2020 Addiction Medicine Essentials Conference

I just had the pleasure of attending NC’s yearly fall Addiction Medicine Conference, which was held online this year, due to COVID.

My expectations weren’t extremely high; the Essentials conference is intended more for providers new to the field, compared to the yearly Spring conference, plus it was online. However, I’m glad I went because I learned a great deal that I can use, and the speakers were great.

On the first day, Dr. James Finch started with Basic Concepts of Addiction Medicine, but his talk was more than data. He exhorted his listeners to be more thoughtful and compassionate, and to look at the big picture of how and why we want to help our patients. And I was impressed that he gave his talk despite being hospitalized.  That truly is dedication. I pray you have a rapid return to health, Jim!

We had two speakers address racial inequities in Addiction Medicine, and about the explicit and implicit biases that exist in healthcare. Speakers presented some truly depressing data about racial health inequities, but also provided some action steps to address these health inequities. I also learned the new acronym: BIPOC, which stands for Black, Indigenous, and People of Color.

From the speakers, I got some ideas about how to assess our OTP for problem areas, as a prelude to making changes to reduce inequities, at least over issues we can control.

During a lecture on Update in Treating Tobacco Dependence in Mental Health Setting, I was in the “Amen!” corner. As the presenter said, we have data that shows people in recovery who stop smoking have lower rates of return to drug use, as well as better mental and physical health. Nicotine use disorder needs to be addressed in every patient.

At our OTP, about 95% of our patients smoke. Lately I’ve been talking to patients about participating in a free smoking cessation program at our local hospital, and I’ve been surprised at how many patients are receptive. This program offers free samples of patches, nicotine gum and lozenges, as an incentive for participation in group online counseling and support sessions.

At our OTP, we are NOT smoke-free, and we need to be. Our biggest problem may be addressing smoking cessation with our own employees, who often smoke outside on our front porch with the patients. I love our employees and would never hurt their feelings for anything, but I think that’s bad. They are setting a terrible example, besides putting themselves at risk for illness and premature deaths. That last part makes me sad.

We had an interesting session for opioid treatment program medical providers. Our presenter was a cardiologist who talked about the dangers of prolongation of the QT interval in patients treated with methadone. His recommendations about when to obtain an EKG on patients on methadone differed significantly from recommendations given by the American Society of Addiction Medicine. Listening to him speak, I perceived he focused on the dangers of methadone. As Addiction Medicine physicians, we also focus on the dangers of not prescribing methadone. We had good discussion about the topic, though not as many people attended as I would have hoped.

I learned much in a lecture about methamphetamine given by Dr. Richard Rawson of Vermont.

In the past, the methamphetamine found in our area was made by small-town “cooks” from over-the-counter decongestants. After laws were passed that restricted access to these raw materials, that type of manufacture decreased. Now, most of the methamphetamine used by people in our state comes from Mexican labs which make their product from the P2P method. This gives a more potent product which produces more severe complications.

Dr. Rawson said that since 2014, more methamphetamine and cocaine has been contaminated with fentanyl. In fact, in 2020, some areas of the country have found most of their cocaine to contain fentanyl as well.

This contaminated supply of stimulant drugs has caused a “fourth wave” of overdose deaths in the U.S.: first was opioid pain pills, then heroin, then fentanyl, and now stimulants contaminated with fentanyl.

This is not good news.

Dr. Rawson also mentioned a new drug, called “iso” for isotonitazene, a new drug found in overdose victims in the Midwest in June of 2020, who thought they were using cocaine. This was the first time I heard about this drug, which is a designer opioid, slightly more potent than fentanyl. This drug was just put on Schedule 1 by the DEA in the U.S.

The methamphetamine being used now is more potent and more dangerous. Dr. Rawson quoted studies indicating that people who use methamphetamine have more than a six-fold increase of risk of death compared to same-age controls.  Most deaths from methamphetamines are caused by cerebrovascular and cardiovascular disease. Even young patients have strokes, both hemorrhagic and ischemia, due to methamphetamine and other stimulant use.

The more potent methamphetamine being used now is toxic to the brain, causing cell death and brain dysfunction like that seen in patients with degenerative disease of the center nervous system. Even after active use of methamphetamine has ceased, studies show impaired verbal fluency, poor learning and comprehension, and slower processing of information. According to Dr. Rawson, more than two-thirds of users have cognitive impairment. This impairment is worse with intravenous use, older age, and higher quantity used.

As we would expect, patients who are in treatment for opioid use disorder who also use methamphetamine are at higher risk for leaving treatment.

Treatment of methamphetamine use disorder is challenging. Thus far, there are no FDA-approved medications that help with the treatment of methamphetamine use disorder, though there have been some promising trials using bupropion (brand name Wellbutrin) and mirtazapine (brand name Remeron). The mainstay of treatment remains counseling techniques, especially contingency management along with community reinforcement approach. Cognitive behavioral counseling and motivational enhancement counseling also may help.

Anyway, I learned a great deal during Dr. Rawson’s talk as well as others.

If you work in the substance use disorder field in any capacity, I highly recommend the Governor’s Institute’s fall and spring sessions. Our spring session this was truncated by the arrival of COVID 19, but we still had a small online conference.

Either in-person on online, these conferences are always worth the time.

Here’s a link to the Governors Institute website: https://governorsinstitute.org/

One response to this post.

  1. Posted by Larry Lovelace on October 21, 2020 at 7:27 pm

    Dr Burson. I am a fellow physician at an OTP. I started 4 years ago with ZERO knowledge about opioid use disorder. I read tip 43, the federal guidelines, the Addiction Medicine Society guidelines, the opioid chapter in the textbook on Addiction medicine, The Australian guidelines, and ALL of your blogs. The honest to God truth is I learned more from your blogs than all of the other resources put together. Please don’t stop blogging. I would be happy to buy your book. It’s a much needed resource for physicians transitioning to Addiction Medicine. How can I get your book?

    Reply

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