Scott W. Stern, LCSW
Psychotherapist, Empowerment Professional
|Posted on June 14, 2015 at 1:14 AM||comments (31)|
ASAM officially favors empirical research findings over experiential anecdotes for opioid treatment.
ASAM Releases National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use
by ASAM Staff | Jun 02, 2015
FOR IMMEDIATE RELEASE
Contact: Beth Haynes, 301-547-4123 CHEVY CHASE, MD, June 2, 2015 – ASAM announces the release of its National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use (Practice Guideline).
The Practice Guideline will assist clinicians prescribing pharmacotherapies to patients with addiction related to opioid use. It addresses knowledge gaps about the benefits of treatment medications and their role in recovery, while guiding evidence-based coverage standards by payers.The Practice Guideline is a timely resource as the United States is currently experiencing an opioid epidemic.
According to the National Institute on Drug Abuse (NIDA), 2.1 million Americans live with pain reliever opioid addiction disease, while 467,000 Americans live with heroin opioid addiction disease. Overdose deaths are now comparable to the number of deaths caused by motor vehicle crashes, and the societal costs of opioid misuse is estimated to be above $55 billion per year.Medications are both clinical and cost-effective interventions.
While the effectiveness of medications has been researched and documented, their utilization is low and coverage varies dramatically. Less than 30% of treatment programs offer medications and less than half of eligible patients in those programs receive medications.According to Dr. Jeffrey Goldsmith, ASAM President, “Opioid addiction is a chronic, life-threatening disease with significant medical, emotional, criminal justice and societal costs. This guideline is the first to address all the available medications to treat opioid addiction. It will help save lives.”
ASAM worked with Treatment Research Institute (TRI) to develop thePractice Guideline using the RAND/UCLA Appropriateness Method (RAM), a consensus process that combines scientific evidence with clinical knowledge. A Guideline Committee, made up of experts from multiple disciplines, including addiction medicine, psychiatry, obstetrics/gynecology and internal medicine, participated in the consensus process and helped write the guideline. Dr. Kyle Kampman chaired the Guideline Committee and served as TRI’s Principal Investigator.
“The Practice Guideline is the most current document of its kind combining review of existing guidelines, current literature and a systematic process for developing practice recommendations.”ASAM has been working on a number of quality improvement initiatives. The Practice Guideline builds upon several other recent ASAM clinical documents, including the "Standards of Care: For the Addiction Specialist Physician" and “Performance Measures for the Addiction Specialist Physician.”
According to Dr. Margaret Jarvis, chair of the Quality Improvement Council, ASAM’s guideline oversight committee, “The Practice Guidelineis an invaluable document for the addiction medicine field. It will assure a more uniform delivery of quality patient care. We are making a copy of the full guideline available now but are planning publication and a summary article for the Journal of Addiction Medicine and the release of derivative products and educational activities later this summer and fall.
We want the Practice Guideline to be widely used and accepted.”The National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use can be accessed HERE, on ASAM’s website:
|Posted on May 26, 2015 at 4:13 AM||comments (28)|
|Posted on February 15, 2015 at 7:17 PM||comments (19)|
Addiction Expert, Scott W. Stern, Interviewed
by CBS News Correspondent, Dr. Max Gomez
and host, Sarah Hiner About Our Growing
Epidemic of Prescription Drug Addiction
|Posted on February 15, 2015 at 10:29 AM||comments (24)|
"Why the polarizing of addiction professionals regarding abstinence versus harm reduction therapy is so absurd."
--by Scott W. Stern, Psychotherapist/Empowerment Professional
Focused on Addictions, Anxiety, OCD, Trauma & PTSD
Private and Corporate Services
During the past 20 years I've been in practice, I have found that all addiction treatments are, in fact, some form of harm reduction. We've yet to find an infallible treatment for addictions and substance use disorders.
However, the change in the DSM terminology is very significant. It differentiates diagnoses of substance abuse and chemical dependency from it's evolved diagnosis of substance use disorder - mild, moderate or severe. Those with severe diagnoses (co-morbidity involving diabetes, liver damage, severe psychiatric conditions, dementia, legal, etc) would certainly be appropriate candidates for abstinence over moderation. But as I see it, at the end of the day, from moderation to abstinence it's all harm reduction.
For every patient who repeatedly relapses and is referred to the "higher level of care," this, too, is about harm reduction. We've learned how poor the success rates are at inpatient facilities that practice abstinence-only 12-step model approaches. Without guarantees, this too is a harm reduction approach.
In this regard, I believe the term "harm reduction" is obsolete. It is a "given" in any treatment to practice some form of harm reduction. The professional who believes relapse prevention techniques and behavior modification are not a form of harm reduction is terribly misinformed. Even the Hippocratic oath clearly states "Do no harm."
But I will state for the record, I believe more substance users will be attracted to treatment facilities that are not abstinence-only, where clients' lives will be saved by being medically monitored by trained professionals. Once stabilized, every patient--regardless of their clinical needs, has the right to have reasonable access and education regarding current evidence-based treatment.
Ultimately, it is the patient's right to be empowered to make choices regarding his or her own health and treatment. Unfortunately, the polarizing of professionals who see harm reduction and abstinence as opposing treatment models often do not empower clients with education of all current treatment options for substance use disorders.
This is a serious bias in our field that dis-empowers patients ("knowledge is power"), with potential to cause more harm to those substance users at risk.
|Posted on November 26, 2014 at 7:47 AM||comments (32)|
The New York Times (11/21, Parker-Pope) “Well” blog reports that according to a report released Nov. 20 by the Centers for Disease Control and Prevention and the Substance Abuse and Mental Health Services Administration in the CDC’s Preventing Chronic Disease journal, the majority of “people who drink to get drunk are not alcoholics.” The conclusions of “a government survey of 138,100 adults counters the conventional wisdom that every ‘falling-down drunk’” has an addiction to alcohol. Rather, “the results from the National Survey on Drug Use and Health show that nine out of 10 people who drink too much are not addicts, and can change their behavior with a little – or perhaps a lot of – prompting.”
The Washington Post (11/21, Izadi) “To Your Health” blog points out that approximately “10 percent of people who drank excessively also met the clinical definition for alcohol dependence.” The report also found that “the vast majority of excessive drinking is binge drinking, a pattern of behavior where men consume roughly five or more drinks and women consume four or more within a short period of time.” Also covering the story are the NPR (11/21, Aubrey) “The Salt” blog, HealthDay(11/21, Reinberg) and Reuters(11/21, Beasley) also cover the story.
Alcohol dependence was defined as past-year drinking, 3 or more (of 7) dependence criteria, and consuming at least 1 drink on 6 or more days in the past 12 months (11). The alcohol dependence questions in the NSDUH align with the diagnostic criteria for alcohol dependence in the fourth edition of the DSM (DSM-IV) (7).
These include tolerance, withdrawal, impaired control, unsuccessful attempts to cut down or stop drinking, continued use despite problems, neglect of activities, and time spent in alcohol-related activity. The classification of alcohol dependence in this study is based on self-reported responses to the NSDUH and is not based on a diagnosis in a clinical setting or from medical records; therefore, alcohol dependence in this study is based on respondents’ survey data.
|Posted on November 11, 2014 at 8:46 PM||comments (11)|
Advances in Neuropsychiatry Regarding Bipolar Disorder and Risk Taking
This interesting article explores the links between Bipolar Disorder, Neuropsychiatry and Risk Taking (which likely include compulsive gambling, severe substance use and other addictive disorders.
Researchers are beginning to discover some of the reasons why bipolar disorder can cause people to engage in risky behavior. The condition involves fluctuating depression and mania.
In the manic stage, the patient often feels intense excitement and irritability, which can trigger unpredictable risky behavior. Work, family, and social life all can be impaired by this risk-taking.
Professor Wael El-Deredy of Manchester University, UK, and colleagues investigated the neuroscience behind this risky behavior. They engaged 20 individuals with bipolar disorder but not taking anti-psychotic medication and 20 without bipolar disorder.
They measured with fMRI these individuals’ brain activity while playing a game of roulette. Participants were encouraged to make both safe and risky gambles in the game.
This showed “a dominance of the brain’s pleasure center” among those with bipolar disorder, say the team. This area, the nucleus accumbens, drives us to seek out and pursue rewards, they explain, and is not under conscious control. Healthy participants had a less strongly activated nucleus accumbens than those with bipolar disorder.
There were also differences in the prefrontal cortex, a more recently developed part of the brain which allows us to make conscious decisions. The team describe the prefrontal cortex as “much like the conductor of an orchestra.”
They say it gives us the ability to coordinate our various drives and impulses, such as quelling our urges when faced with risky decisions, allowing people to make decisions that are less immediately rewarding but better in the long run.
Participants with bipolar disorder showed greater neural activity for risky gambles, whereas the non-bipolar roulette players were guided by their prefrontal cortex toward safer gambles.
The study is published in the journal Brain. These findings will help to design, evaluate, and monitor therapies for bipolar disorder, the team believes. They now plan to work on psychological therapies that help people engage with their value systems and have greater regulation over their pursuit of goals.
“The greater buzz that people with bipolar disorder get from reward is a double-edged sword,” said El-Deredy.
“On the one hand, it helps people strive toward their goals and ambitions, which may contribute to the success enjoyed by many people with this diagnosis. However, it comes at a cost: these same people may be swayed more by immediate rewards when making decisions and less by the long-term consequences of these actions.”
Co-author Professor Richard Bentall pointed out that this study shows how the new tools of neuroscience, such as advances in fMRI, can be used to better understand the psychological mechanisms that lead to a psychiatric disorder.
Impulsivity and risky decision-making is also characteristic of some other disorders including substance dependence, attention deficit hyperactivity disorder, and pathological gambling.
The team say their findings suggest that in bipolar disorder, and potentially other disorders characterized by impulsivity, the weighting of signals in an area called the ventromedial prefrontal cortex “may be biased towards the ventral striatal contribution, and away from the dorsolateral signal.”
The outcome of this bias is that “lower-order, strongly desired outcomes are favoured above and beyond those that fit with the long-term goal.”
A tendency toward hyperactivation of ventral striatum appears to take place both during anticipation and experience of rewards, among participants with bipolar disorder.
“When immediate rewards are likely to be available, this group have a greater drive to obtain them,” the researchers explain, because rewards have “a greater hedonic impact” and are “more enticing.”
This process may be part of the link between mania and increases in impulsive and unrestrained reward-seeking behavior. Hence, “bipolar disorder cannot be reduced to affective instability alone,” believes the team.
“Our findings have implications for clinical intervention,” they add. For example, psychotherapeutic interventions might be aided by specifically focusing on problems with goal regulation.
In addition, the brain pathways involved could suggest targets for new pharmacological treatments. “In particular, interventions that bolster dorsolateral prefrontal cortex-mediated cognitive control may be an important direction for future research,” they conclude.
Commenting on the study, Professor Peter Kinderman of Liverpool University said, “This excellent study is yet another example of how psychologists are piecing together the picture of why people experience mental health problems.
“Researchers here found that some people are more strongly motivated to take risks to pursue their goals, feel somewhat more of an emotional ‘high,’ but are also somewhat more likely to experience the distressing mood swings that lead to a diagnosis of bipolar disorder.
“That makes a lot of sense, could point the way to effective therapies, but also helps to make sense of mental health problems; too often seen as inexplicable ‘illnesses.’”
Collingwood, J. (2014). Study Probes Neuroscience of Bipolar Risk-Taking.Psych Central. Retrieved on November 12, 2014, from http://psychcentral.com/news/2014/11/10/bipolar-risk-taking-explained/77165.html
|Posted on November 7, 2014 at 5:08 PM||comments (28)|
The question of whether 12 step programs "cure" or "cause" anything is a misrepresentation of 12 step doctrine, and, thus, misleading.
12 step doctrine says addiction is a chronic disease that cannot be cured; rather, it is a disease that can be "arrested" so that the disease goes into a full remission, optimally for the rest of one's life.
So to clarify, 12 step programs neither claim to "cause" or "cure" anything.
The research on suicide and other co-occurring mental health issues of a significant number of substance abusers is true, without question. But there are no studies on rates of suicide by 12 steppers to build this argument upon.
Robin Williams' suicide may not have been prevented by his 12 step work, but I don't know that this proves AA caused him harm. There are too many unknown variables to prove his 12 step work encouraged him to end his life. The variables disclosed about Robin included his just having been diagnosed with Parkinson's disease and bipolar disorder. Other variables we know nothing about include the suicide history within his family or origin, the stability of his home life, work life, and PTSD going back to childhood and more. An autopsy confirmed that there were no addictive substance in Robin's body following his death. And had Robin had a drink or cocaine, who is to say he would not have taken his life anyway.
Although I advocate for harm reduction, I believe Robin Williams' death was sensationalized and exploited to argue that AA was to blame. This, to me, is irresponsible and hurts the evidence-based movement that is the foundation harm reduction.
But what, exactly, is harm reduction? During the past 20 years I've been in practice, I have found that all addiction treatments are, in fact, some form of harm reduction. We've yet to find an infallible treatment for addictions and substance use disorders. However, the change in the DSM terminology is very significant. It differentiates diagnoses of substance abuse and chemical dependency from it's evolved diagnosis of substance use disorder - mild, moderate or severe.
Those with severe diagnoses (co-morbidity involving diabetes, liver damage, severe psychiatric conditions, dementia, legal, etc) would certainly be appropriate candidates for abstinence over moderation. But as I see it, at the end of the day, from moderation to abstinence it's all harm reduction.
For any patient who repeatedly relapses and is referred to the "higher level of care," this, too, is a form of harm reduction. We've learned how poor the success rates are at inpatient facilities that practice abstinence-only 12-step model approaches. Without guarantees, this too is a harm reduction approach.
In this regard, I believe the term "harm reduction" is obsolete. It is a "given" in any treatment to practice some form of harm reduction. The professional who believes relapse prevention techniques and behavior modification are not a form of harm reduction is terribly misinformed.
But I will state for the record, I believe more substance users will be attracted to treatment facilities that are not abstinence-only, where clients' lives will be saved by being medically monitored by trained professionals. Once stabilized, every patient--regardless of their clinical needs, has the right to have reasonable access and education regarding current evidence-based treatment. Ultimately, it is the patient's right to be empowered to make choices regarding his or her own health and treatment.
Unfortunately, the polarization of professionals who see harm reduction and abstinence as opposing treatment models often do not empower clients with education of all current treatment and self help options accessible for substance use disorders.
This is a serious bias in our field that dis-empowers patients ("knowledge is power"), with potential to cause more harm to those substance users at risk out there.
Response to "12 Steps Are Anti-Medication and Anti-Psychiatry"
I've heard some 12 Step members at some meetings discourage the use of any medications for psychiatric disorders. But which ones do and which ones do not is another variable that must be considered before lumping ALL 12 step meetings together.
Furthermore, NA, another 12 step program, does not advise its members to discontinue any medications.
So, I find many generalizations and misinformation in the argument that these programs cause suicides (show me the data--I love research!).
There is no uniformity in 12 step meetings town to town, city to city, state to state, country to country (planet to planet). No two AA meetings are exactly alike or conducted the exact same way. Sponsors vary is how they coach, train or work with sponsees and without uniformity, the variables between meetings and protocols are too great to reach an evidence-based conclusion that "12 step programs cause suicide."
Besides location (NY meetings are run differently from Alabama meetings) other variables include gender, political ideals--there are always politics, even at 12 step meetings, age, sexual orientation, socio-economic backgrounds of members, etc. Furthermore, OA (Overeaters Anonymous), DA (Debtors Anonymous), SA (Sex Anonymous), SCA (Sexual Compulsives Anonymous) and SLA (Sex and Love Anonymous) are also 12-step programs that work with both moderation and abstinence. Again, there is no uniformity within the scope of the 12 steps. It is simply impossible to draw conclusions about all 12 step programs the same way.
Thus, with so many different variables, how can one conclude anything about 12 step meetings as a whole? Too many assumptions are based on opinion or anecdotes without evidence to back them up.
In Response to 12 step programs "playing doctor or psychiatrist"
Regarding physicians and medication, the 3rd Edition of the AA Big Book reads:
"God has abundantly supplied this world with fine doctors, psychologists, and practitioners of various kinds. Do not hesitate to take your health problems to such persons. Most of them give freely of themselves, that their fellows may enjoy sound minds and bodies. Try to remember that though God has wrought miracles among us, we should never belittle a good doctor or psychiatrist. Their services are often indispensable in treating a newcomer and in following his case afterward." (AA Big Book, 3rd Edition p.133.)
I know of no where in the Big Book to support any 12 step member who tries to "play doctor."
I am neither defending nor attacking AA, but I am being objective. And many claims are made with bias instead of research, which is the foundation of evidence-based movement for harm reduction and abstinence treatment models.
|Posted on November 4, 2014 at 12:48 PM||comments (23)|
Pain Management practices would benefit by having an addiction professional as part of their interdisciplinary team just as addiction treatment centers would benefit from a pain management professional educating and monitoring their clients. I would be very interested in working with a pain management practice for the benefit of clients, staff, and the organization as a whole.
Opiate addiction has sky rocketed among the elderly, adolescents, young adults and mid-life adults. Since the cost of heroin is cheaper than the cost of prescription pain killers, I have treated many clients for severe opioid use disorders.
The challenge of pain management and addiction is great. We need more training and research to assist those substance users in chronic pain. No faith-based approach I am aware of addresses this important issue.
Successful pain management in the recovering addict provides primary care physicians with unique challenges. Pain control can be achieved in these individuals if physicians follow basic guidelines such as those put forward by the Joint Commission on Accreditation of Healthcare Organizations in their standards for pain management as well as by the World Health Organization in their stepladder approach to pain treatment.
Legal concerns with using pain medications in addicted patients can be dealt with by clear documentation of indication for the medication, dose, dosing interval, and amount provided. Terms physicians need to be familiar with include physical dependence, tolerance, substance abuse, and active versus recovering addiction. Treatment is unique for 3 different types of pain: acute, chronic, and end of life. Acute pain is treated in a similar fashion for all patients regardless of addiction history.
However, follow-up is important to prevent relapse. The goal of chronic pain treatment in addicted patients is the same as individuals without addictive disorders—to maximize functional level while providing pain relief.
"To minimize abuse potential, it is important to have 1 physician provide all pain medication prescriptions as well as reduce the opioid dose to a minimum effective dose, be aware of tolerance potential, wean periodically to reassess pain control, and use non-psychotropic pain medications when possible.
Patients who are at the end of their life need to receive aggressive management of pain regardless of addiction history. This management includes developing a therapeutic relationship with patients and their families so that pain medications can be used without abuse concerns. By following these strategies, physicians can successfully provide adequate pain control for individuals with histories of addiction."
Treatment is unique for 3 different types of pain: acute, chronic, and end of life. Acute pain is treated in a similar fashion for all patients regardless of addiction history. However, follow-up is important to prevent relapse. The goal of chronic pain treatment in addicted patients is the same as individuals without addictive disorders—to maximize functional level while providing pain relief.
However, to minimize abuse potential, it is important to have 1 physician provide all pain medication prescriptions as well as reduce the opiate dose to a minimum effective dose, be aware of tolerance potential, wean periodically to reassess pain control, and use non-psychotropic pain medications when possible. Patients who are at the end of their life need to receive aggressive management of pain regardless of addiction history.
This management includes developing a therapeutic relationship with patients and their families so that pain medications can be used without abuse concerns. By following these strategies, physicians can successfully provide adequate pain control for individuals with histories of addiction."
Pain Management practices would benefit by having an addiction professional as part of their interdisciplinary team. I would be very interested in working with a pain management practice for the benefit of clients, staff, and the organization as a whole.
|Posted on November 2, 2014 at 1:55 PM||comments (20)|
"Risk factors" refers to an individual's characteristics, circumstances, history and experiences that raise the risk for suicide.
HOW TO READ THE 'NEGATIVE LIFE EVENTS THAT INCREASE SUICIDE RISK' LIST: Having experienced any one (or even several) of the items listed in the Negative Life Events list does not necessarily mean that a person is suicidal or contemplating self-harm. However, these negative experiences do increase the risk of suicidal behavior when compared with individuals who have not experienced such events.
INCREASED DISPOSITION TO ENGAGE IN SELF-HARM: When compared with individuals who have not experienced these events, the occurrence of an immediate "precipitating event" such as a personal crisis may increase the suicide risk for people who have previously encountered the life events noted in the Negative Life Events list.
NEGATIVE LIFE EVENTS THAT INCREASE SUICIDE RISK:
OTHER RISK FACTORS RELEVANT TO MILITARY LIFE:
Protective factors are skills, strengths, or resources that help people deal more effectively with stressful events. Protective factors enhance resilience and help to counterbalance risk factors (negative life events such as academic, occupational, or social pressures). Protective factors may be personal, external, or environmental. A protective factor reduces the likelihood of attempting or completing a suicide. Increasing protective factors can decrease suicide risk. Strengthening protective factors should be an ongoing process to increase resiliency when increased risk factors or other stressful situations occur. Positive resistance to suicide is not necessarily permanent; programs that support and maintain protection against suicide should be ongoing.
Personal Protective Factors
External/Environmental Protective Factors
Definition: Suicide is the deliberate taking or ending of one's own life. It is often associated with a severe crisis that does not go away, that may worsen over time, or that may appear hopeless. Friends or loved ones in crisis may show signs that indicate that they are at risk of attempting or committing suicide.Warning Signs:
WHAT IF I LOSE SOMEONE TO A SUICIDE?
Individuals experience grief uniquely and at their own pace. For some, the experience of grief following a loss can be intense, complex, and long term, while others are able to more readily ‘move on’. The grieving process varies from individual to the next because of many factors: having coped with prior losses; the quality of the relationship with the deceased; the availability of a support system, and so on. What is certain is that the lives of the survivors will be different. At first, and periodically during the next days and months following the loss, survivors may feel an array of sometimes overwhelming emotions. The expression of varying emotions, sometimes accompanied by tears, is a natural part of grieving. Common feelings experienced during grieving include: abandonment, depression, hopelessness, sadness, anger, despair, loneliness, self-blame, anxiety, disbelief, numbness, shame, confusion, guilt, pain, shock, denial, helplessness, rejection, and, of course, general life stress.
WITH SO MANY FEELINGS TO MANAGE, HOW CAN I COPE?
FAMILY AND FRIENDS
SERVICE MEMBERS AND VETERANS
|Posted on November 2, 2014 at 1:23 PM||comments (26)|
PTSD therapies focus on concentrating on
the thoughts and cues that trigger stress.
“We see it all the time and since the wars in Iraq and Afghanistan, we have seen an increase,” said Dr. Ronald Johnson, clinical psychologist at the Lebanon VA Medical Center. “We’ve increased our staff and tried to become more efficient in our therapies in response. We take the safety of our veterans very seriously.”
Returning soldiers are given a medical and mental health assessment twice within the first 90 days after they leave active duty, Johnson said.
“Part of why we do this is to identify what needs they have and get them the services they need right away,” he said.
For a true PTSD diagnosis, in addition to the stressor, there must be intrusive symptoms, said Dr. Scott Bunce, clinical psychologist at Penn State Milton S. Hershey Medical Center.
"Some people with PTSD can get better and function well, but some never do get over it,'' said clinical psychologist Scott Bunce.
Bunce said symptoms may include:
“You’ve learned that certain cues are signals for traumatic events that mean the world is not safe for you and so when you hear or see these cues in the future, you will experience stress whether it’s safe or not,” Bunce explained.
Learning to deal with the memories
Treatment often includes different types of psychotherapy in conjunction with medications such as anti-depressants and mood stabilizers.
Prolonged exposure therapy helps by repeatedly exposing the person to the trauma-related thoughts and situations they have been avoiding, but without experiencing the trauma. This lessens the power of the memories.
Cognitive processing therapy involves the veteran looking at what incorrect thoughts they may have about their role in the trauma and replacing them with accurate, less distressing thoughts, Johnson said.
“For instance, a patient may say, ‘I should’ve seen that roadside bomb up there so it’s my fault what happened.’ The reality is that it’s difficult to see and so they shouldn’t take that responsibility upon themselves,” he said. “You help them discover their thoughts and come to new conclusions.”
Relaxation therapy – learning to relax the body through breathing exercises or muscle relaxing techniques – can also help, Bunce said.
Research into causes and treatments of PTSD is ongoing. One treatment on the horizon is a medication called D-cycloserine, which seems to increase the effectiveness of psychotherapy in helping people process their memories, Bunce said.
“Some people with PTSD can get better and function well, but some never do get over it,’’ Bunce said. “It depends on the situation that created it, [the individual’s] biological constitution, how much support they get and what kind of help they get.”