Posts Tagged ‘American Society of Addiction Medicine’

ASAM Conference

 

Twenty-one hundred people registered to come to this meeting, the biggest yearly event of the American Society of Addiction Medicine. In the vast grand ballroom, row after row of chairs, in section after section, are occupied with medical professionals eager to learn more about their chosen field. Leaders in the field are scheduled to speak.

On this first morning, distinguished and learned people are ready to speak.

But first…a poet spoke to us.

Joseph Greene is a spoken word artist. I didn’t know what that was until he started, but then I discovered I liked it.

He performed his poetry. First, he reminded us to shed our cynicism and pessimism, symptoms of burnout. He reminded us to remember the people we have already helped, and to allow their energy to revitalizes us. Right away, I felt a wave of enthusiasm.

I admired the positivity his poetry evoked in his audience. We are not so easily moved, we doctors who toil on the front lines in the war on the people who use drugs. We can become cynical, and he moved us out of our pessimistic ruts.

The plenary speakers who came after him presented information and had mixed news.

Patrice Harris, MD, MA, Chair of the American Medical Association Board of Trustees, gave us alarming updated information: ninety-one people die from opioid overdose each day in the U.S., according to data from 2015, the last year for which we have data. That’s up from seventy-eight opioid overdose deaths per day in the previous year. That’s depressing news, especially since the amount of opioids prescribed in this country has been dropping since 2014, a little before the American Medical Society’s call to action. From 2013 to 2015, the total amount of opioids prescribed dropped by about 10%.

Mortality grew despite many more physicians signed up to use their states’ prescription monitoring programs, pushes to prescribe more naloxone to reverse overdoses, more medication drop-off so controlled substances don’t fall into unintended hands, and a push to increase treatment availability.

Despite an eighty-one percent increase in physicians trained to prescribe medication-assisted therapies in the years 2012 to 2016, still only twenty percent of U.S. citizens with opioid use disorder got treatment.

Dr. Barbara Mason, PhD, winner of the R. Brinkley Smithers Distinguished Scientist award, spoke next. She reminded us that despite all the attention paid to opioid use disorder, alcohol still causes many more deaths per year. In the U.S., about eighty-eight thousand deaths per year are attributable to alcohol. Alcohol is the fourth leading cause of preventable death in the U.S. Dr. Mason gave us information about new studies on medications which may be approved for use in alcohol use disorder treatment.

At present, we have only three medications approved by the FDA: disulfiram (Antabuse, acamprosate (Campral), and naltrexone (Revia, Vivitrol). Only around ten percent of people with alcohol use disorders are prescribed any of these three medications.

Next we heard from Vivek Murthy, MD, MBA, Surgeon General of the U.S. He planned to talk to us in person but due to airplane delays, had to join us via internet. We also had plenary sessions with talks from George Koob, PhD, Director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and from Wilson Compton, MD, MPE, Deputy Director of the National Institute on Drug Abuse (NIDA).

All of the speakers were good, and most of them were great.

I’ve learned much, socialized a little, ate some great food, and relaxed.

Being around this many people who are all excited about helping people with substance use disorders change their lives is exhilarating. Even better than the data I learned is the enthusiasm I’ve re-discovered.

Thank you, American Society of Addiction Medicine, for another great conference!

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Conference

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I just got back from the yearly American Society of Addiction Medicine conference. As always, it was a treat. It’s so refreshing to be surrounding by other physicians who know addiction is a treatable illness and not a moral shortcoming. I feel revitalized from being around people who also love treating people with substance use disorders, and who also love seeing people get well and get back to being themselves.

This conference was huge. Over 1800 people attended. When I went to my first ASAM meeting in 2004, I think there were around 300 attendees. What a difference!

This year, I sensed even more hopefulness and enthusiasm than in past years. Last month, Addiction Medicine was finally recognized as a legitimate specialty of medicine. Finally, we got recognition that we have a substantial body of science with data that supports the work we do.

Recently, there’s more conversation about treating people with opioid addiction. We see television shows, online articles, and blog posts about the opioid addiction epidemic and the death toll it’s exacting on our nation. Even President Obama recently emphasized the importance of treating people with opioid addiction, and the obligation of incorporating medication-assisted treatment. More federal and state grants are available to start programs to help people with substance use disorders.

All of these recent changes encouraged me, but the speakers at the ASAM conference pushed my enthusiasm further.

On the first session of the first day, Dr. Nora Volkow, director of NIDA (National Institute on Drug Abuse), spoke. She was her usual brilliant self, giving a concise summary of this nation’s present opioid addiction situation. She discussed many of the same studies I’ve highlighted in my blog over this past year, so I felt good about that.

Next to speak was Dr. William Miller, the “father” of Motivational Interviewing. His lecture, titled “The Power of Empathy in Addiction Treatment,” was a gift. It reminded me of why I love what I do, and how I can continue to improve as a clinician.

I also went to his ninety-minute session about the basics of Motivational Interviewing. I’ve read all three editions of his book, “Motivational Interviewing,” and I’ve seen videos of therapists using MI as a counseling technique. Motivational Interviewing is an evidence-based method of counseling people in order to help them change.

MI sounds much easier than it is. It also looks easy when I watch other people do it, but it’s much more difficult than it looks. Fortunately, my fiancé is a “MINTee,” meaning he’s one of the Motivational Interviewing Network of Trainers for Motivational Interviewing. I figure that can’t help but rub off on me. Plus, he helps train the counselors at our local opioid treatment program. In my obviously biased opinion, he’s helped our counselors become much better at their jobs, which ultimately benefits our patients.

I went to many other ASAM sessions – from a lecture on contingency management techniques to a discussion about buprenorphine doses above 16mg. All were excellent. Even though it’s impossible to attend all the sessions, since many times there were four of five going on at the same time in different rooms, I plan to listen to the recordings of them all on ASAM’s website when they become available.

And I will return to work a better, more enthusiastic doctor.

 

American Society of Addiction Medicine: Two Conferences

Over the last month, I went to North Carolina’s Society of Addiction Medicine’s yearly conference, in Asheville, and the American Society of Addiction Medicine’s annual Medical-Scientific conference, in Atlanta. Both were great. Big chunks of both conferences were about aspects of opioid addiction and treatment, so I’ll have some great, brand new material for my blog over the next few weeks.

It was fun being around a group of like-minded people. The doctors and others at the conference were there because we all want to learn more about how to do a better job of treating people with addiction. I basked in the positive energy circulating at both conferences.

During one of the conferences, I heard about a new statement being issued by a committee made up of physician members of both the American College of Obstetricians and Gynecologists and of the American Society of Addiction Medicine. This statement, issued May of 2012, contained the committee opinion regarding opioid abuse, dependence, and addiction in pregnancy.

The seven-page report contained many good points, and the bottom line recommendations were much as I expected. Opioid use, abuse, and addiction are not uncommon in pregnant women, and are associated with worse outcomes than women not addicted to opioids. The current recommended standard of care for an opioid-dependent pregnant woman is methadone maintenance for the duration of the pregnancy. However, buprenorphine should also be considered, because of encouraging data, recently published, that shows milder neonatal withdrawal symptoms in babies born to moms on buprenorphine than on methadone.

The opinion paper does not recommend discontinuation of opioids during pregnancy due to the increased complications often seen during withdrawal: preterm labor, fetal distress and fetal death.

Did you ask if I sent a copy of this committee opinion to Angry Doctor, the subject of my April 15th blog? Oh, you know I did. With important parts highlighted with yellow marker.

Tramadol, AKA Ultram, Ultracet

I just returned from the American Society of Addiction Medicine’s spring conference, held in Washington, D.C. I go to at least one of their meetings every year, to stay current with the latest research and developments in Addiction Medicine. It was impossible to attend all of the sessions, since four or five meetings are often conducted at the same time. This makes it the intellectual equivalent of a three ring circus. I think I learned some new stuff, and will share some of this in my blog over the coming weeks.

The first day, I went to a day-long course called “Pain and Addiction: Common Threads.” I think this is the fourth time I’ve attended that particular seminar over the last eight years. I hear something new every year.

 It’s striking how much this meeting has changed. The first year I went was 2005. At that time, pain medicine specialists still debated with the addiction medicine specialists about the risk of addiction in patients who were prescribed opioids long-term for chronic non-cancer pain. By 2010, I didn’t hear any debates about the risk of addiction. I heard lectures about how to manage chronic pain without opioids, and about the risk of hyperalgesia in patients on long-term opioids. Hyperalgesia is an increased sensitivity to pain, sometimes seen in patients prescribed opioids for months or years. The human body accommodates to the presence of these prescribed opioids, which adjusts the pain threshold, making a patient on opioids paradoxically more sensitive to pain.

This year, the Pain and Addiction conference had lectures on several interesting topics, but one that captured my interest was about the not-so-safe “safe” medications. Included were carisoprodol (Soma), zolpidem (Ambien), butalbital (found in Fioricet and Fiorinal), and tramadol (Ultram). These are all medications that many doctors think are safe for addicts, but really aren’t all that safe.

I’ve seen many patients develop problems with tramadol, so the rest of this blog is about this medication.

Tramadol is a messy drug. It’s a pain reliever that has actions on several types of brain receptors: the mu opioid, serotonin, norepinephrine, NMDA, and other receptors. Because it stimulates the mu opioid receptors, it can cause feelings of pleasure as well as pain relief. Tramadol is far less active at the mu opioid receptors than its metabolite, and it takes time for the tramadol to be metabolized in the liver to its first metabolite. Because of this delay, some experts thought it wouldn’t appeal to addicts, who prefer an immediate high. Overall this is probably true, and tramadol has a much lower rate of addiction than other opioids, but it still causes addiction in some patients.

Some of tramadol’s pain relieving properties may also be produced by its actions on serotonin and norepinephrine receptors, since tramadol’s pain relieving capability is only partially reversed by a pure opioid antagonist like naloxone.

When this medication was first released, it wasn’t a controlled substance. That is, the DEA didn’t control it strictly like medications that can cause addiction. Now, it’s a Schedule IV drug, thought to have benefit but also some risk of addiction, though lower than that of hydrocodone, for example.

Tramadol is usually dosed in 50mg pills, one or two every six hours, giving the maximum dose of 400mg per day. Recreational use of this medication (to get high) is dangerous, since it causes seizures at doses higher than 400mg. In susceptible patients, it can even cause seizures at lower prescribed doses.

I’ve seen patients in tramadol withdrawal who were so sick it frightened me. This drug can produce a severe withdrawal. When it’s stopped suddenly, patients have opioid withdrawal symptoms like sweating, nausea, diarrhea, high blood pressure and heart rate, and severe muscle and joint pains. The sickest patient I’ve ever seen in opioid withdrawal had been using only tramadol, in doses of around 600mg per day. She had fever to 103 degrees, and dehydration from the diarrhea and vomiting. That patient needed hospitalization.

Besides the opioid-withdrawal symptoms, some of these patients also have withdrawal symptoms similar to those seen when certain serotonin-affecting antidepressants, like Paxil and Celexa, are stopped suddenly. They can have fairly severe anxiety, depression, mood swings, and restlessness. Many times they have weird sensory experiences, often called “brain zaps,” or the sensation of electric shocks throughout the body. They can have seizures during this withdrawal.

If the patient had only physical dependency and no addiction, the dose of tramadol can usually be tapered slowly over a few weeks to months, as an outpatient. But if the patient has not only physical dependency but also the disease of addiction, the obsession and craving for the medication will usually prevent a successful outpatient taper, unless a dependable non-addict holds the pill bottle, and dispenses it as prescribed.

Traditional treatment for tramadol addiction starts with detoxification. As above, that can rarely be done as an outpatient, so medical inpatient detoxification admissions for five to seven days can be helpful. However, since tramadol acts so much like an opioid, patients ready to leave detox probably need to go on to an inpatient residential treatment center for at least thirty days.  Intensive outpatient treatment probably isn’t enough support for these addicts. But that’s only my opinion, since I haven’t found any studies describing success rates with tramadol addicts.

Opioid maintenance medications like methadone and buprenorphine do stop the opioid-type withdrawal symptoms from tramadol, and patients probably benefit from medication-assisted therapy just like any other opioid addicts. Using these medications, they can be successfully treated as outpatients. However, as above, I can’t find any long-term studies of tramadol addicts on replacement medications. One of the addictionologists with whom I work doesn’t think it’s wise to put an addict who is addicted only to tramadol on methadone, given the lack of data. However, usually these addicts are using other opioids too, and physically addicted to them as well as tramadol.

Often, methadone patients at the opioid treatment centers where I work are given tramadol by their primary care doctors who think it’s a low risk medication for opioid addicts. It probably is lower in its risk for abuse, but it can cause withdrawal in patients on stable, blocking doses of methadone. (1)

Tramadol is a synthetic, pared-down version of codeine. Interestingly, a structurally similar medication, tapentadol, has just been released, and is now being sold under the brand name Nucynta. That medication is a schedule II drug, presumably because of a higher abuse potential than we’ve seen with tramadol. Tapentadol stimulates opioid mu receptors, and also acts as a norepinephrine re-uptake inhibitor, like some antidepressants. It will be interesting to follow abuse and addiction patterns with this medication.

The bottom line is this: if you are in recovery from addiction (alcohol or drugs) this medication should be used with caution. Let your doctor know that you’re in recovery from addiction. If you must take a potentially addicting medication, talk to your sponsor and your support network. Go to extra meetings. Let a dependable non-addict hold the pill bottle and dispense as prescribed. If you have to take the medication for more than a few weeks, have your doctor taper your dose instead of stopping suddenly.

I’ll have upcoming blog entries concerning Soma, Ambien, and Fioricet.

  1. Leavitt, MA, PhD, “Methadone-Drug Interactions,” Pain Treatment Topics, Addiction Treatment Forum, January 2006