction can even occur to things like exercise or sugar, <a href="https://www.hazelden.org/OA_HTML/ibeCCtpItmDspRte.jsp?item=3438&sitex=10020:22372:US">according to pamphlets </a>and even therapists who have worked in the field for years and years.<br />
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But is it even true? Is the notion of cross-addiction supported by empirical evidence - or does it fall on its face under scientific scrutiny?<br />
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According to a new report, published September 10 in JAMA Psychiatry, the answer is a resounding, "No."<br />
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The study, "<a href="http://archpsyc.jamanetwork.com/article.aspx?articleid=1901525">Testing the Drug Substitution Switching-Addictions Hypothesis</a>," analyzed data from the National Epidemiological Study on Alcohol and Related Conditions (NESARC) to investigate whether participants developed new-onset substance use disorders (SUD) after remission from a previous SUD. These data were then compared against people with a SUD who did <i>not </i>achieve remission but also developed a new-onset SUD.<br />
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The authors discovered that, "<span style="background-color: white; color: #333333; font-family: Georgia, Cambria, Times, 'Times New Roman', serif; font-size: 13px; line-height: 19.5px;">As compared with those who do not remit from an SUD, remitters have less than half the risk of developing a new SUD. Contrary to clinical lore, achieving remission does not typically lead to drug substitution but rather is associated with a lower risk of new SUD onsets.</span>"<br />
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This is probably the best evidence to-date that addresses the concept of cross-addiction. Will counselors and agencies begin to pull back from this concept - or will clients still be subjected to homework assignments and lectures warning against it?<br />
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Here's the abstract from JAMA Psychiatry (found here: http://archpsyc.jamanetwork.com/article.aspx?articleid=1901525):<br />
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<div style="background-color: white; border: 0px; color: #333333; font-family: Georgia, Cambria, Times, 'Times New Roman', serif; font-size: 13px; line-height: 1.5; margin-bottom: 10px; padding: 0px; vertical-align: baseline;">
<strong style="border: 0px; font-family: inherit; font-size: 14px; font-style: inherit; font-variant: inherit; line-height: inherit; margin: 0px; padding: 0px; vertical-align: baseline;">Importance</strong> <span style="border: 0px; font-family: inherit; font-size: inherit; font-style: inherit; font-variant: inherit; font-weight: inherit; line-height: inherit; margin: 0px; padding: 0px; vertical-align: baseline;">Adults who remit from a substance use disorder (SUD) are often thought to be at increased risk for developing another SUD. A greater understanding of the prevalence and risk factors for drug substitution would inform clinical monitoring and management.</span></div>
<div style="background-color: white; border: 0px; color: #333333; font-family: Georgia, Cambria, Times, 'Times New Roman', serif; font-size: 13px; line-height: 1.5; margin-bottom: 10px; padding: 0px; vertical-align: baseline;">
<strong style="border: 0px; font-family: inherit; font-size: 14px; font-style: inherit; font-variant: inherit; line-height: inherit; margin: 0px; padding: 0px; vertical-align: baseline;">Objective</strong> <span style="border: 0px; font-family: inherit; font-size: inherit; font-style: inherit; font-variant: inherit; font-weight: inherit; line-height: inherit; margin: 0px; padding: 0px; vertical-align: baseline;">To determine whether remission from an SUD increases the risk of onset of a new SUD after a 3-year follow-up compared with lack of remission from an SUD and whether sociodemographic characteristics and psychiatric disorders, including personality disorders, independently predict a new-onset SUD.</span></div>
<div style="background-color: white; border: 0px; color: #333333; font-family: Georgia, Cambria, Times, 'Times New Roman', serif; font-size: 13px; line-height: 1.5; margin-bottom: 10px; padding: 0px; vertical-align: baseline;">
<strong style="border: 0px; font-family: inherit; font-size: 14px; font-style: inherit; font-variant: inherit; line-height: inherit; margin: 0px; padding: 0px; vertical-align: baseline;">Design, Setting, and Participants</strong> <span style="border: 0px; font-family: inherit; font-size: inherit; font-style: inherit; font-variant: inherit; font-weight: inherit; line-height: inherit; margin: 0px; padding: 0px; vertical-align: baseline;">A prospective cohort study where data were drawn from a nationally representative sample of 34 653 adults from the National Epidemiologic Survey on Alcohol and Related Conditions. Participants were interviewed twice, 3 years apart (wave 1, 2001–2002; wave 2, 2004–2005).</span></div>
<div style="background-color: white; border: 0px; color: #333333; font-family: Georgia, Cambria, Times, 'Times New Roman', serif; font-size: 13px; line-height: 1.5; margin-bottom: 10px; padding: 0px; vertical-align: baseline;">
<strong style="border: 0px; font-family: inherit; font-size: 14px; font-style: inherit; font-variant: inherit; line-height: inherit; margin: 0px; padding: 0px; vertical-align: baseline;">Main Outcomes and Measures</strong> <span style="border: 0px; font-family: inherit; font-size: inherit; font-style: inherit; font-variant: inherit; font-weight: inherit; line-height: inherit; margin: 0px; padding: 0px; vertical-align: baseline;">We compared new-onset SUDs among individuals with at least 1 current SUD at wave 1 who did not remit from any SUDs at wave 2 (n = 3275) and among individuals with at least 1 current SUD at wave 1 who remitted at wave 2 (n = 2741).</span></div>
<div style="background-color: white; border: 0px; color: #333333; font-family: Georgia, Cambria, Times, 'Times New Roman', serif; font-size: 13px; line-height: 1.5; margin-bottom: 10px; padding: 0px; vertical-align: baseline;">
<strong style="border: 0px; font-family: inherit; font-size: 14px; font-style: inherit; font-variant: inherit; line-height: inherit; margin: 0px; padding: 0px; vertical-align: baseline;">Results</strong> <span style="border: 0px; font-family: inherit; font-size: inherit; font-style: inherit; font-variant: inherit; font-weight: inherit; line-height: inherit; margin: 0px; padding: 0px; vertical-align: baseline;">Approximately one-fifth (n = 2741) of the total sample had developed a new-onset SUD at the wave 2 assessment. Individuals who remitted from 1 SUD during this period were significantly less likely than those who did not remit to develop a new SUD (13.1% vs 27.2%, <i style="border: 0px; font-family: inherit; font-size: inherit; font-variant: inherit; font-weight: inherit; line-height: inherit; margin: 0px; padding: 0px; vertical-align: baseline;">P</i> < .001). Results were robust to sample specification. An exception was that remission from a drug use disorder increased the odds of a new SUD (odds ratio [OR] = 1.46; 95% CI, 1.11-1.92). However, after adjusting for the number of SUDs at baseline, remission from drug use disorders decreased the odds of a new-onset SUD (OR = 0.66; 95% CI, 0.46-0.95) whereas the number of baseline SUDs increased those odds (OR=1.68; 95% CI, 1.43-1.98). Being male, younger in age, never married, having an earlier age at substance use onset, and psychiatric comorbidity significantly increased the odds of a new-onset SUD during the follow-up period.</span></div>
<div style="background-color: white; border: 0px; color: #333333; font-family: Georgia, Cambria, Times, 'Times New Roman', serif; font-size: 13px; line-height: 1.5; margin-bottom: 10px; padding: 0px; vertical-align: baseline;">
<strong style="border: 0px; font-family: inherit; font-size: 14px; font-style: inherit; font-variant: inherit; line-height: inherit; margin: 0px; padding: 0px; vertical-align: baseline;">Conclusions and Relevance</strong> <span style="border: 0px; font-family: inherit; font-size: inherit; font-style: inherit; font-variant: inherit; font-weight: inherit; line-height: inherit; margin: 0px; padding: 0px; vertical-align: baseline;">As compared with those who do not remit from an SUD, remitters have less than half the risk of developing a new SUD. Contrary to clinical lore, achieving remission does not typically lead to drug substitution but rather is associated with a lower risk of new SUD onsets.</span></div>
Anonymoushttp://www.blogger.com/profile/02083530358646742701noreply@blogger.com0tag:blogger.com,1999:blog-6154923121857389373.post-60364317567958988972014-06-13T08:33:00.000-05:002014-06-13T08:33:23.587-05:00Informed Consent in Addiction Treatment: An Ethical Obligation<h1 class="title" style="color: #00434d; font-family: georgia, 'times new roman', serif; font-size: 1.3em; font-weight: normal; line-height: 1.3em; margin: 0px; padding-bottom: 10px;">
Informed Consent in Opioid Addiction Treatment: An Ethical Obligation</h1>
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<span style="background-color: white; color: #1f497d; font-family: Calibri, sans-serif; font-size: 15px;">This article was originally published in </span><i style="background-color: white; color: #1f497d; font-family: Calibri, sans-serif; font-size: 15px;"><a href="http://www.carlataddictiontreatment.com/" target="_blank">The Carlat Addiction Treatment Report</a>,</i><span style="background-color: white; color: #1f497d; font-family: Calibri, sans-serif; font-size: 15px;"> Volume 2, #3, May 2014</span></div>
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Source: </div>
CATR, May 2014, Vol 2, Issue 3, <a href="http://www.carlataddictiontreatment.com/issue/vol2-no3-1" style="color: #b03300; text-decoration: none;">Opioid Addiction</a></div>
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<a href="http://www.carlataddictiontreatment.com/mark-willenbring-md-0" style="color: #b03300; font-weight: bold; text-decoration: none;">Mark Willenbring, MD</a></h3>
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Founder and CEO, Alltyr Clinic, St. Paul, MN, Former Director, Division of Treatment and Recovery Research, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD</div>
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Dr. Willenbring has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.</div>
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Informed consent—whether it be for psychotherapy, prescribing a medication, or performing a surgical procedure—is an ethical principle firmly established in law and medicine.</div>
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While there has been no formal research on this subject, my experience suggests that many addiction treatment programs fail to obtain valid informed consent. The starkest example occurs in the treatment of opioid addiction, where the practices and beliefs of clinicians often differ markedly from the evidence regarding effective treatments.</div>
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<strong>What is Informed Consent?</strong></div>
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Informed consent refers to the collaborative process that a provider and patient go through to develop a treatment plan for the patient’s problems. This moral requirement is based on the principle of respecting a person’s autonomy, that is, their right “to hold views, to make choices, and to take actions based on their values and beliefs” (Beauchamp TL & Childress JF.<em>Principles of Bio-medical Ethics, 7th ed.</em> New York: Oxford University Press, 2013:122–123).</div>
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Valid consent fulfills three criteria (Grimm DA, <em>N M Law Rev</em> 2007;37(1):39–83). First, the patient needs to have decision-making capacity. Capacity, in a medical context, refers to patients’ ability to understand information, appreciate their situation, use reason to make a decision, and communicate their choices (Applebaum PS, <em>N Engl J Med</em> 2007;357(18):1834–1840). This is referred to as the “capacity” criterion.</div>
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Second, the provider needs to present the full range of available treatment options based on current scientific knowledge. During this discussion, he or she needs to outline the risks and benefits of these various options and what could be reasonably expected if the patient declines treatment altogether. This is called the “disclosure” criterion.</div>
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Finally, valid consent requires that patients are free from coercion—that is, they are in a position to voluntarily choose any treatment option that they feel is best for them. This is described as the “voluntariness” criterion.</div>
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A provider has failed to obtain valid informed consent if any of these elements are missing.</div>
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<strong>Legal Standards</strong></div>
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Legal requirements for consent have evolved over centuries. Until relatively recently, courts used a physician-oriented point of view: the physician was required to provide information he or she felt was in the patient’s best interests. This resulted in practices such as informing a spouse, but not the patient, of a terminal disease. In other cases, providers deliberately omitted certain treatment options from their discussions with patients because of their personal beliefs or biases against them.</div>
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Through a series of court decisions, a new standard, the “reasonable person” or “prudent person” standard, emerged. Providers are now expected to present patients with information that a reasonable or prudent person would want to know in order to make healthcare decisions (Berg JW et al.<em>Informed Consent: Legal Theory and Clinical Practice, 2d ed. </em>New York: Oxford University Press, 2001:48).</div>
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In clinical practice, a provider is not allowed to withhold information from a patient based on his or her judgment that one treatment is better than another. The provider is thus required to present the scientific evidence supporting available treatment options, the expected outcomes of these various treatments, and the clinician’s recommendation for the patient and the rationale for it. This recommendation also needs to take into account any patient-specific features that factored into the provider’s decision-making.</div>
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This means that clinicians are legally obligated to provide information that they may prefer to withhold. The purpose of informed consent, however, is not to “conveniently promote a treatment plan; it requires informing patients with the recognition that they may disagree with a recommended treatment plan and retain the authority to do so” (Berg et al, <em>op.cit</em>).</div>
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There is also an important distinction between the actual process of obtaining autonomous authorization for a treatment or procedure and institutional requirements that patients sign informed consent documents. Patients frequently sign such documents in the absence of true informed consent (Beauchamp & Childress, <em>op.cit</em>).</div>
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<strong>Evidence-Based Treatment</strong></div>
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Providers are obligated to summarize the scientific data concerning the effectiveness of various treatment options. The only treatment with consistent, strong evidence of effectiveness for opioid addiction is indefinite opioid maintenance therapy with either buprenorphine or methadone (Mattick RP et al, <em>Cochrane Database Syst Rev </em>2014;2:CD002207).</div>
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Currently, the World Health Organization, US Centers for Disease Control and Prevention, US Department of Health and Human Services, and many other agencies and organizations recommend methadone and buprenorphine maintenance as first-line treatments.</div>
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In contrast, there is no evidence commending drug-free (or so-called abstinence-based) treatments (Mayet S et al, <em>Cochrane Database Syst Rev</em>2005;1:CD004330). Moreover, there is good evidence that psychosocial or intensive behavioral approaches fail to improve outcomes compared to minimal drug counseling in patients receiving opioid maintenance therapy (Amato L et al, <em>Cochrane Database Syst Rev </em>2011;10:CD004147; Fiellin DA et al, <em>Am J Med </em>2013;126(1):74.e11–17).</div>
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Naltrexone is the only other medication that has been approved by the FDA for opioid addiction. Oral naltrexone (ReVia) is ineffective (Minozzi S et al,<em>Cochrane Database Syst Rev </em>2011;4: CD001333) and the efficacy of extended-release, injectable naltrexone (Vivitrol) was established in just a single, industry-sponsored study conducted in Russia, where buprenorphine and methadone are not legally available (Krupitsky E et al, <em>Lancet</em>2011;377(9776):1506–1513).</div>
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Presently, evidence for Vivitrol’s effectiveness is limited and generalization of clinical trial data to other countries is questionable. (For more, see<a href="http://www.carlataddictiontreatment.com/vivitrol-another-option-opioid-addiction" style="color: #b03300; text-decoration: none;" target="_blank">“Vivitrol: Another Option for Opioid Addiction?”</a>)</div>
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<strong>Meeting the Capacity Criterion</strong></div>
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In addiction treatment, patients who are experiencing severe withdrawal symptoms may not have capacity due to pain and emotional distress. Other confounders include co-occurring mental disorders and cognitive impairment associated with prescribed medications and substances of abuse. Although beyond the scope of this article, simple bedside instruments allow providers to evaluate and easily document a patient’s decision-making capacity (Tunzi M, <em>Am Fam Physician </em>2001;64(2):299–306).</div>
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<strong>Meeting the Disclosure Criterion</strong></div>
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Providers need to have a clear understanding of available treatment options and the scientific evidence supporting each one, so they can meet their obligation concerning disclosure.</div>
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This article’s brief summary may serve as a starting point. Standard textbooks are also a ready source of such information (eg, Strain EC & Stitzer ML eds. <em>The Treatment of Opioid Dependence.</em> Baltimore, MD: Johns Hopkins University Press, 2006). In addition, a number of plain language resources geared toward patients are available (eg,<a href="http://1.usa.gov/1ibCKou" style="color: #b03300; text-decoration: none;" target="_blank">http://1.usa.gov/1ibCKou</a>).</div>
<div style="margin-bottom: 1.5em;">
Providers need to present patients with more than their program’s philosophy or even the community standard of care. Remember, the standard for disclosure is what a reasonable or prudent patient would want to know, not a narrow presentation concerning usual care or the provider’s personal preferences. In the case of opioid addiction, this means summarizing the scientific data on the effectiveness of treatment options. This is a fiduciary duty that trumps the clinician’s personal preferences and their program’s philosophy of care.</div>
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<strong>Meeting the Voluntariness Criterion</strong></div>
<div style="margin-bottom: 1.5em;">
Providers need to be very sensitive to overt, and more subtle covert, coercion when discussing treatment options with patients. Many people presenting for substance use treatment are subject to significant coercion from the legal system, employers, and families. Thus, we need to ensure that consent is truly voluntary and that we are not using coercion to impose our own views concerning treatment upon patients.</div>
<div style="margin-bottom: 1.5em;">
This ethical obligation may require advocating for a treatment option different than what a judge, probation officer, employer, or family prefers or recommends.</div>
<div style="margin-bottom: 1.5em;">
<strong>CATR’s Take:</strong> Addiction treatment has historically been very prescriptive and patients often had little choice about the care that they received. This article is a good reminder that providers have an affirmative duty to obtain informed consent and engage patients in shared decision-making.</div>
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Mark Willenbring, MDhttp://www.blogger.com/profile/10556707753571367243noreply@blogger.com0tag:blogger.com,1999:blog-6154923121857389373.post-64896388532199060762014-06-08T10:29:00.000-05:002014-06-08T10:29:37.072-05:00Alltyr Clinic Featured on NPR's Weekend Edition!<div style="background-color: white; font-family: proxima-nova, 'Helvetica Neue', Helvetica, Arial, sans-serif; font-size: 15px; line-height: 24px;">
<a href="http://www.alltyr.com/" target="_blank">Alltyr Clinic</a> is featured on <a data-cke-saved-href="http://www.npr.org/2014/06/08/319527437/for-addiction-the-road-to-wellness-has-more-than-one-path" href="http://www.npr.org/2014/06/08/319527437/for-addiction-the-road-to-wellness-has-more-than-one-path" style="color: #2777ae; margin-top: 0px; outline: none; text-decoration: none;" target="_blank">NPR's Weekend Edition Sunday</a> today, June 8, 2014. We are positioned as an alternative to traditional rehab, in this case <a data-cke-saved-href="http://www.hazelden.org" href="http://www.hazelden.org/" style="color: #2777ae; margin-bottom: 0px; outline: none; text-decoration: none;" target="_blank">Hazelden</a>. One of our patients, Shane Linehan, was brave enough to share his experience with both Hazelden (where he went first) and Alltyr Clinic (where he is being treated now.) I want to thank him and applaud his courage for speaking out. (For the record, Alltyr Clinic gave him no incentive; we simply offered the opportunity to many of our patients.) We are honored to be compared to arguably the best known traditional rehab in the country (if not the world.)</div>
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Unfortunately, in the summary on the program's landing page, our approach is described as being almost totally oriented around prescribing anti-relapse medications. <i>Although we use every proven anti-relapse medication, we also use every evidence-based behavioral/psychosocial approach</i>. This includes individual and group therapy using motivational, cognitive-behavioral, coping skills, 12-Step Facilitation, EMDR, CRAFT, DBT, psychodynamic, community reinforcement, couples and family approaches. Which we use depends on the needs of the patient. Our team includes addiction psychiatrists, addiction medicine specialists, psychologists, social workers, counselors and recovery coaches.</div>
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<i>Furthermore, we fully integrate treatment for any co-existing mental health disorder</i>, such as anxiety, depression, PTSD, personality disorders, bipolar disorder, cognitive disorders, as well as medical problems such as insomnia and chronic pain. We really aim to be a "one-stop shop." If sober housing is needed we work with community partners to help our patients secure it. </div>
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The bottom line is this: coming to Alltyr Clinic is like coming to a mental health clinic or any other health care service using a multi-disciplinary approach. Each patient receives a comprehensive individual evaluation upon which the treatment recommendations are based. Selecting from a large menu of services, a truly individualized treatment plan is arrived at by the patient, the treatment team, and if appropriate, the family. After treatment is started, the plan is modified as needed. The length and intensity of treatment is also completely individual and flexible. <i>We do whatever we can and we stay with you as long as it takes. We aren't a program, we're a clinic.</i></div>
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<strong style="color: #111111; margin-bottom: 0px; margin-top: 0px;"><span style="font-size: 15px;">At Alltyr Clinic, "We Don't Just Call Addiction a Disease, We Treat It Like One."</span><span style="font-size: xx-small;">TM</span></strong></div>
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Mark Willenbring, MDhttp://www.blogger.com/profile/10556707753571367243noreply@blogger.com0tag:blogger.com,1999:blog-6154923121857389373.post-40226261842807688682014-06-03T08:20:00.001-05:002014-06-03T08:20:33.110-05:00A Sad State of Affairs: Psychostimulant Addiction Treatment Leaves Much to be Desired<a href="http://www.sciencedirect.com/science/article/pii/S0028390814001282" target="_blank">The authors of a new paper</a>, published ahead of a special issue of <i><a href="http://www.sciencedirect.com/science/article/pii/S0028390814001282" target="_blank">Neuropharmacology</a></i>, give the reader a good look at the current state of psychostimulant substance use disorder treatment - and the results are disappointing. Starting with behavioral treatments and ending with a review of medications, the clear fact remains that there is no single treatment that outperforms most others.<br />
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Meta-analyses of behavioral interventions for the treatment of cocaine use disorder have shown <a href="http://ajp.psychiatryonline.org/data/Journals/AJP/3849/08aj0179.PDF" target="_blank">modest benef<u>its</u></a>; while <a href="http://www.ncbi.nlm.nih.gov/pubmed/19307968" target="_blank">one review found</a>, "there is currently no evidence for a differential treatment effect of any psychosocial treatment in the management of" cocaine or amphetamine use disorders. CBT and Contingency Management (CM) remain the mainstay of psychostimulant treatment, and the authors <a href="http://www.ncbi.nlm.nih.gov/pubmed/21261406" target="_blank">cite data suggesting a </a>combination of CM plus Community Reinforcement Approach might produce the best outcomes.<br />
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In terms of pharmacological treatments, researched medications include antagonist therapy, agonist therapy, medications to treat withdrawal symptoms and medications to treat co-occurring psychiatric symptoms or disorders; and the authors of the present paper devote the bulk of their attention to weighing the evidence of such options.<br />
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Naltrexone, they note, has shown some promise in laboratory studies, as it has been shown to weaken amphetamine- and cocaine-related effects in some subjects in both human and animal trials. <a href="http://www.sciencedirect.com/science/article/pii/S0028390811001602" target="_blank">Because it also seems to weaken the subjective euphoric effects of methylphenidate (Ritalin)</a>, one area of promise could be in the combination of naltrexone and methylphenidate to limit the abuse potential of an agonist-like treatment.<br />
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Disulfiram (aka Antabuse) has also shown some promise in the lab, but mainly in the treatment of cocaine-use disorders. It was shown to increase the brain ratio of dopamine to norepinephrine and to <a href="http://link.springer.com/article/10.1007%2Fs00213-011-2447-5" target="_blank">prevent stress-induced cocaine reinstatement.</a> In pilot studies, disulfiram was shown to be effective in reducing cocaine use in patients with cocaine use disorders (CUD), and among buprenorphine-maintained polydrug users. However, <a href="http://www.sciencedirect.com/science/article/pii/S0376871612001822" target="_blank">in a more recent study, disulfiram showed less promise</a> reducing cocaine use among methadone-maintained patients. The authors of the review point to evidence that disulfiram may only be effective among CUD patients with specific genotypes - and may be more effective among men than women.<br />
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Agonist-like treatments are also reviewed by the authors, and appear to offer some of the more exciting, and possibly effective, interventions for psychostimulant addiction. <a href="http://journals.lww.com/psychopharmacology/pages/articleviewer.aspx?year=2001&issue=10000&article=00010&type=abstract" target="_blank"><span style="font-size: xx-small;">D</span>-amphetamine has been shown to improve treatment retention and reduce illicit cocaine use in early trials</a>; <a href="http://www.nature.com/clpt/journal/v89/n2/full/clpt2010307a.html" target="_blank">while a later study showed</a> a reduction in withdrawal and craving, but a failure to reduce methamphetamine use. Not mentioned in the review, <a href="http://mattsub.blogspot.com/2012/12/potential-new-treatment-for-cocaine.html" target="_blank">but a small study we wrote about in 2012</a> appeared to show promising results in the combination of mixed amphetamine salts (Adderall) and topiramate (Topamax)<br />
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For its part, sustained-release <a href="http://www.sciencedirect.com/science/article/pii/S0376871608003797" target="_blank">methamphetamine has been tested</a> as a maintenance agent for CUD, and appeared to significantly reduce cocaine-positive urine samples and cocaine craving. The familiar medication, methylphenidate, has been shown to be <a href="http://onlinelibrary.wiley.com/doi/10.1111/add.12109/abstract;jsessionid=E45C1191ECBC1A7D8344012DA69ED84B.f01t02?systemMessage=Wiley+Online+Library+will+be+disrupted+Saturday%2C+7+June+from+10%3A00-15%3A00+BST+%2805%3A00-10%3A00+EDT%29+for+essential+maintenance" target="_blank">non-superior to placebo</a> in some studies for meth/amphetamine use and <a href="http://journals.lww.com/psychopharmacology/pages/articleviewer.aspx?year=1997&issue=12000&article=00008&type=abstract" target="_blank">cocaine use</a>, but appears to warrant further research at improved dosages. The other agonist-like medication discussed, modafanil, seems to be an interesting candidate for maintenance treatment. Known to be a cognitive enhancer, modafanil may be useful in addressing the impairments in a range of cognitive functions that can result from psychostimulant addiction; but studies have thus far produced more "equivocal" results in most trials as treatments<a href="http://www.journalofsubstanceabusetreatment.com/article/S0740-5472%2812%2900006-2/abstract" target="_blank"> for cocaine</a> or <a href="http://www.sciencedirect.com/science/article/pii/S0376871611003115" target="_blank">for methamphetamine</a> - <a href="http://journal.frontiersin.org/Journal/10.3389/fpsyt.2012.00077/full" target="_blank">even when combined with <span style="font-size: xx-small;">D</span>-amphetamine</a>. Post-hoc analysis of the available data does, however, suggest efficacy in the less severe cases of addiction.<br />
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Additionally, researchers in Latin America have argued in favor oral coca for the treatment of cocaine use disorder. Their <a href="http://www.bvcedro.org.pe/bitstream/123456789/415/1/833-BRCM-S-COCA.pdf" target="_blank">"Handbook on Oral Cocaine as Agonist Therapy for Cocaine Dependence"</a> is an intriguing read, and the authors of the review posit that political, cultural and commercial barriers - not scientific ones - are likely to blame for the "lack of follow-up on this line of research".<br />
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A host of other medications have been tried and tested for psychostimulant use disorders, with little success. Vaccines, on the other hand, are now gaining momentum in the field and are being used in multiple studies at various phases. A vaccine that that produces antibodies to prevent cocaine from crossing the blood-brain barrier has performed well in <a href="http://www.sciencedirect.com/science/article/pii/S0264410X0100425X" target="_blank">Phase I</a> and <a href="http://www.biologicalpsychiatryjournal.com/article/S0006-3223%2805%2900493-2/abstract" target="_blank">Phase II</a> trials. A methamphetamine vaccine is still in preclinical development, but initial<a href="http://www.sciencedirect.com/science/article/pii/S0376871612003717" target="_blank"> results have shown good levels</a> of antibodies in animal models and a Phase I trial is scheduled to begin in 2015.<br />
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Considering <a href="http://mattsub.blogspot.com/2014/01/new-report-sheds-light-on-global.html" target="_blank">the vast global toll which is the result of psychostimulant addiction</a>, treatment for these disorders is as desperately needed as ever. If there is one thing that this review makes clear, it's the fact that we still have a long way to go before we can say that we have effective treatment options for the consumer. A question for readers of this blog: what are the techniques and interventions that you have found to be helpful stimulant use disorders? Is there a particular line of research that you feel would be important to investigate further? Do you see the utility of agonist-like medications? Your thoughts are always appreciated.Anonymoushttp://www.blogger.com/profile/02083530358646742701noreply@blogger.com0tag:blogger.com,1999:blog-6154923121857389373.post-25251050702604131332014-05-13T21:59:00.001-05:002014-05-13T21:59:41.770-05:00Many Patients with Alcohol Use Disorders Not Offered Medications<a href="http://jama.jamanetwork.com/article.aspx?articleid=1869208" target="_blank">An exhaustive and brand new meta-analysis and systematic review</a>, published today in the <i><a href="http://jama.jamanetwork.com/journal.aspx" target="_blank">Journal of the American Medical Association</a></i>, paints a disappointing picture of medication access for those with alcohol use disorders (AUD) in the US. The authors included 123 studies, involving nearly 23,000 participants, and determined that while acamprosate and naltrexone have been shown to be effective treatments, fewer than 10% of those who might benefit are ever prescribed an AUD medication.<div>
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Here's the Abstract, via JAMA:</div>
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<span style="color: #444444;">IMPORTANCE Alcohol use disorders cause substantial morbidity and early mortality yet</span></div>
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<span style="color: #444444;">remain greatly undertreated. Medications are considerably underused.</span></div>
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<span style="color: #444444;"><br /></span></div>
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<span style="color: #444444;">OBJECTIVE To conduct a systematic review and meta-analysis of the benefits and harms of</span></div>
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<span style="color: #444444;">medications (US FDA-approved and others) for adults with alcohol use disorders.</span></div>
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<span style="color: #444444;"><br /></span></div>
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<span style="color: #444444;">DATA SOURCES PubMed, Cochrane Library, PsycINFO, CINAHL, EMBASE, FDA website, and</span></div>
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<span style="color: #444444;">clinical trials registries (January 1, 1970, to March 1, 2014).</span></div>
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<span style="color: #444444;"><br /></span></div>
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<span style="color: #444444;">STUDY SELECTION Two reviewers selected randomized clinical trials (RCTs) with at least 12</span></div>
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<span style="color: #444444;">weeks’ duration that reported eligible outcomes and head-to-head prospective cohort</span></div>
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<span style="color: #444444;">studies reporting health outcomes or harms.</span></div>
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<span style="color: #444444;"><br /></span></div>
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<span style="color: #444444;">DATA EXTRACTION AND SYNTHESIS We conducted meta-analyses using random-effects</span></div>
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<span style="color: #444444;">models and calculated numbers needed to treat for benefit (NNTs) or harm (NNHs).</span></div>
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<span style="color: #444444;"><br /></span></div>
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<span style="color: #444444;">MAIN OUTCOMES AND MEASURES Alcohol consumption, motor vehicle crashes, injuries,</span></div>
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<span style="color: #444444;">quality of life, function, mortality, and harms.</span></div>
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<span style="color: #444444;"><br /></span></div>
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<span style="color: #444444;">RESULTS We included 122 RCTs and 1 cohort study (total 22 803 participants). Most assessed</span></div>
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<span style="color: #444444;">acamprosate (27 studies, n = 7519), naltrexone (53 studies, n = 9140), or both. The NNT to</span></div>
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<span style="color: #444444;">prevent return to any drinking for acamprosate was 12 (95% CI, 8 to 26; risk difference [RD],</span></div>
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<span style="color: #444444;">−0.09; 95% CI, −0.14 to −0.04) and was 20 (95% CI, 11 to 500; RD, −0.05; 95% CI, −0.10 to</span></div>
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<span style="color: #444444;">−0.002) for oral naltrexone (50 mg/d). The NNT to prevent return to heavy drinking was 12</span></div>
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<span style="color: #444444;">(95% CI, 8 to 26; RD −0.09; 95% CI, −0.13 to −0.04) for oral naltrexone (50 mg/d).</span></div>
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<span style="color: #444444;">Meta-analyses of trials comparing acamprosate to naltrexone found no statistically significant</span></div>
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<span style="color: #444444;">difference between them for return to any drinking (RD, 0.02; 95% CI, −0.03 to 0.08) or</span></div>
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<span style="color: #444444;">heavy drinking (RD, 0.01; 95% CI, −0.05 to 0.06). For injectable naltrexone, meta-analyses</span></div>
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<span style="color: #444444;">found no association with return to any drinking (RD, −0.04; 95% CI, −0.10 to 0.03) or heavy</span></div>
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<span style="color: #444444;">drinking (RD, −0.01; 95% CI, −0.14 to 0.13) but found an association with reduction in heavy</span></div>
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<span style="color: #444444;">drinking days (weighted mean difference [WMD], −4.6%; 95% CI, −8.5% to −0.56%). Among</span></div>
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<span style="color: #444444;">medications used off-label, moderate evidence supports an association with improvement in</span></div>
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<span style="color: #444444;">some consumption outcomes for nalmefene (heavy drinking days per month: WMD, −2.0;</span></div>
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<span style="color: #444444;">95% CI, −3.0 to −1.0; drinks per drinking day: WMD, −1.02; 95% CI, −1.77 to −0.28) and</span></div>
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<span style="color: #444444;">topiramate (% heavy drinking days: WMD, −9.0%; 95% CI, −15.3% to −2.7%; drinks per</span></div>
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<span style="color: #444444;">drinking day: WMD, −1.0; 95% CI, −1.6 to −0.48). For naltrexone and nalmefene, NNHs for</span></div>
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<span style="color: #444444;">withdrawal from trials due to adverse events were 48 (95% CI, 30 to 112) and 12 (95% CI, 7 to</span></div>
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<span style="color: #444444;">50), respectively; risk was not significantly increased for acamprosate or topiramate.</span></div>
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<span style="color: #444444;"><br /></span></div>
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<span style="color: #444444;">CONCLUSIONS AND RELEVANCE Both acamprosate and oral naltrexone were associated with</span></div>
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<span style="color: #444444;">reduction in return to drinking. When directly compared with one another, no significant</span></div>
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<span style="color: #444444;">differences were found between acamprosate and naltrexone for controlling alcohol</span></div>
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<span style="color: #444444;">consumption. Factors such as dosing frequency, potential adverse events, and availability of</span></div>
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<span style="color: #444444;">treatments may guide medication choice.</span></div>
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<span style="color: #444444;"><br /></span></div>
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Would love to know what readers think about the results of this large study. What are the main drivers of this gap, and why aren't more patients requesting these medications? What needs to be done to improve access?</div>
Anonymoushttp://www.blogger.com/profile/02083530358646742701noreply@blogger.com0tag:blogger.com,1999:blog-6154923121857389373.post-1991014246889180892014-04-30T21:03:00.000-05:002014-04-30T21:03:23.965-05:00Who Benefits from Additional Drug Counseling among Prescription Opioid Dependent Patients on Suboxone?<a href="http://www.sciencedirect.com/science/article/pii/S037687161400831X" target="_blank">In a secondary analysis</a> of the Prescription Opioid Addiction Treatment Study (POATS), the original study's author, Roger Weiss, and colleagues parse the data to determine if there are common characteristics among those who benefited from additional opioid dependence counseling (ODC) - above and beyond the standard medical management (SMM) and buprenorphine-naloxone medication. It is a very good question, considering the <a href="http://mattsub.blogspot.com/2013/07/buprenorphine-4counseling-0-it-hasnt.html" target="_blank">host of recent studies</a> which found no additional benefit to counseling in terms of measured outcomes, including the large and highly-regarded POATS.<br />
<br />
In searching for an answer, the authors looked at two sources of variability - patient characteristics, and adherence to treatment. Specifically, the authors sought to answer three questions: 1) Did participants with more severe problems have better outcomes with SMM + ODC than with SMM alone (N=360)? 2) Among participants with adequate adherence to treatment, were those assigned to SMM + ODC more likely to have successful outcomes than those receiving SMM alone, regardless of severity (n = 266)? And 3), among participants with adequate adherence to treatment, were those with more severe problems more likely to succeed with additional counseling than with standard medical management only (n = 266)?<br />
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In response to question 1, the analysis found that "the association between severity and outcome did not vary by treatment condition for any of the three severity measures." Those without past use of heroin had more favorable outcomes across the entire study. Regarding question 2, "adequate adherence" was defined as attending at least 60% of scheduled scheduled sessions in both treatment conditions, and most participants (73.9%) attended at least 60% of sessions. Subjects in the SMM-only condition were more likely meet this criterion but, once again, outcomes did not differ by treatment condition. Finally, in answering question 3, the authors found that, "Among participants who had ever used heroin, those assigned to SMM + ODC were more likely to succeed than those in SMM only (66.7% vs. 35.0%, n = 70, χ2(1) = 6.88, p=.016)."<br />
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<b><span style="font-size: 8.0pt;">Table 1</span></b><br />
<div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">Likelihood of successful opioid use outcomes at Phase
2, weeks 9–12. <sup><a href="https://www-clinicalkey-com.ezp2.lib.umn.edu/#tblfn0005">a</a></sup><o:p></o:p></span></div>
<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="background: white; border-collapse: collapse; mso-padding-alt: 0in 0in 0in 0in; mso-yfti-tbllook: 1184; width: 747px;">
<thead>
<tr>
<td style="background: #DFF3FF; border-bottom: solid #CCCCCC 1.0pt; border-left: none; border-right: none; border-top: solid #CCCCCC 1.0pt; mso-border-bottom-alt: solid #CCCCCC .75pt; mso-border-top-alt: solid #CCCCCC .75pt; padding: 0in 0in 0in 0in;" valign="top"></td>
<td style="background: #DFF3FF; border-bottom: solid #CCCCCC 1.0pt; border-left: none; border-right: none; border-top: solid #CCCCCC 1.0pt; mso-border-bottom-alt: solid #CCCCCC .75pt; mso-border-top-alt: solid #CCCCCC .75pt; padding: 0in 0in 0in 0in;" valign="top"><div align="left" class="MsoNormal">
<b><span style="font-size: 8.0pt;">OR<o:p></o:p></span></b></div>
</td>
<td style="background: #DFF3FF; border-bottom: solid #CCCCCC 1.0pt; border-left: none; border-right: none; border-top: solid #CCCCCC 1.0pt; mso-border-bottom-alt: solid #CCCCCC .75pt; mso-border-top-alt: solid #CCCCCC .75pt; padding: 0in 0in 0in 0in;" valign="top"><div align="left" class="MsoNormal">
<b><span style="font-size: 8.0pt;">95% CI p Value</span></b></div>
</td><td style="background: #DFF3FF; border-bottom: solid #CCCCCC 1.0pt; border-left: none; border-right: none; border-top: solid #CCCCCC 1.0pt; mso-border-bottom-alt: solid #CCCCCC .75pt; mso-border-top-alt: solid #CCCCCC .75pt; padding: 0in 0in 0in 0in;" valign="top"></td>
</tr>
</thead>
<tbody>
<tr>
<td colspan="4" style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">(a) All participants ( <i>n</i>= 360)<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td colspan="4" style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">Main effects<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">Heroin<o:p></o:p></span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">2.0<o:p></o:p></span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">1.3–3.3 <o:p></o:p></span><b><span style="font-size: 8pt;">.004</span></b></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<br /></div>
</td>
</tr>
<tr>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">Chronic pain<o:p></o:p></span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">1.3<o:p></o:p></span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">0.8–2.0 <o:p></o:p></span><span style="font-size: 11px;">.240</span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<br /></div>
</td>
</tr>
<tr>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">Drug severity<o:p></o:p></span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">2.9<o:p></o:p></span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">0.2–58.2 </span><span style="font-size: 11px;">.484</span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<br /></div>
</td>
</tr>
<tr>
<td colspan="4" style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">Interaction with Phase 2 treatment<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">Heroin<o:p></o:p></span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">1.6<o:p></o:p></span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">0.6–4.2 <o:p></o:p></span><span style="font-size: 11px;">.342</span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<br /></div>
</td>
</tr>
<tr>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">Chronic pain<o:p></o:p></span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">0.6<o:p></o:p></span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">0.2–1.4 <o:p></o:p></span><span style="font-size: 11px;">.218</span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<br /></div>
</td>
</tr>
<tr>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">Drug severity<o:p></o:p></span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">0.2<o:p></o:p></span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">0.0–76.8 <o:p></o:p></span><span style="font-size: 11px;">.585</span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">.<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td colspan="4" style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"></td>
</tr>
<tr>
<td colspan="4" style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">(b) Participants with adequate adherence to treatment
( <i>n</i>= 266)<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">Main effect of Phase 2 treatment<o:p></o:p></span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">0.7<o:p></o:p></span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">0.4–1.1 <o:p></o:p></span><span style="font-size: 11px;">.107</span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<br /></div>
</td>
</tr>
<tr>
<td colspan="4" style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">Interaction with Phase 2 treatment<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">Heroin<o:p></o:p></span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">3.7<o:p></o:p></span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">1.1–11.8 <o:p></o:p></span><b><span style="font-size: 8pt;">.03</span></b></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<br /></div>
</td>
</tr>
<tr>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">Chronic pain<o:p></o:p></span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">0.5<o:p></o:p></span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">0.2–1.5 <o:p></o:p></span><span style="font-size: 11px;">.213</span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<br /></div>
</td>
</tr>
<tr>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">Drug severity<o:p></o:p></span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">1.5<o:p></o:p></span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<span style="font-size: 8.0pt;">0.001–4023.5 <o:p></o:p></span><span style="font-size: 11px;">.915</span></div>
</td>
<td style="padding: 6.0pt 6.0pt 6.0pt 6.0pt;" valign="top"><div align="left" class="MsoNormal">
<br /></div>
</td>
</tr>
</tbody></table>
<div align="left" class="MsoNormal">
<sup><span style="font-size: 8.0pt;"><a href="https://www-clinicalkey-com.ezp2.lib.umn.edu/#inline-ref-tblfn0005">a</a> </span></sup><span style="font-size: 8.0pt;">All models were adjusted for Phase 1 treatment
condition.<o:p></o:p></span></div>
<div align="left" class="MsoNormal">
<br />
Treatment outcomes did not appear to differ among those who had never used heroin, suggesting that prescription opioid-addicted patients with a history of heroin use may be the participants who are most likely to benefit from additional counseling in suboxone treatment. Importantly, those patients had to also attend enough sessions (and receive an adequate "dose" of counseling) in order to see their outcomes improve to rates similar to those without a history of heroin use.<br />
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So, do these results line up with the experience of the readers of this blog? Are there populations with whom you believe counseling is especially important? Or, do the results simply reinforce the lessons of past studies? Let us know</div>
Anonymoushttp://www.blogger.com/profile/02083530358646742701noreply@blogger.com0tag:blogger.com,1999:blog-6154923121857389373.post-47093716169977549402014-04-17T07:05:00.003-05:002014-04-17T07:05:59.119-05:00Can THC Protect the Brain against Methamphetamine's Toxicity?<div>
A fascinating new study in the journal <i><a href="http://www.sciencedirect.com/science/article/pii/S0028390814001099" target="_blank">Neuropharmacology</a>, </i>suggests the brain's endocannabinoid system can be aided in its neuroprotective efforts against the toxicity of methamphetamine by introducing external cannabinoids to increase the system's "endogenous tone". The cannabinoids in question, THC, URB and JZL, appear to inhibit the breakdown of the brain's own endocannabinoids, improving the ability of the brain to protect itself against the "external insult" of overdoses of methamphetamine.<br />
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Here is the abstract, via ScienceDirect:<br />
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Abstract</h2>
<div id="abspara0010" style="background-color: white; border: 0px; color: #2e2e2e; font-family: 'Arial Unicode MS', 'Arial Unicode', Arial, 'URW Gothic L', Helvetica, Tahoma, sans-serif; font-size: 13px; line-height: 20px; margin-bottom: 9px; padding: 0px; text-align: justify; vertical-align: baseline; word-spacing: -0.15ex;">
Methamphetamine toxicity is associated with cell death and loss of dopamine neuron terminals in the striatum similar to what is found in some neurodegenerative diseases. Conversely, the endocannabinoid system (ECS) has been suggested to be neuroprotective in the brain, and new pharmacological tools have been developed to increase their endogenous tone. In this study, we evaluated whether ECS stimulation could reduce the neurotoxicity of high doses of methamphetamine on the dopamine system. We found that methamphetamine alters the levels of the major endocannabinoids, anandamide (AEA) and 2-arachidonoyl glycerol (2-AG) in the striatum, suggesting that the ECS participates in the brain responses to methamphetamine. Δ<sup style="border: 0px; font-size: 0.75em; line-height: 0; margin: 0px; padding: 0px;">9</sup>-tetrahydrocannabinol (THC), a cannabis-derived agonist of both CB<sub style="border: 0px; font-size: 0.75em; line-height: 0; margin: 0px; padding: 0px;">1</sub> and CB<sub style="border: 0px; font-size: 0.75em; line-height: 0; margin: 0px; padding: 0px;">2</sub>cannabinoid receptors, or inhibitors of the main enzymes responsible for the degradation of AEA and 2-AG (URB597 and JZL184, respectively), blunted the decrease in striatal protein levels of tyrosine hydroxylase induced by methamphetamine. In addition, antagonists of CB<sub style="border: 0px; font-size: 0.75em; line-height: 0; margin: 0px; padding: 0px;">2</sub>, but not of CB<sub style="border: 0px; font-size: 0.75em; line-height: 0; margin: 0px; padding: 0px;">1</sub>, blocked the preventive effects of URB597 and JZL184, suggesting that only the former receptor subtype is engaged in neuroprotection exerted by ECS stimulation. Finally, we found that methamphetamine increases striatal levels of the cytokine tumor necrosis factor alpha, an effect that was blocked by ECS stimulation. Altogether, our results indicate that stimulation of ECS prior to the administration of an overdose of methamphetamine considerably reduces the neurotoxicity of the drug through CB<sub style="border: 0px; font-size: 0.75em; line-height: 0; margin: 0px; padding: 0px;">2</sub> receptor activation and highlight a protective function for the ECS against the toxicity induced by drugs and other external insults to the brain.</div>
And here is a table showing levels of two of the major endocannabinoids, AEA and 2-AG, following doses of methamphetamine:<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEigBXfvFZQd5ctYAvvEHZA1x-TUzQNsI3GtNML2Ucn17R1ClZZTba71dplsxnu4icULkXUZXesajVQj5zkHIBzbWwnuuRQHRCXRUZ9WJ-l_T5g8SuXiht2NxYELI0Vs56VbAMGY6UPKFj5v/s1600/1-s2.0-S0028390814001099-gr1.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEigBXfvFZQd5ctYAvvEHZA1x-TUzQNsI3GtNML2Ucn17R1ClZZTba71dplsxnu4icULkXUZXesajVQj5zkHIBzbWwnuuRQHRCXRUZ9WJ-l_T5g8SuXiht2NxYELI0Vs56VbAMGY6UPKFj5v/s1600/1-s2.0-S0028390814001099-gr1.jpg" height="640" width="361" /></a></div>
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And finally striatal levels of the cytokine tumor necrosis factor alpha:<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4zslbU_ekLUb3APPW20BSFhhiz5HGP_ay8sLeOldGI7lXkls-Uo7lhN3iHYX5I8KtQbPyfg6CZreOtog0LRDXU9BgOvkNYwPPEywONONbw9e9orU5QW08sfU-aL7Fy-yyZbDqcdlOQX3Z/s1600/1-s2.0-S0028390814001099-gr5.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4zslbU_ekLUb3APPW20BSFhhiz5HGP_ay8sLeOldGI7lXkls-Uo7lhN3iHYX5I8KtQbPyfg6CZreOtog0LRDXU9BgOvkNYwPPEywONONbw9e9orU5QW08sfU-aL7Fy-yyZbDqcdlOQX3Z/s1600/1-s2.0-S0028390814001099-gr5.jpg" height="305" width="400" /></a></div>
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Source:<br />
http://www.sciencedirect.com/science/article/pii/S0028390814001099<br />
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<br />Anonymoushttp://www.blogger.com/profile/02083530358646742701noreply@blogger.com0tag:blogger.com,1999:blog-6154923121857389373.post-50559155144482308092014-04-04T07:30:00.003-05:002014-04-04T07:30:52.155-05:00Baclofen Shows Promise for Treating Relapse in Cocaine Use DisordersVia <i><a href="http://www.sciencedaily.com/releases/2014/04/140401172914.htm" target="_blank">ScienceDaily</a>:</i><br />
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<div id="first" style="margin: -2px 0px 3px; padding: 5px 0px;">
<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">Relapse is the most painful and expensive feature of drug addiction -- even after addicted individuals have been drug-free for months or years, the likelihood of sliding back into the habit remains high. The National Institute on Drug Abuse estimates that 40 to 60 percent of addicted individuals will relapse, and in some studies the rates are as high as 80 percent at six months after treatment. Though some relapse triggers can be consciously avoided, such as people, places and things related to drug use, other subconscious triggers related to the brain's reward system may be impossible to avoid -- they can gain entry to the unconscious brain, setting the stage for relapse.</span></div>
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<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">Researchers at Penn Medicine's Center for Studies of Addiction have now found that the drug baclofen, commonly used to prevent spasms in patients with spinal cord injuries and neurological disorders, can help block the impact of the brain's response to "unconscious" drug triggers well before conscious craving occurs. They suggest that this mechanism has the potential to prevent cocaine relapse. The new findings are reported in the <em>Journal of Neuroscience</em>.</span></div>
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<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">"The study was inspired by patients who had experienced moments of 'volcanic craving', being suddenly overcome by the extreme desire for cocaine, but without a trigger that they could put their finger on," says senior author Anna Rose Childress, PhD,research professor of Psychiatry, director of the Brain-Behavioral Vulnerabilities Division in the Perelman School of Medicine at the University of Pennsylvania. Dr. Childress and colleagues previously found that subliminal drug "reminder cues" (the sights, sounds, smells, and memories of the drug) could activate the brain's reward circuit. "Now, we wanted to understand whether a medication could inhibit these early brain responses," said Childress.</span></div>
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<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">Kimberly Young, PhD, an NIH/NIDA Post-doctoral Fellow at Penn, and first author of the study explained that, "Drug reward and motivation is largely mediated by dopamine transmission in the brain's reward circuit -- even drug "reminder cues" can cause dopamine release. Since baclofen and similar medications reduce these effects in laboratory animals, we wanted to examine whether it could prevent drug-cue induced activation in the human brain."</span></div>
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<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">The study tested baclofen, which was approved by the U.S. Food and Drug Administration in 1977 for spasm, on 23 cocaine-dependent men, ages 18 to 55. Each reported using cocaine on at least eight of 30 days before screening. Inclusion in the study required that they stay for up to 10 days in a supervised inpatient drug treatment facility, be drug-free for the duration, not be on any medication affecting dopamine or neurotransmitter response, and have no history of psychosis, seizures, or brain syndromes unrelated to cocaine use.</span></div>
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<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">Upon admission, patients were randomized to receive baclofen or placebo. Over the first six days, patients in the baclofen group received the medication in increasing dosage to 60 mg. While on the full 60 mg dose of baclofen, patients were placed in an fMRI and shown a series of images, to measure their neural responses to "ultra-brief" pictures of cocaine or other comparison pictures. Each of the ultra-brief 33 msec "target" pictures was immediately followed by longer picture of non-drug objects or scenes. Under these conditions, the participants are aware of the longer pictures, but the ultra-brief target pictures remain completely outside conscious awareness -- they are "backward-masked."</span></div>
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<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">"We wanted to present the key stimulus: images of drug use and preparation, sexual images, and other aversive images in a way such that the brain could not consciously process them, but so that we could measure their earliest, subconscious effect on the brain," said Childress.</span></div>
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<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">What the team found was that the patients who were treated with baclofen showed a significantly lower response in the reward and motivational circuits to subliminal cocaine cues versus neutral cues, as compared to the placebo-treated control group. In addition, no difference was seen in the active versus the control group in their response to sexual and aversive cues, indicating that the effects of baclofen on cue-induced brain activation were specific to drug cues.</span></div>
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<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">"These findings suggest that the brain response to drug cues presented outside of awareness can be pharmacologically inhibited, providing a mechanism for baclofen's potential therapeutic benefit in addiction," says Young. "Further studies will show whether the prevention of these early brain responses is associated with reduced rates of craving and relapse in cocaine-dependent patients," added Childress. </span></div>
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<span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">Source: </span><a href="http://www.sciencedaily.com/releases/2014/04/140401172914.htm?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+sciencedaily%2Fmind_brain%2Faddiction+%28Addiction+News+--+ScienceDaily%29" style="font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif;">http://www.sciencedaily.com/releases/2014/04/140401172914.htm</a></div>
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This could be exciting news for one of the most difficult substance use disorders to treat. Does anyone have experience using baclofen with patients with cocaine use disorders?</div>
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Anonymoushttp://www.blogger.com/profile/02083530358646742701noreply@blogger.com0tag:blogger.com,1999:blog-6154923121857389373.post-1723629677741437952014-03-31T20:59:00.001-05:002014-03-31T21:03:01.462-05:00Study: Are Drug Screens Sufficient for Adolescent Treatment?Could it be that we are missing something when it comes to treating adolescents with a substance use disorder? According to a study in the most recent edition of the <i><a href="http://www.jsad.com/jsad/article/Effectiveness_of_Treatment_for_Adolescent_Substance_Use_Is_Biological_Drug/4940.html" target="_blank">Journal of Studies on Alcohol Drugs</a></i>, if you aren't using drug screens when treating this population, the answer is likely "Yes".<br />
In the article, Schuler, et al. looked at data from SAMHSA's <a href="http://beta.samhsa.gov/about-us/who-we-are/offices-centers/csat" target="_blank">CSAT</a> 2007 adolescent treatment database, which tracks outcomes for CSAT-sponsored providers. The total sample consisted of 5,186 adolescents who received either Motivational Enhancement Therapy/Cognitive Behavioral Therapy5 (MET/CBT5) - with or without biological drug screen (BDS) - or were part of the BDS-only or No-Treatment groups within another study. Below is a breakdown of the subjects:<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjLz9G4x22xaX42hiJJ5aU_qGbFarrMwp0pxYAZaGdAdnZOMDxRF8VEQ9VOmcLx0yzXEdmB4z7xPP8yZWjgcmWUKMi8wNXNC9zRNryWBl2SUUdZy65bpsjCFrg6rbQQ19TnvJ_gmXiER9M3/s1600/22222222222222222.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjLz9G4x22xaX42hiJJ5aU_qGbFarrMwp0pxYAZaGdAdnZOMDxRF8VEQ9VOmcLx0yzXEdmB4z7xPP8yZWjgcmWUKMi8wNXNC9zRNryWBl2SUUdZy65bpsjCFrg6rbQQ19TnvJ_gmXiER9M3/s1600/22222222222222222.png" height="364" width="640" /></a></div>
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All participants responded to the GAIN structured clinical interview, so scores on the Substance Use Frequency Scale and Substance Problem Scale were the primary outcomes measured. Propensity score methods were used to adjust for baseline differences among youth in the four groups, given the non-randomized nature of the data. The results are striking:<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhjVJpgVTYU92MUNrpkK_KrbxbtbDGb9JdTmhT87Vi9TeUvbRFvAwT3D-THjXgemprf52kRrSpVWgPdUPwqnshh9rHnJmNyeSz686Z66-7ZqD2lfoyFuN5Vc3o-WkaMPS-OAxPu_8qjx-nn/s1600/aaaaa.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhjVJpgVTYU92MUNrpkK_KrbxbtbDGb9JdTmhT87Vi9TeUvbRFvAwT3D-THjXgemprf52kRrSpVWgPdUPwqnshh9rHnJmNyeSz686Z66-7ZqD2lfoyFuN5Vc3o-WkaMPS-OAxPu_8qjx-nn/s1600/aaaaa.png" height="442" width="640" /></a></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgUF217kkqFcR8_D3ATKzkzd_Y2H1KdcHcWSDLLVq_08tqSahmEF3Mz-j9uyQn2vZJo-wQk8bFL1k7Na6wMFhWn6QZF76X11hNk0sDjAgD-Q-tSj-K3haGAdZ1X-BkNsfyv-kFVqTL3b9hq/s1600/111111111.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgUF217kkqFcR8_D3ATKzkzd_Y2H1KdcHcWSDLLVq_08tqSahmEF3Mz-j9uyQn2vZJo-wQk8bFL1k7Na6wMFhWn6QZF76X11hNk0sDjAgD-Q-tSj-K3haGAdZ1X-BkNsfyv-kFVqTL3b9hq/s1600/111111111.png" height="442" width="640" /></a></div>
The BDS-only condition seemed to outperform all groups at baseline, 3-, 6- and 12-months on Substance Problem Scale scores and at 6- and 12-months on Substance Frequency Scale scores.<br />
What could account for the significant differences? The authors point out that many adolescents who are involved in treatment and/or the criminal justice system may earn rewards for negative drug screens - or face significant consequences for positive screens. Therefore, the self-report nature of the data could skew the results. That would not necessarily explain the consistent differences across groups, however.<br />
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What do you think about these results? If you work with adolescents, does this surprise you? Could evidence like this impact the interventions you use?<br />
<br />Anonymoushttp://www.blogger.com/profile/02083530358646742701noreply@blogger.com0tag:blogger.com,1999:blog-6154923121857389373.post-75303360085070760712014-03-21T06:18:00.000-05:002014-03-21T06:18:06.503-05:00What Aren't More Docs Prescribing Buprenorphine?<div>
On the heels of recent coverage over the <a href="http://www.nytimes.com/2013/11/17/health/in-demand-in-clinics-and-on-the-street-bupe-can-be-savior-or-menace.html" target="_blank">"dangers"</a> of the medication buprenorphine, researchers are seeking to better understand what keeps doctors from using one of the two the most effective tools for opioid use disorders at their disposal. The most recent study, "Barriers to Primary Care Physicians Prescribing Buprenorphine", was published in the <i>Annals of Family Medicine</i> and<a href="http://annfammed.org/content/12/2/128.full" target="_blank"> is available in-full online</a> - for free. The study came out of the Rural Opioid Addiction Management in Washington state, during which 120 physicians were trained in opioid addiction and buprenorphine prescribing. Disappointingly, of the 78 respondents who were analyzed for the study, 50 went on to obtain a DATA waiver, yet a mere 22 doctors ever went on to prescribe the medication to anyone. It begs the question: why aren't more docs prescribing buprenorphine?</div>
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Here's the breakdown from the piece of perceived barriers to prescribing:<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjJEgkHgVWthlvaLPRwZ8R77ASoOBp1i-mUoHAE9yyHm9yeLPwWLqyZp5hjpPoUdR7UudXBJ-itoXq4MJq81pcMVY_iRsNZYQl3yjKc429VjuRvXlrxqsejDwtYKWh-0lahpennLnW9OpwV/s1600/F1.large.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjJEgkHgVWthlvaLPRwZ8R77ASoOBp1i-mUoHAE9yyHm9yeLPwWLqyZp5hjpPoUdR7UudXBJ-itoXq4MJq81pcMVY_iRsNZYQl3yjKc429VjuRvXlrxqsejDwtYKWh-0lahpennLnW9OpwV/s1600/F1.large.jpg" height="408" width="640" /></a></div>
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Among the barriers cited by the doctors in the study, "Lack of psychosocial support" was cited as the number one barrier by both prescribers and non-prescribers, despite the lack of evidence that<a href="http://www.ascpjournal.org/content/7/1/10" target="_blank"> behavioral adjuncts</a> or a<a href="http://mattsub.blogspot.com/2013/07/buprenorphine-4counseling-0-it-hasnt.html" target="_blank">dditional counseling improve</a> outcomes. (Granted, the authors point out that in order to get reimbursed by a number of payers, additional counseling must be offered to patients.)<br />
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A quick scan across the literature leads us to another important and common driver of physician attitudes toward this medication: institutional support. It appears that <a href="http://www.sciencedirect.com/science/article/pii/S0740547213002201">study</a> after <a href="https://www.stfm.org/fmhub/fm2006/May/Chinazo336.pdf">study</a> cite the impact of the hospital/clinic/practice culture on the subsequent interest. training and prescription of buprenorphine by its docs. In the present study, "resistance from practice partners" and "lack of institutional support" were commonly cited as barriers. <a href="http://www.journalofsubstanceabusetreatment.com/article/S0740-5472(13)00220-1/abstract" target="_blank">A recent article from the March</a> issue of the<i><a href="http://www.journalofsubstanceabusetreatment.com/home" target="_blank"> Journal of Substance Abuse Treatment</a></i> described how important "A strong leader championing the new treatment" was to the implementation of buprenorphine prescribing across a large system. <div class="separator" style="clear: both;">
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What do you think? How can we be more effective at impacting change at the prescriber level? If culture plays an important role, how do we improve the culture around this proven tool?</div>
Anonymoushttp://www.blogger.com/profile/02083530358646742701noreply@blogger.com0tag:blogger.com,1999:blog-6154923121857389373.post-83020325660115700472014-03-17T08:48:00.000-05:002014-03-17T08:48:43.992-05:00Is Addiction Always Permanent?Recently, a colleague challenged what he perceived to be my "insistence that addiction is permanent." Here is my reply:<br />
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Dear John (not his real name):</div>
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As you know, I'm well aware of the studies regarding the life course of people who at some point in their lives meet dxic criteria for a SUD. And also, as you are aware, I've been talking about that, and therefore the need to have a wider continuum of care and to individualize approaches to SUDs for at least 10 years. In my presentation, Alcoholism Isn't What It Used to Be, which you frequently reference, I point out that 20 years after onset of DSM IV Alcohol Dependence, the most common outcome is low-risk drinking (40%), followed by abstinence (roughly 1/3), partial remission (about 20%) and then finally currently dependent (8%). So I'm not sure what the basis is for concluding that I have made blanket statements about ALL addicts in ALL circumstances.</div>
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What I do believe, and here I think the science and epidemiology are equally persuasive, is that in the case of severe addiction, there are brain neuroadaptations that are irreversible. For example, the likelihood of achieving non-abstinent recovery is inversely related to the severity of alcohol dependence. Conversely, abstinent outcomes become more likely as severity increases. This is as true in rodents as in humans. Since rehab and AA are populated almost exclusively by people at the very severe end of the spectrum, the likelihood of sustained non-abstinent recovery for current treatment seekers or AA members is relatively low. Thus, the AA stance is accurate for most AA members. Severity of dependence is the strongest predictor of AA affiliation, especially long-term affiliation, as opposed to a few weeks or months after a spell in rehab. Established heroin or other opioid addiction is another example; thus buprenorphine and methadone maintenance and the virtually complete failure of abstinence (or moderation) for treatment seekers. Those who could stop on the their own do so and therefore do not present for tx. That, of course, is a function of the awfulness, expense, stigmatization and disruption most current treatment includes.</div>
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At Alltyr Clinic, for example, I have seen many pts who come with a mild AUD who achieve non-abstinent recovery.</div>
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Just as abstinence is not a requirement for everyone who develops a SUD, neither is moderation possible for a sizeable proportion of them. The size varies by drug: Probably close to 100% of dependent smokers will require lifelong abstinence, whereas, most cannabis users will not, etc. Heroin, meth and cocaine addiction also probably have high to relatively high proportions where abstinence (which includes people taking opioid agonist therapy) is the only positive outcome option. In alcohol, I think it's probably somewhere in the middle, a large minority achieve non-abstinent recovery.</div>
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So the newer data simply seem to affirm the NESARC data, that conclusions have been based on clinical samples, and that if you look at community samples, the picture is very different. That's true for almost all common complex diseases, such as asthma or arthritis or even hypertension, the difference being that with SUDs there is a very high full remission rate, something that happens in very few other common complex diseases. Depression is very likely to be a pretty good analogue as well.</div>
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Finally, noting that many people have milder, self-limiting forms of SUDs doesn't mean they aren't brain disesases. How can you have a behavioral illness that doesn't include failures in brain regulation of behavior? It's just that in too many instances, people misinterpret "brain disease" to mean "permanent". Also, it hasn't helped that NIDA and SAMHSA keep stressing the chronicity of addiction, something I constantly fought against when i was at NIH. It's often not chronic. Neither is asthma, but I suspect you wouldn't have trouble thinking of mild, self-limited childhood asthma as a lung disease, or immune disease.</div>
Mark Willenbring, MDhttp://www.blogger.com/profile/10556707753571367243noreply@blogger.com0tag:blogger.com,1999:blog-6154923121857389373.post-23021137217060468422014-03-13T18:30:00.000-05:002014-03-13T18:30:01.635-05:00Americans Spending $100 Billion on Illegal Drugs AnnuallyThe U.S. White House Office of National Drug Control Policy (ONDCP) commissioned the RAND Corporation to investigate how much Americans were spending on the four most common illegal drugs from 2000-2010. <a href="http://www.whitehouse.gov/sites/default/files/ondcp/policy-and-research/wausid_results_report.pdf">The study</a>, published recently on the <a href="http://www.whitehouse.gov/ondcp/research-and-data/estimation-drug-expenditures-consumption-supply">whitehouse.gov </a>website, uses a variety of sources to develop an estimate in yearly spending by consumers of cannabis, heroin, cocaine (including crack), and methamphetamine. Their conclusion: over $100 billion is spent on just these four drugs, every year. Interestingly, this number has stayed relatively constant throughout the past decade, despite the <a href="http://www.whitehouse.gov/sites/default/files/ondcp/about-content/fy_2015_budget_highlights_-_final.pdf">$25.2 billion that was spent "</a><a href="http://www.whitehouse.gov/sites/default/files/ondcp/about-content/fy_2015_budget_highlights_-_final.pdf">to reduce drug use and its consequences</a>" in the US in fiscal year 2014 alone (!).<br /><br />Since 2002, spending on cocaine and marijuana has flipped. Researchers note that cocaine consumption has dropped by about half, while marijuana consumption has increased by around 40%. Heroin consumption has remained stable throughout the decade, with a small increase detected in the later years. Methamphetamine consumption, the authors note, has been harder to track, as "national datasets do not do a good job of capturing its use." Across the board, heavy users are the main drivers of spending and consumption, and are defined as folks who use at least 21 days/month.<div>
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The authors culled data from a variety of sources, including the National Survey on Drug Use and Health, the Arrestee Drug Abuse Monitoring Program, various law enforcement and seizure databases, and more. Despite the apparent rigor involved in the creation of these estimates, the authors caution about the inherent uncertainty in this type of data analysis - especially considering that the bulk of the data came from self-report surveys.</div>
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Nevertheless, the fact remains that despite the increasing public investments in the so-called War on Drugs, demand-side consumption and expenditures are constant or rising throughout the country. Could this be one reason the <a href="http://www.nytimes.com/2014/03/14/us/politics/holder-endorses-proposal-to-reduce-drug-sentences.html?_r=0" target="_blank">Attorney General has agreed</a> to endorse changes to Federal drug sentencing? What do readers think about the current state of availability and expense?</div>
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You can read the full report here:</div>
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Anonymoushttp://www.blogger.com/profile/02083530358646742701noreply@blogger.com0tag:blogger.com,1999:blog-6154923121857389373.post-34172211616131145972014-03-06T22:30:00.001-06:002014-03-06T22:30:14.721-06:00"First Controlled Study of LSD-Assisted Psychotherapy in More Than 40 Years"Researchers from Switzerland and the Multidisciplinary Association for Psychedelic Studies have conducted what they are calling the first study of its kind in over 40 years: a randomized, double-blind, active placebo-controlled study of LSD-assisted psychotherapy. The participants, 12 patients with anxiety related to life-threatening illnesses like metastatic cancer, non-Hodgkin's lymphoma, Parkinson's disease, etc., participated in drug-free therapy sessions as well as 2 LSD-assisted psychotherapy sessions over the course of the study. Follow-up interviews were conducted at 2- and 12-months post-treatment and indicated lasting, statistically-significant improvements in anxiety. The study is posted in its entirety for free online via <i><a href="http://journals.lww.com/jonmd/Documents/90000000.0-00001.pdf" target="_blank">The Journal of Nervous and Mental Disease</a></i>.<br />
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The main outcome measures were scores on the <a href="http://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/trait-state.aspx" target="_blank">State-Trait Anxiety Inventory</a> (STAI). Exclusion criteria included current drug or alcohol disorders, primary psychotic, dissociative or bipolar 1 disorders, neurocognitive impairment or pregnancy/nursing. Participants in the experimental arm participated in 2 full-day LSD-assisted psychotherapy sessions, 2 to 3 weeks apart, that were "embedded within an ongoing process of [six]drug-free psychotherapy sessions for preparatory and integrative purposes." Subjects received doses of 200 micrograms of pure LSD and the day-long sessions lasted 8 hours, or until the effects of the medication wore off. Participants in the active placebo group received the exact same set of psychotherapy sessions, but were given 20-microgram doses of LSD. After the 2-month follow-up interview, these participants were informed of their place in the control group and were offered the full, open-label intervention.<br />
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The results indicate statistically significant STAI scores for both state and trait anxiety at 2 and 12 months for the experimental groups. The active placebo did not produce statistically-significant improvements. The researchers calculate the effect size at 1.1 for trait anxiety, and 1.2 for state anxiety. They also, as you would imagine, call for more research with larger controlled studies. Importantly, neither the experimental drug nor the placebo produced any serious adverse effects, leading the authors to seem confident in the safety of this type of therapy.<br />
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Considering the research on LSD ground to a halt by the 1970s, do readers think it's time to revisit this(<a href="http://www.maps.org/research/psilo-lsd/" target="_blank">or other psychedelics</a>, for that matter) as a therapeutic tool? If you have experience with this, it would be fascinating to hear your take, too.<br />
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Interested to hear readers opinions on the matter...<br />
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Source:<br />
<a href="http://journals.lww.com/jonmd/Documents/90000000.0-00001.pdf">http://journals.lww.com/jonmd/Documents/90000000.0-00001.pdf</a>Anonymoushttp://www.blogger.com/profile/02083530358646742701noreply@blogger.com0tag:blogger.com,1999:blog-6154923121857389373.post-73728570641639739822014-02-27T20:43:00.001-06:002014-03-02T10:01:09.477-06:00Can Alcohol Dependent Patients Adhere to an ‘As-Needed' Medication
Regimen? Yes: Study<div>According to researchers, AUD patients can benefit from as-needed medication regimens:</div><div><br></div>Abstract:<div><p class="small" style="margin: 0px 0px 20px;"><span style="-webkit-text-size-adjust: auto; background-color: rgba(255, 255, 255, 0);">A pooled analysis of ‘as-needed medication use' data from 1,276 patients in two randomised, double-blind, placebo-controlled, parallel-group trials of nalmefene in the treatment of alcohol dependence was performed to explore whether an ‘as-needed' regimen is an acceptable and feasible strategy in patients seeking help for alcohol dependence. Adherence was defined as alcohol consumption and medication intake, or no alcohol consumption (with or without medication intake). Nalmefene was taken on approximately half of the study days; placebo was taken more often than nalmefene (52.8 vs. 64.5% of days, respectively). In each treatment group medication intake appeared to vary according to patients' needs in that intake correlated with the baseline drinking pattern. Sixty-eight percent of the nalmefene-treated patients (78% of the study completers) adhered to the as-needed treatment regimen on at least 80% of the study days. In conclusion, as-needed use is a feasible, patient-centred approach that engages patients with alcohol dependence in the active management of their illness. © 2014 S. Karger AG, Basel</span></p></div><div>Source: <a href="http://www.karger.com/Article/FullText/357865" style="font-family: 'Helvetica Neue Light', HelveticaNeue-Light, helvetica, arial, sans-serif;">http://www.karger.com/Article/FullText/357865</a></div>Anonymoushttp://www.blogger.com/profile/02083530358646742701noreply@blogger.com0