This new research identifies how cocaine changes the configuration of receptors and function in the reward areas of the brain. It adds to the evidence that an increase in glutamate is a key feature of addiction. Some of the medications currently used for alcohol dependence, such as topiramate, baclofen and acamprosate, may work by helping to restore the balance between glutamate and GABA.
MW
Cocaine inverts rules for synaptic plasticity of glutamate transmission in the ventral tegmental area
Manuel Mameli, Camilla Bellone, Matthew T C Brown & Christian Lüscher
Nature Neuroscience (2011) 14, 414-416
The manner in which drug-evoked synaptic plasticity affects reward circuits remains largely elusive. We found that cocaine reduced NMDA receptor excitatory postsynaptic currents and inserted GluA2–lacking AMPA receptors in dopamine neurons of mice. Consequently, a stimulation protocol pairing glutamate release with hyperpolarizing current injections further strengthened synapses after cocaine treatment. Our data suggest that early cocaine-evoked plasticity in the ventral tegmental area inverts the rules for activity-dependent plasticity, eventually leading to addictive behavior.
Tuesday, March 29, 2011
Sunday, March 27, 2011
Treating Pain Is a Real Pain
Our current tools for treating chronic severe pain are inadequate at best. Opioids such as morphine or methadone reduce chronic pain on average about 30%, with a range of perhaps 0-50%. And of course they come with multiple liabilities, such as constipation, sweating, nausea and physiological tolerance which means that symptoms occur if the drug is suddenly stopped. Although unproven there is concern that chronic use of these medications could actually increase pain sensitivity. Other methods such as cognitive behavioral therapy, moderate exercise, physical therapy, injections, surgery, neurostimulators, biofeedback, etc., have a modest impact if any. We desperately need new tools. This article describes new research on a compound that may reduce pain without the disadvantages of opioids. Cannabinoid receptors, by the way, are those that responde to drugs like marijuana and hashish. There are more of these receptors in peripheral tissues than the brain. It is possible that the effect of cannabis on pain are due to their effects on these peripheral receptors.
MW
Anandamide suppresses pain initiation through a peripheral endocannabinoid mechanism
Jason R Clapper, Guillermo Moreno-Sanz, Roberto Russo, Ana Guijarro, Federica Vacondio, Andrea Duranti, Andrea Tontini, Silvano Sanchini, Natale R Sciolino, Jessica M Spradley, Andrea G Hohmann, Antonio Calignano, Marco Mor, Giorgio Tarzia & Daniele Piomelli
Nature Neuroscience 13, 1265–1270 (2010) doi:10.1038/nn.2632
Peripheral cannabinoid receptors exert a powerful inhibitory control over pain initiation, but the endocannabinoid signal that normally engages this intrinsic analgesic mechanism is unknown. To address this question, we developed a peripherally restricted inhibitor (URB937) of fatty acid amide hydrolase (FAAH), the enzyme responsible for the degradation of the endocannabinoid anandamide. URB937 suppressed FAAH activity and increased anandamide levels outside the rodent CNS. Despite its inability to access brain and spinal cord, URB937 attenuated behavioral responses indicative of persistent pain in rodent models of peripheral nerve injury and inflammation and prevented noxious stimulus–evoked neuronal activation in spinal cord regions implicated in nociceptive processing. CB1 cannabinoid receptor blockade prevented these effects. These results suggest that anandamide-mediated signaling at peripheral CB1 receptors controls the access of pain-related inputs to the CNS. Brain-impenetrant FAAH inhibitors, which strengthen this gating mechanism, might offer a new approach to pain therapy.
MW
Anandamide suppresses pain initiation through a peripheral endocannabinoid mechanism
Jason R Clapper, Guillermo Moreno-Sanz, Roberto Russo, Ana Guijarro, Federica Vacondio, Andrea Duranti, Andrea Tontini, Silvano Sanchini, Natale R Sciolino, Jessica M Spradley, Andrea G Hohmann, Antonio Calignano, Marco Mor, Giorgio Tarzia & Daniele Piomelli
Nature Neuroscience 13, 1265–1270 (2010) doi:10.1038/nn.2632
Peripheral cannabinoid receptors exert a powerful inhibitory control over pain initiation, but the endocannabinoid signal that normally engages this intrinsic analgesic mechanism is unknown. To address this question, we developed a peripherally restricted inhibitor (URB937) of fatty acid amide hydrolase (FAAH), the enzyme responsible for the degradation of the endocannabinoid anandamide. URB937 suppressed FAAH activity and increased anandamide levels outside the rodent CNS. Despite its inability to access brain and spinal cord, URB937 attenuated behavioral responses indicative of persistent pain in rodent models of peripheral nerve injury and inflammation and prevented noxious stimulus–evoked neuronal activation in spinal cord regions implicated in nociceptive processing. CB1 cannabinoid receptor blockade prevented these effects. These results suggest that anandamide-mediated signaling at peripheral CB1 receptors controls the access of pain-related inputs to the CNS. Brain-impenetrant FAAH inhibitors, which strengthen this gating mechanism, might offer a new approach to pain therapy.
Friday, March 25, 2011
More on treatment for opioid addiction
Here is the text of a letter I sent today to a reporter at Minnesota Public Radio. They had previously run a program that was neither accurate nor complete.
MW
Dear Kerri,
I'm writing about your recent program on painkiller addiction. Unfortunately, I was not able to join the call, but became aware of it after the fact. I appreciate your attention to this problem, as it is particularly affecting young people.
I have been an addiction psychiatrist for over 30 years, and I have treated something like 1500 opioid addicts including about 30 in my current practice. In addition, I am an expert in treating highly complex pain patients who are using opioids. I used to run the addiction program at the VAMC in Minnepolis, which included a methadone maintenance clinic and eventually Suboxone treatment. From 2004 to 2009 I was Director of the Division of Treatment and Recovery Research at the National Institute on Alcohol Abuse and Alcoholism. (Not to brag, but I wanted to give you some sense of bona fides.)
One area where addiction treatment in the US really lags is in making scientifically based treatment available to people who need it, or even informing them of the evidence and their options. This is no where more true than opioid addiction. There are now multiple well done randomized controlled trials that have unequivocally and without exception found that for established (>1 year) opioid addiction, the only proven effective treatment is long-term opioid maintenance with either methadone or Suboxone. The most recent study, reported last spring at the American Psychiatric Association, focused on prescription opioid addicts, not heroin addicts. (Most previous research has been on heroin addicts.) This large and very well done study found that even after 9 months of Suboxone maintenance, along with enhanced psychosocial (behavioral) treatment of a quality far in excess of that available in the community, the relapse rate after tapering off of Suboxone was 95%. A recent naturalistic study in the UK followed opioid addicts who sought treatment. Those choosing abstinence had twice the mortality rate in the following year as compared to maintenance. These are only two of the most recent studies. There are dozens more. Among experts on opioid dependence, there is no controversy about this. (To anticipate a possible counterargument, there is evidence that an injectible drug that blocks the effects of opioids may be effective during the period when someone is on probation under the condition of agreement. However it is also true that almost all relapse as soon as they are off probation.)
Here's the problem. Due to devotion to 12-step concepts of addiction (which are not scientifically grounded), most treatment programs in the US fail to inform people of this evidence, let alone offer to provide it. Opioid dependence continues to be treated with an abstinence based approach grounded in the 12 steps. When the predictable relapse occurs, patients and families are told that the individual needs more abstinence-based rehab. The patient is held responsible for the failure of the treatment. There is an implication that if a person only accepts the program whole cloth and practices it religiously, then success is assured. In fact, it is the treatment that is ineffective, not the patient. Addiction treatment is the only place in modern health care where providers are not held responsible to give full informed consent to their patients, or for the success of their treatment. I currently have several patients who have been through multiple abstinence programs at a cost of tens of thousands of dollars each, who are now doing well on maintenance treatment.
This is not merely about infighting among the experts. Active opioid dependence has a high fatality rate; in one study 50% of the sample died between the mid-twenties and mid-fifties! And in the UK study, there was a mortality difference detectable after only one year. In addition, insurance companies and families spend millions of dollars on treatment clearly demonstrated to be ineffective, as much as $30-60,000 per month for residential treatment. Maintenance treatment, on the other hand is not only much more effective, it is much cheaper, on the order of a few hundred dollars per month. If we use $300 has an average maintenance cost, then one month for one patient in a residential program that cost $30,000 would buy actually effective maintenance treatment for 8 patients for a whole year! And that doesn't factor in the increased health care, criminal justice costs and loss of productivity that occurs with the higher relapse rate for abstinence based treatment. One study estimated the cost of maintenance treatment yielded savings more than 7 times a much.
I apologize for the long email, but I strongly feel that the public needs to have this information available to them. After being involved in research for over thirty years, I decided when I left NIH that the research didn't matter if there wasn't a vehicle for making it available to the people who are suffering with the disorder. So I am now devoted full time to transforming the treatment system into one that is based on science, professionalism, and cost-effectiveness and that is dedicated to offering consumers choice.
Thank you for reading this (if you get this far before pressing Delete). Of course references are available on request. I have had a lot of media experience and I have appeared on Mid-Morning before I went to Washington (I'm back in this area now.) I would be more than happy to participate in a program that presented a more balanced view. I could possibly suggest a patient or two who might be willing to talk about this on air as well.
Warm regards,
Mark
MW
Dear Kerri,
I'm writing about your recent program on painkiller addiction. Unfortunately, I was not able to join the call, but became aware of it after the fact. I appreciate your attention to this problem, as it is particularly affecting young people.
I have been an addiction psychiatrist for over 30 years, and I have treated something like 1500 opioid addicts including about 30 in my current practice. In addition, I am an expert in treating highly complex pain patients who are using opioids. I used to run the addiction program at the VAMC in Minnepolis, which included a methadone maintenance clinic and eventually Suboxone treatment. From 2004 to 2009 I was Director of the Division of Treatment and Recovery Research at the National Institute on Alcohol Abuse and Alcoholism. (Not to brag, but I wanted to give you some sense of bona fides.)
One area where addiction treatment in the US really lags is in making scientifically based treatment available to people who need it, or even informing them of the evidence and their options. This is no where more true than opioid addiction. There are now multiple well done randomized controlled trials that have unequivocally and without exception found that for established (>1 year) opioid addiction, the only proven effective treatment is long-term opioid maintenance with either methadone or Suboxone. The most recent study, reported last spring at the American Psychiatric Association, focused on prescription opioid addicts, not heroin addicts. (Most previous research has been on heroin addicts.) This large and very well done study found that even after 9 months of Suboxone maintenance, along with enhanced psychosocial (behavioral) treatment of a quality far in excess of that available in the community, the relapse rate after tapering off of Suboxone was 95%. A recent naturalistic study in the UK followed opioid addicts who sought treatment. Those choosing abstinence had twice the mortality rate in the following year as compared to maintenance. These are only two of the most recent studies. There are dozens more. Among experts on opioid dependence, there is no controversy about this. (To anticipate a possible counterargument, there is evidence that an injectible drug that blocks the effects of opioids may be effective during the period when someone is on probation under the condition of agreement. However it is also true that almost all relapse as soon as they are off probation.)
Here's the problem. Due to devotion to 12-step concepts of addiction (which are not scientifically grounded), most treatment programs in the US fail to inform people of this evidence, let alone offer to provide it. Opioid dependence continues to be treated with an abstinence based approach grounded in the 12 steps. When the predictable relapse occurs, patients and families are told that the individual needs more abstinence-based rehab. The patient is held responsible for the failure of the treatment. There is an implication that if a person only accepts the program whole cloth and practices it religiously, then success is assured. In fact, it is the treatment that is ineffective, not the patient. Addiction treatment is the only place in modern health care where providers are not held responsible to give full informed consent to their patients, or for the success of their treatment. I currently have several patients who have been through multiple abstinence programs at a cost of tens of thousands of dollars each, who are now doing well on maintenance treatment.
This is not merely about infighting among the experts. Active opioid dependence has a high fatality rate; in one study 50% of the sample died between the mid-twenties and mid-fifties! And in the UK study, there was a mortality difference detectable after only one year. In addition, insurance companies and families spend millions of dollars on treatment clearly demonstrated to be ineffective, as much as $30-60,000 per month for residential treatment. Maintenance treatment, on the other hand is not only much more effective, it is much cheaper, on the order of a few hundred dollars per month. If we use $300 has an average maintenance cost, then one month for one patient in a residential program that cost $30,000 would buy actually effective maintenance treatment for 8 patients for a whole year! And that doesn't factor in the increased health care, criminal justice costs and loss of productivity that occurs with the higher relapse rate for abstinence based treatment. One study estimated the cost of maintenance treatment yielded savings more than 7 times a much.
I apologize for the long email, but I strongly feel that the public needs to have this information available to them. After being involved in research for over thirty years, I decided when I left NIH that the research didn't matter if there wasn't a vehicle for making it available to the people who are suffering with the disorder. So I am now devoted full time to transforming the treatment system into one that is based on science, professionalism, and cost-effectiveness and that is dedicated to offering consumers choice.
Thank you for reading this (if you get this far before pressing Delete). Of course references are available on request. I have had a lot of media experience and I have appeared on Mid-Morning before I went to Washington (I'm back in this area now.) I would be more than happy to participate in a program that presented a more balanced view. I could possibly suggest a patient or two who might be willing to talk about this on air as well.
Warm regards,
Mark
Here's a recent synthesis of studies on the course and remission rate for amphetamine, cannabis, cocaine and opioid dependence. Importantly they calculated remission rates using the assumption that drop outs from the studies were using and dependent (relapsed). This will result in an overly pessimistic view, since it is almost certain that not all of the study dropouts are still dependent. However, they do point that although addiction is frequently described as a "chronic, relapsing disease," there are surprisingly few studies that examine that.
MW
Systematic review of prospective studies investigating 'remission' from amphetamine, cannabis, cocaine or opioid dependence.
Calabria B., Degenhardt L., Briegleb C. et al. Request reprint
Addictive Behaviors: 2010, 35, p. 741–749.
Review synthesises evidence on how many people recover each year (with or without treatment) from their dependence on stimulants, heroin-type drugs or cannabis, providing a baseline against which to assess improvement efforts.
Original abstract Aims To review and summarise prospective studies reporting on remission from dependence on amphetamines, cannabis, cocaine or opioids.
Methods Systematic searches of the peer-reviewed literature were conducted to identify prospective studies of people dependent on amphetamines, cannabis, cocaine or opioids like heroin, which followed them up for at least three years to investigate how many experienced remission from their dependence. Treatment trials were excluded, but studies of patients who entered treatment in the normal way were included along with non-treatment and general population samples. Remission was defined as abstinence from the drug of dependence or no longer meeting diagnostic criteria for drug dependence. The remission rate was estimated for each drug type, allowing pooling across studies with varying follow-up times. Searches were limited to publications between 1990 and 2009. Reference lists of review articles and important studies were searched to identify additional studies.
Results There were few studies examining the course of psychostimulant dependence that met inclusion criteria (one for amphetamines and four for cocaine). There were ten studies of opioid dependence, none of which were of general population samples, and three of cannabis dependence, all of which were of general population samples. Definitions of remission varied and most studies did not clearly assess remission from dependence. Where possible, data from the studies was used to calculate the annual proportion of patients who remitted, firstly as proportions of the patients who could be followed up. A figure for cannabis was not calculated. Based on a single US study of methamphetamine users, amphetamine dependence had the highest annual remission rate (0.45 or 45% a year no longer dependent), followed by opioid (0.22 or 22%) and cocaine dependence (0.14 or 14%). The single study (from the USA) of a general population sample of cocaine-dependent people found that 39% had remitted four years after initially surveyed.
However, studies reporting remission rates based solely on the followed-up sample inflate remission estimates, given that people who drop out are probably less likely to have remitted. The data was recalculated on the conservative assumption that every patient who could not be followed up was still dependent or had died dependent. These estimates differed quite markedly from the levels typically reported in papers. On this basis, remission rates were highest for cannabis dependence (0.17 or 17% a year no longer dependent) followed by amphetamine (just under 0.17 or 17%), opioids (0.092 or 9%) and cocaine dependence (0.05 or 5%).
Conclusions Despite the fact that drug dependence is commonly described as a "chronic" disorder, surprisingly few follow-up studies have documented the course of this disorder. In addition definitions used are often imprecise and inconsistent across studies. There remains considerable uncertainty about the longitudinal course of dependence upon these most commonly used illicit drugs. The limited prospective evidence suggests that 'remission' from dependence may occur relatively frequently but rates differ across drugs. Remission from amphetamine dependence was highest overall with almost one in two persons remitting during a given year; the conservative estimate of remission from amphetamine or cannabis dependence was one in six annually. Remission from opioid dependence ranged from one to two in ten each year; and remission from cocaine dependence ranged from one in twenty to one in eight. The findings of this review for cannabis are similar to the results of retrospective surveys (when people are asked to look back to recall whether they were dependent on the drugs rather than followed up) that have found cannabis to have the highest rates of cessation of use. The results are not consistent for opioid dependence, which has been found in retrospective surveys to have the lowest remission rates.
Last revised 16 March 2011
MW
Systematic review of prospective studies investigating 'remission' from amphetamine, cannabis, cocaine or opioid dependence.
Calabria B., Degenhardt L., Briegleb C. et al. Request reprint
Addictive Behaviors: 2010, 35, p. 741–749.
Review synthesises evidence on how many people recover each year (with or without treatment) from their dependence on stimulants, heroin-type drugs or cannabis, providing a baseline against which to assess improvement efforts.
Original abstract Aims To review and summarise prospective studies reporting on remission from dependence on amphetamines, cannabis, cocaine or opioids.
Methods Systematic searches of the peer-reviewed literature were conducted to identify prospective studies of people dependent on amphetamines, cannabis, cocaine or opioids like heroin, which followed them up for at least three years to investigate how many experienced remission from their dependence. Treatment trials were excluded, but studies of patients who entered treatment in the normal way were included along with non-treatment and general population samples. Remission was defined as abstinence from the drug of dependence or no longer meeting diagnostic criteria for drug dependence. The remission rate was estimated for each drug type, allowing pooling across studies with varying follow-up times. Searches were limited to publications between 1990 and 2009. Reference lists of review articles and important studies were searched to identify additional studies.
Results There were few studies examining the course of psychostimulant dependence that met inclusion criteria (one for amphetamines and four for cocaine). There were ten studies of opioid dependence, none of which were of general population samples, and three of cannabis dependence, all of which were of general population samples. Definitions of remission varied and most studies did not clearly assess remission from dependence. Where possible, data from the studies was used to calculate the annual proportion of patients who remitted, firstly as proportions of the patients who could be followed up. A figure for cannabis was not calculated. Based on a single US study of methamphetamine users, amphetamine dependence had the highest annual remission rate (0.45 or 45% a year no longer dependent), followed by opioid (0.22 or 22%) and cocaine dependence (0.14 or 14%). The single study (from the USA) of a general population sample of cocaine-dependent people found that 39% had remitted four years after initially surveyed.
However, studies reporting remission rates based solely on the followed-up sample inflate remission estimates, given that people who drop out are probably less likely to have remitted. The data was recalculated on the conservative assumption that every patient who could not be followed up was still dependent or had died dependent. These estimates differed quite markedly from the levels typically reported in papers. On this basis, remission rates were highest for cannabis dependence (0.17 or 17% a year no longer dependent) followed by amphetamine (just under 0.17 or 17%), opioids (0.092 or 9%) and cocaine dependence (0.05 or 5%).
Conclusions Despite the fact that drug dependence is commonly described as a "chronic" disorder, surprisingly few follow-up studies have documented the course of this disorder. In addition definitions used are often imprecise and inconsistent across studies. There remains considerable uncertainty about the longitudinal course of dependence upon these most commonly used illicit drugs. The limited prospective evidence suggests that 'remission' from dependence may occur relatively frequently but rates differ across drugs. Remission from amphetamine dependence was highest overall with almost one in two persons remitting during a given year; the conservative estimate of remission from amphetamine or cannabis dependence was one in six annually. Remission from opioid dependence ranged from one to two in ten each year; and remission from cocaine dependence ranged from one in twenty to one in eight. The findings of this review for cannabis are similar to the results of retrospective surveys (when people are asked to look back to recall whether they were dependent on the drugs rather than followed up) that have found cannabis to have the highest rates of cessation of use. The results are not consistent for opioid dependence, which has been found in retrospective surveys to have the lowest remission rates.
Last revised 16 March 2011
Monday, February 28, 2011
SBIRT Doesn't Work in EDs
Another study documenting that emergency department Screening, Brief Intervention and Referral to Treatment (SBIRT) doesn't work. Unfortunately, advocates for SBIRT have moved out quite a ways ahead of the evidence. This is not likely to be harmful for patients, obviously, but it may hurt the cause in the long run. It's also a waste of money and time. By the way, the same holds true for hospitalized patients. SBIRT doesn't work because most of the patients identified are dependent drinkers.
MW
Oxford Journals
Medicine
Alcohol and Alcoholism
Volume45, Issue6
Pp. 514-519.
The Impact of Screening, Brief Intervention and Referral for Treatment in Emergency Department Patients’ Alcohol Use: A 3-, 6- and 12-month Follow-up
Academic ED SBIRT Research Collaborative
Corresponding author: Robert H. Aseltine, Jr., Division of Behavioral Sciences and Community Health, MC 3910, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030-3910, USA. Tel: +1 860 679 3282; Fax: +1 860 679 1342; E-mail: aseltine@uchc.edu
Received October 26, 2009.
Revision received July 30, 2010.
Accepted August 23, 2010.
Abstract
Aims: This study aims to determine the impact of Screening, Brief Intervention and Referral for Treatment (SBIRT) in reducing alcohol consumption in emergency department (ED) patients at 3, 6, and 12 months following exposure to the intervention. Methods: Patients drinking above the low-risk limits (at-risk to dependence), as defined by National Institute of Alcohol Abuse and Alcoholism (NIAAA), were recruited from 14 sites nationwide from April to August 2004. A quasi-experimental comparison group design included sequential recruitment of intervention and control patients at each site. Control patients received a written handout. The Intervention group received the handout and participated in a brief negotiated interview with direct referral for treatment if indicated. Follow-up surveys were conducted at 3, 6, and 12 months by telephone using an Interactive Voice Response (IVR) system. Results: Of the 1132 eligible patients consented and enrolled (581 control, 551 intervention), 699 (63%), 575 (52%) and 433 (38%) completed follow-up surveys via IVR at 3, 6, and 12 months, respectively. Regression analysis adjusting for the clustered sampling design and using multiple imputation procedures to account for subject attrition revealed that those receiving SBIRT reported roughly three drinks less per week than controls (B = −3.00, SE = 1.06, P < 0.05) and the level of maximum drinks per occasion was approximately three-fourths of a drink less than controls (B = -0.76, SE = 0.29, P < 0.05) at 3 months. At 6 and 12 months post-intervention, these effects had weakened considerably and were no longer statistically or substantively significant. Conclusion: SBIRT delivered by ED providers appears to have short-term effectiveness in reducing at-risk drinking, but multi-contact interventions or booster programs may be necessary to maintain long-term reductions in risky drinking.
MW
Oxford Journals
Medicine
Alcohol and Alcoholism
Volume45, Issue6
Pp. 514-519.
The Impact of Screening, Brief Intervention and Referral for Treatment in Emergency Department Patients’ Alcohol Use: A 3-, 6- and 12-month Follow-up
Academic ED SBIRT Research Collaborative
Corresponding author: Robert H. Aseltine, Jr., Division of Behavioral Sciences and Community Health, MC 3910, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030-3910, USA. Tel: +1 860 679 3282; Fax: +1 860 679 1342; E-mail: aseltine@uchc.edu
Received October 26, 2009.
Revision received July 30, 2010.
Accepted August 23, 2010.
Abstract
Aims: This study aims to determine the impact of Screening, Brief Intervention and Referral for Treatment (SBIRT) in reducing alcohol consumption in emergency department (ED) patients at 3, 6, and 12 months following exposure to the intervention. Methods: Patients drinking above the low-risk limits (at-risk to dependence), as defined by National Institute of Alcohol Abuse and Alcoholism (NIAAA), were recruited from 14 sites nationwide from April to August 2004. A quasi-experimental comparison group design included sequential recruitment of intervention and control patients at each site. Control patients received a written handout. The Intervention group received the handout and participated in a brief negotiated interview with direct referral for treatment if indicated. Follow-up surveys were conducted at 3, 6, and 12 months by telephone using an Interactive Voice Response (IVR) system. Results: Of the 1132 eligible patients consented and enrolled (581 control, 551 intervention), 699 (63%), 575 (52%) and 433 (38%) completed follow-up surveys via IVR at 3, 6, and 12 months, respectively. Regression analysis adjusting for the clustered sampling design and using multiple imputation procedures to account for subject attrition revealed that those receiving SBIRT reported roughly three drinks less per week than controls (B = −3.00, SE = 1.06, P < 0.05) and the level of maximum drinks per occasion was approximately three-fourths of a drink less than controls (B = -0.76, SE = 0.29, P < 0.05) at 3 months. At 6 and 12 months post-intervention, these effects had weakened considerably and were no longer statistically or substantively significant. Conclusion: SBIRT delivered by ED providers appears to have short-term effectiveness in reducing at-risk drinking, but multi-contact interventions or booster programs may be necessary to maintain long-term reductions in risky drinking.
Sunday, February 27, 2011
Charlie Sheen on the Myths of Rehab - Time Gets It Right!
Here's a brief snippet from Maia Szalavitz, a health reporter at Time. She really hits the facts right on.
MW
Can You Use Crack 'Socially?' Addiction Myth Watch: Charlie Sheen Edition
By Maia Szalavitz Tuesday, February 15, 2011
The subject of addiction swirls with myths and misinformation. It doesn't help that so many people seem to believe that their own struggle with addiction — or a few drop-ins to Alcoholics Anonymous meetings — make them unquestionable experts on the topic. As the latest news about Charlie Sheen's escapades show, sometimes the seemingly crazy statements of an apparently active addict can be more accurate than those of people who have spent years in recovery and even some "addiction experts" — if you go by the science, that is. (More on Time.com: New Hope For An Anti-Cocaine Vaccine)
Myth One: Everyone Who Takes Crack Is An Addict
On Monday, during a radio interview with the sports-talk "Dan Patrick Show," Sheen mentioned that some crack users can "manage it socially." (He said his own attempts to be a social crack user "kind of blew up in my face. Like an exploding crack pipe, Dan.")
Although crack cocaine is indeed one of the most addictive drugs, Sheen's statement about social use is true of most people who have tried the drug, if by "social" you mean use that does not qualify you for a diagnosis of substance dependence. Far from being universally addictive, crack is actually unattractive to the majority of people who've tried it: only about 15%-20% of initial users become hooked. (More on Time.com: Bonus: 4 Tips for Staying on the Wagon)
Indeed, according to data from the National Survey on Drug Use and Health, about 75.6% of those who tried crack between 2004 and 2006 were not using it at all two years later. Another 15% were still hitting the pipe occasionally, but not at levels that would qualify them as addicts. About 9.2% were addicted.
So, although Sheen's terminology may be inexact, he's correct about the existence of non-addicted crack users. He's also correct to note that drinking chocolate milk is much, much safer.
Myth Two: Residential Treatment Works Better than Outpatient Treatment, and Must Be Done in Groups
People magazine recently reported that Sheen would go into treatment for substance abuse for the third time, this time at home: "Surrounded by a team of professionals, the Two and Half Men star will attend no meetings with other patients, check into no center. He could do it all at home or in some other private setting." (More on Time.com: Does Suffering From Withdrawal Really Mean You're Addicted?)
Commenting on Sheen's rehab plan, Dr. Drew told the magazine that "treatment of addiction is a group process when done properly — not an individual thing at all." Yet actual addiction research shows this is not the case. For example, the largest study ever done on alcoholism treatment, Project Match, was conducted mainly through individual therapy sessions (though one arm did focus on improving 12-step group participation): its aim was not to compare individual to group treatment, but overall, it found individual treatment just as successful.
Further, studies that have directly compared inpatient treatment to outpatient therapy have found that there is little difference in outcomes for most addicts, except for very severe cases, particularly amongst the homeless and jobless — these people lack social and family support, or other important goals to work toward, things that have been found to aid recovery. For employed professionals — like Sheen — outpatient and inpatient treatment tend to be equally effective. (More on Time.com: 'i-Dosing': Can You Download a Drug High?)
Myth Three: 12-Step Programs are Required for Recovery
Although celebrities, including Sheen's own father, swear by them, 12-step programs like Alcoholics Anonymous are not the only way to recover from addiction. Project Match, in fact, found that on most measures, cognitive behavioral therapy and motivational enhancement therapy were as effective as 12-step facilitation (TSF), a program that worked to enhance 12-step attendance. When patients received these therapies as after-care following inpatient treatment, all three groups did equally well. However, in outpatient-treated addicts, those in the TSF group had slightly better rates of complete abstinence in the year following treatment. (More on Time.com: Study: Do Energy Drinks Lead to Alcohol Abuse?)
So, although Sheen may not exactly be a model citizen — or rehab patient — his distaste for 12-step programs does not mean that he's untreatable. Maybe he just needs to find a rehab or addiction "professional" who is familiar with the scientific literature.
Find this article at:
http://healthland.time.com/2011/02/15/can-you-use-crack-socially-addiction-myth-watch-charlie-sheen-edition/
MW
Can You Use Crack 'Socially?' Addiction Myth Watch: Charlie Sheen Edition
By Maia Szalavitz Tuesday, February 15, 2011
The subject of addiction swirls with myths and misinformation. It doesn't help that so many people seem to believe that their own struggle with addiction — or a few drop-ins to Alcoholics Anonymous meetings — make them unquestionable experts on the topic. As the latest news about Charlie Sheen's escapades show, sometimes the seemingly crazy statements of an apparently active addict can be more accurate than those of people who have spent years in recovery and even some "addiction experts" — if you go by the science, that is. (More on Time.com: New Hope For An Anti-Cocaine Vaccine)
Myth One: Everyone Who Takes Crack Is An Addict
On Monday, during a radio interview with the sports-talk "Dan Patrick Show," Sheen mentioned that some crack users can "manage it socially." (He said his own attempts to be a social crack user "kind of blew up in my face. Like an exploding crack pipe, Dan.")
Although crack cocaine is indeed one of the most addictive drugs, Sheen's statement about social use is true of most people who have tried the drug, if by "social" you mean use that does not qualify you for a diagnosis of substance dependence. Far from being universally addictive, crack is actually unattractive to the majority of people who've tried it: only about 15%-20% of initial users become hooked. (More on Time.com: Bonus: 4 Tips for Staying on the Wagon)
Indeed, according to data from the National Survey on Drug Use and Health, about 75.6% of those who tried crack between 2004 and 2006 were not using it at all two years later. Another 15% were still hitting the pipe occasionally, but not at levels that would qualify them as addicts. About 9.2% were addicted.
So, although Sheen's terminology may be inexact, he's correct about the existence of non-addicted crack users. He's also correct to note that drinking chocolate milk is much, much safer.
Myth Two: Residential Treatment Works Better than Outpatient Treatment, and Must Be Done in Groups
People magazine recently reported that Sheen would go into treatment for substance abuse for the third time, this time at home: "Surrounded by a team of professionals, the Two and Half Men star will attend no meetings with other patients, check into no center. He could do it all at home or in some other private setting." (More on Time.com: Does Suffering From Withdrawal Really Mean You're Addicted?)
Commenting on Sheen's rehab plan, Dr. Drew told the magazine that "treatment of addiction is a group process when done properly — not an individual thing at all." Yet actual addiction research shows this is not the case. For example, the largest study ever done on alcoholism treatment, Project Match, was conducted mainly through individual therapy sessions (though one arm did focus on improving 12-step group participation): its aim was not to compare individual to group treatment, but overall, it found individual treatment just as successful.
Further, studies that have directly compared inpatient treatment to outpatient therapy have found that there is little difference in outcomes for most addicts, except for very severe cases, particularly amongst the homeless and jobless — these people lack social and family support, or other important goals to work toward, things that have been found to aid recovery. For employed professionals — like Sheen — outpatient and inpatient treatment tend to be equally effective. (More on Time.com: 'i-Dosing': Can You Download a Drug High?)
Myth Three: 12-Step Programs are Required for Recovery
Although celebrities, including Sheen's own father, swear by them, 12-step programs like Alcoholics Anonymous are not the only way to recover from addiction. Project Match, in fact, found that on most measures, cognitive behavioral therapy and motivational enhancement therapy were as effective as 12-step facilitation (TSF), a program that worked to enhance 12-step attendance. When patients received these therapies as after-care following inpatient treatment, all three groups did equally well. However, in outpatient-treated addicts, those in the TSF group had slightly better rates of complete abstinence in the year following treatment. (More on Time.com: Study: Do Energy Drinks Lead to Alcohol Abuse?)
So, although Sheen may not exactly be a model citizen — or rehab patient — his distaste for 12-step programs does not mean that he's untreatable. Maybe he just needs to find a rehab or addiction "professional" who is familiar with the scientific literature.
Find this article at:
http://healthland.time.com/2011/02/15/can-you-use-crack-socially-addiction-myth-watch-charlie-sheen-edition/
Monday, February 7, 2011
Addiction Treatment Parity Doesn't Add Costs
Contrary to the hysterical warnings issued by the insurance industry and the Chamber of Commerce, it turns out that parity for addiction treatment does not add significantly to costs. One key reason is underutilization. Replacing the expensive and minimally effective rehab approach with a fully professional, scientifically based approach will not only make treatment even more cost effective, it will increase access to and utilization of treatment.
MLW
From Medscape Medical News > Psychiatry
No Increase in Substance Abuse Treatment Due to Mental Health Parity Law
Findings Should Squelch Fears That Controversial Legislation Will Cause Health Costs to Skyrocket
Deborah Brauser
February 4, 2011 — Parity in insurance coverage of substance abuse treatment has not led to increased use of this service or an increase in costs. It has done what it was designed to do — lower out-of-pocket expenses for covered individuals, new research suggests.
Employers who provide health insurance plans for mental and substance use disorders are now required by the Federal Mental Health Parity Act of 2008 to provide benefits that are equal to those given for general medical care.
There is always a fear that for substance abuse and for mental health, every time a plan is more generous, utilization will skyrocket...But this is not true.
"There is always a fear that for substance abuse and for mental health, every time a plan is more generous, the utilization will skyrocket, the costs will be so high, and all the insurance companies will start complaining that they won't be able to afford these services. But this is not true," lead study author Vanessa Azzone, PhD, researcher and biostatistician in the Department of Health Care Policy at Harvard Medical School in Boston, Massachusetts, told Medscape Medical News.
"I think these findings, along with those found in other studies, clear the air for all the people who have been criticizing parity law for mental health treatment," said Dr. Azzone.
The investigators note that the extensive use of managed care organizations (MCOs) within employer-based health insurance may be the reason for costs not rising.
"These MCOs administer behavioral health benefits and contain costs by managing the delivery of care — for example, through negotiated reduction in fees with a network of preferred providers and review of appropriateness of services to eliminate unnecessary use," they explain.
"Still, it's always a balance between getting more for the patient but also, from the plan side, controlling that services are only provided as needed," added Dr. Azzone.
The study is published in the February issue of Psychiatric Services.
Paucity of Research
Although previous research on the impact of mental health parity mandates "has undoubtedly helped to pave the way for passage of comprehensive federal legislation," there have been few studies on the effects of parity mandates for substance abuse treatment benefits, write the study authors.
"This is a group that is not studied as much. They're pretty sick and their services are very expensive. So there's been fear that the parity law could have a real impact," said Dr. Azzone.
Insurance plans for federal workers have been required to provide parity coverage since 2001. Because of this, the investigators decided to evaluate claims data on substance abuse treatment in 6 Federal Employees Health Benefit (FEHB) preferred provider organization plans between 1999 and 2001 (before parity was implemented) and between 2001 and 2002 (after implementation).
The use and costs of these plans were then compared with those found in a matched set of health plans without parity coverage.
Results showed no statistically significant differences in the use of substance abuse treatment services between the 2 plan types and no significant differences in probability rates of initiation and engagement.
Those enrolled in the FEHB plans had a significantly larger reduction in average out-of-pocket spending for these services (mean difference per user, −$101.09; P < .05) compared with those in the non-FEHB plans.
Although the FEHB group also had smaller increases in total substance abuse spending compared with the non-FEHB group, these differences were not significant.
Finally, more of the patients with parity were identified by their care providers as having a substance use disorder (difference-in-difference risk, 0.10; 95% confidence interval, 0.02 to 0.19; P < .05).
"Findings suggest that for continuously enrolled populations, providing parity of substance abuse treatment coverage improved insurance protection but had little impact on utilization, costs for plans, or quality of care," write the researchers.
Clinicians' 'Biggest Stress'
According to Dr. Azzone clinicians' biggest stress is trying to get paid for services because insurance companies erect so many barriers to reimbursement.
"Still, there is this law, and I think clinicians should push more for their patients, even if it is hard for them to promote services when they have so many obstacles. This is already a population that finds it very hard to engage in and continue to get services," she said.
She added that her team is conducting other studies looking at the possibility of parity coverage differences for other groups.
"This includes patients with bipolar disorder or major depression that usually are more expensive and require more services. These patient populations could have a differential effect. We're also concentrating on children to see if the effect we found in adults overall is the same or not," she explained.
"I think this study is significant and an important step in the analysis of overall healthcare costs," Anita S. Everett, MD, director of Community Psychiatry Services at Johns Hopkins Bayview Medical Center in Baltimore, Maryland, told Medscape Medical News.
Dr. Anita Everett
"Providing parity for substance abuse services didn't increase the overall costs. And that is the big fear that everyone has — open the floodgates and all these people will want these very expensive services," said Dr. Everett, who was not involved with this study.
"Also, the number of individuals who actually sought the services didn't go up that much. I think that that is important, although not shocking, and consistent with what we already know: a lot of people with a substance abuse disorder don't recognize their need for treatment or are unwilling to seek treatment. Offering parity is not all of a sudden going to break down their resistance."
Dr. Everett pointed out that a big part of "substance abuse disease" is to be in denial about the magnitude of the problem.
Parity Law Won't 'Break the Bank'
"The clinical significance of parity is that it enables a clinician to be able to help patients and to 'strike while the iron is hot,' so to speak. If they're at a point where they're ready, then hopefully we'll be able to immediately meet that readiness," she said.
Dr. Everett, who is also chair of the American Psychiatric Association's Council on Healthcare Systems and Finance, said that some primary care physicians might not be aware that the parity law has passed.
"I know that the American Psychiatric Association, along with a number of other organizations, is actively working to promote awareness for healthcare providers, patients, and their families that parity for substance abuse and for mental health services does exist," she said.
"I also think that resources such as referral services should be collected and offered in primary care offices."
I think this is critical information that helps us understand that enabling access to some of these services is not going to break the bank.
She noted that, although these findings are important, the study population might not be representative of all groups in the United States.
"These were people who were fairly motivated and are probably comparable to other private pay insurance groups — but maybe not to the Medicare or Medicaid populations. We know it can give us some ideas about applicability to the general public, but it may or may not be predictive of the other 300 million Americans who are not federal employees," explained Dr. Everett.
"However, I think this is critical information that helps us understand that enabling access to some of these services is not going to break the bank."
The study was funded by a grant from the National Institute on Drug Abuse through the Brandeis-Harvard Center for Managed Care and Drug Abuse Treatment. Its data were originally collected in a study funded by the Department of Health and Human Services. The study authors and Dr. Everett have disclosed no relevant financial relationships.
Psychiatr Serv. 2011;62:129-134.
Medscape Medical News © 2011 WebMD, LLC
Send comments and news tips to news@medscape.net.
MLW
From Medscape Medical News > Psychiatry
No Increase in Substance Abuse Treatment Due to Mental Health Parity Law
Findings Should Squelch Fears That Controversial Legislation Will Cause Health Costs to Skyrocket
Deborah Brauser
February 4, 2011 — Parity in insurance coverage of substance abuse treatment has not led to increased use of this service or an increase in costs. It has done what it was designed to do — lower out-of-pocket expenses for covered individuals, new research suggests.
Employers who provide health insurance plans for mental and substance use disorders are now required by the Federal Mental Health Parity Act of 2008 to provide benefits that are equal to those given for general medical care.
There is always a fear that for substance abuse and for mental health, every time a plan is more generous, utilization will skyrocket...But this is not true.
"There is always a fear that for substance abuse and for mental health, every time a plan is more generous, the utilization will skyrocket, the costs will be so high, and all the insurance companies will start complaining that they won't be able to afford these services. But this is not true," lead study author Vanessa Azzone, PhD, researcher and biostatistician in the Department of Health Care Policy at Harvard Medical School in Boston, Massachusetts, told Medscape Medical News.
"I think these findings, along with those found in other studies, clear the air for all the people who have been criticizing parity law for mental health treatment," said Dr. Azzone.
The investigators note that the extensive use of managed care organizations (MCOs) within employer-based health insurance may be the reason for costs not rising.
"These MCOs administer behavioral health benefits and contain costs by managing the delivery of care — for example, through negotiated reduction in fees with a network of preferred providers and review of appropriateness of services to eliminate unnecessary use," they explain.
"Still, it's always a balance between getting more for the patient but also, from the plan side, controlling that services are only provided as needed," added Dr. Azzone.
The study is published in the February issue of Psychiatric Services.
Paucity of Research
Although previous research on the impact of mental health parity mandates "has undoubtedly helped to pave the way for passage of comprehensive federal legislation," there have been few studies on the effects of parity mandates for substance abuse treatment benefits, write the study authors.
"This is a group that is not studied as much. They're pretty sick and their services are very expensive. So there's been fear that the parity law could have a real impact," said Dr. Azzone.
Insurance plans for federal workers have been required to provide parity coverage since 2001. Because of this, the investigators decided to evaluate claims data on substance abuse treatment in 6 Federal Employees Health Benefit (FEHB) preferred provider organization plans between 1999 and 2001 (before parity was implemented) and between 2001 and 2002 (after implementation).
The use and costs of these plans were then compared with those found in a matched set of health plans without parity coverage.
Results showed no statistically significant differences in the use of substance abuse treatment services between the 2 plan types and no significant differences in probability rates of initiation and engagement.
Those enrolled in the FEHB plans had a significantly larger reduction in average out-of-pocket spending for these services (mean difference per user, −$101.09; P < .05) compared with those in the non-FEHB plans.
Although the FEHB group also had smaller increases in total substance abuse spending compared with the non-FEHB group, these differences were not significant.
Finally, more of the patients with parity were identified by their care providers as having a substance use disorder (difference-in-difference risk, 0.10; 95% confidence interval, 0.02 to 0.19; P < .05).
"Findings suggest that for continuously enrolled populations, providing parity of substance abuse treatment coverage improved insurance protection but had little impact on utilization, costs for plans, or quality of care," write the researchers.
Clinicians' 'Biggest Stress'
According to Dr. Azzone clinicians' biggest stress is trying to get paid for services because insurance companies erect so many barriers to reimbursement.
"Still, there is this law, and I think clinicians should push more for their patients, even if it is hard for them to promote services when they have so many obstacles. This is already a population that finds it very hard to engage in and continue to get services," she said.
She added that her team is conducting other studies looking at the possibility of parity coverage differences for other groups.
"This includes patients with bipolar disorder or major depression that usually are more expensive and require more services. These patient populations could have a differential effect. We're also concentrating on children to see if the effect we found in adults overall is the same or not," she explained.
"I think this study is significant and an important step in the analysis of overall healthcare costs," Anita S. Everett, MD, director of Community Psychiatry Services at Johns Hopkins Bayview Medical Center in Baltimore, Maryland, told Medscape Medical News.
Dr. Anita Everett
"Providing parity for substance abuse services didn't increase the overall costs. And that is the big fear that everyone has — open the floodgates and all these people will want these very expensive services," said Dr. Everett, who was not involved with this study.
"Also, the number of individuals who actually sought the services didn't go up that much. I think that that is important, although not shocking, and consistent with what we already know: a lot of people with a substance abuse disorder don't recognize their need for treatment or are unwilling to seek treatment. Offering parity is not all of a sudden going to break down their resistance."
Dr. Everett pointed out that a big part of "substance abuse disease" is to be in denial about the magnitude of the problem.
Parity Law Won't 'Break the Bank'
"The clinical significance of parity is that it enables a clinician to be able to help patients and to 'strike while the iron is hot,' so to speak. If they're at a point where they're ready, then hopefully we'll be able to immediately meet that readiness," she said.
Dr. Everett, who is also chair of the American Psychiatric Association's Council on Healthcare Systems and Finance, said that some primary care physicians might not be aware that the parity law has passed.
"I know that the American Psychiatric Association, along with a number of other organizations, is actively working to promote awareness for healthcare providers, patients, and their families that parity for substance abuse and for mental health services does exist," she said.
"I also think that resources such as referral services should be collected and offered in primary care offices."
I think this is critical information that helps us understand that enabling access to some of these services is not going to break the bank.
She noted that, although these findings are important, the study population might not be representative of all groups in the United States.
"These were people who were fairly motivated and are probably comparable to other private pay insurance groups — but maybe not to the Medicare or Medicaid populations. We know it can give us some ideas about applicability to the general public, but it may or may not be predictive of the other 300 million Americans who are not federal employees," explained Dr. Everett.
"However, I think this is critical information that helps us understand that enabling access to some of these services is not going to break the bank."
The study was funded by a grant from the National Institute on Drug Abuse through the Brandeis-Harvard Center for Managed Care and Drug Abuse Treatment. Its data were originally collected in a study funded by the Department of Health and Human Services. The study authors and Dr. Everett have disclosed no relevant financial relationships.
Psychiatr Serv. 2011;62:129-134.
Medscape Medical News © 2011 WebMD, LLC
Send comments and news tips to news@medscape.net.
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