The Rosenthal Report - August 2016

Rosenthal Reports
What Congress Didn’t Do

Before it broke camp for its seven-week summer recess, Congress passed legislation to address the nation’s epidemic of opioid addiction. With more than 28,600 overdose deaths in 2014, an army of addicts uncovered or insufficiently covered by health care insurance, and a health system that lacks adequate capacity to meet today’s substance abuse treatment needs, President Obama had pressed Congress to provide $1.1 billion in new money, most of which would go to the states to support medically-assisted treatment (MAT) of opioid addiction.

After painful compromises had been worked out in both houses and the conference committee, the measure was passed and sent to the President. It authorizes the federal government to make grants to the states for addiction treatment and prevention programs, but fails to appropriate the funds for them. Although there was strong pressure—and clearly need—for an immediate appropriation, the summer recess began without it. House Republicans say they will appropriate $581 million (far less than the $1.1 billion requested by the administration) when they return to Washington, but there is no guarantee that this promise will survive the haggling over appropriations that comes as the government’s fiscal year winds down at the end of September.    

What Congress and HHS Did Do

As part of the addiction treatment measure, Congress has made it possible for physician assistants and nurse practitioners to prescribe buprenorphine for patients in opioid treatment programs (OTPs).  In a more significant move, the Department of Health and Human Services (HHS) increased the number of patients for whom authorized physicians (and now their surrogates) can prescribe buprenorphine step-down medications (such as Suboxone) from 100 patients to 275.

Threatened to be lost in the shuffle is the federal requirement that opioid treatment programs offering medically assisted treatment  (MAT) provide “a range of services to reduce, eliminate, or prevent the use of illicit drugs, potential criminal activity and/or the spread of infectious disease.”

Bear in mind that the key word in medically assisted treatment is “assisted.” Medication itself is not treatment.  SAMHSA (Substance Abuse and Mental Health Services Administration) defines medically assisted treatment as “the use of medications, in combination with counseling and behavioral therapies to provide a ‘whole patient approach’ to substance use disorders.” HHS requires physicians seeking to increase their patient limit to “attest” that they will “adhere to evidence-based treatment guidelines.”

It is not likely, however, that much in the way of behavioral healthcare services will be available at the “Suboxone clinics” now proliferating in states hit hard by the opioid abuse epidemic.  And the prescription of buprenorphine’s step-down (and addictive) medications to an expanding list of patients troubles a good many health officials there. As the medical director of Tennessee’s Department of Mental Health and Substance Abuse Services warns, “I think the focus has been so much on expanding treatment and getting treatment out to people, that they really haven’t focused on some of the unintended consequences.”

High Risk Munchies

Pot is all too often good for a giggle, but news about marijuana edibles from the National Poison Data System is anything but humorous. Reporting on “single substance exposure calls” for marijuana cookies, candies and the like between January 2013 and December 2015, the poison service found 430 calls nationally with more than half from the two states that have legalized recreational marijuana use. There were 166 calls from Colorado and 96 from Washington, with the number of calls increasing over the course of the study. The age group found most at risk were children under five, who were the subjects of 109 calls. Lethargy, rapid heartbeat, and agitation were the most common symptoms. Three exposed patients (including a four-year-old) had to be intubated, half were hospital treated and released, and three admitted to a critical care unit. Our friends at NFIA (National Families in Action) and SAM (Smart Approaches to Marijuana) alerted us to the Poison Center’s report and also to news about Défoncé Chocolatier’s high end marijuana chocolates (see below).

High Test Bonbons

The high style, high powered inaugural bar of Défoncé chocolate comes in 18 pyramid-shaped detachable segments and 180 milligrams of THC. With concentrated cannabis extract alleged to spread evenly throughout the bar, each pyramid section should deliver a ten-milligram hit of THC, believed to be roughly equivalent to several good pipe puffs. Défoncé (it’s French for “stoned”) is the creation of a former production manager at Apple set on delivering a fashionable product with predictable high-making capacity. Available now in California dispensaries, the Défoncé bar comes in such flavors as coffee, vanilla bean, dark, mint, and hazelnut. The obvious question is how hard is it for consumers to stop munching after a pot-laden pyramid or two.

1st August 2016
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The Rosenthal Report - July 2016

Rosenthal Reports
Drug Abuse by Any Other Name

It made headlines when Michael Botticelli, the White House drug czar blamed “terms like abuser and addict” for discouraging people with drug use disorders from seeking treatment. The head of the Office of National Drug Control policy was hardly setting a trend. The words “abuse” and “abuser” no longer appear in publications and communications of the Substance Abuse and Mental Health Administration and “abuse” has been replaced by “substance use disorder” in psychiatry’s latest Diagnostic and Statistical Manual of Mental Disorders. Government and the treatment field in general seem bent on expunging language they see as contributing to the stigmatization of addiction, and they would rename the National Institute on Drug Abuse if this didn’t require action by Congress.

Stigma, it seems, has a bad name. It has—to make perhaps too fine a point—been stigmatized and unfairly so, for stigma has served for centuries as one of the most useful of social mechanisms. It is the most civil means of sanctioning behavior that threatens the community, violates community mores or norms, or is simply unattractive. This is not at all a bad thing when you consider the alternative. Without informal social controls communities turn to power to modify behavior they find sufficiently frightening, repugnant, or aberrant. We call the cops to curb the negative behaviors we cannot shame. We criminalize it, as we did with substance misuse.

Now that we are in the process of decriminalizing drug use it is no time to abandon stigma as well.  If stigma is cool enough to use against smokers, why decide it’s too cruel to turn on heroin addicts? Shame works, argues psychiatrist Sally Satel in an article that answers positively the question “Can Shame Be Useful?” Although repeated drug use may indeed alter the brain, especially the regions that mediate self-control, “A vast literature,” she points out, “shows that addiction is an activity that can be altered by its foreseeable consequences.”  As for the notion that drugs hold captive (or highjack) the drug user’s brain, see below.

Doubting the Disease Model

A slowly growing wave of dissent appears to be challenging the conviction put forth in the New England Journal of Medicine at the start of the year by Nora Volkow, the head of NIDA, and her co-authors. Their article celebrated increasing acceptance of addiction as “a chronic relapsing brain disease” and resulting neurobiological advances due to acceptance of the brain disease model.

In June, the neuroscientist Marc Lewis challenged the disease model in The Guardian. If addiction is a disease, he wrote, “We might wonder how the disease of addiction could be overcome as a result of willpower, changing perspective, changing environments, or emotional growth. There is evidence that each of these factors can be crucial in beating addiction, yet none of them is likely to work on cancer, pneumonia, diabetes, or malaria.” Further, Lewis reasons, “Once they recover, as most addicts eventually do, it is confusing and debilitating to be told they are chronically ill.” 

Before the month ended, writer Maia Szalavitz put forth her own case in the Sunday Times that “addiction is neither a sin nor a progressive disease.” It is, she contends, a learning disorder. Addiction, she allows, “skews choice—but doesn’t completely eliminate free will.”

Moreover, belief in the disease model is nowhere near as widespread as the Volkow article suggests. A recent survey of public perceptions of drugs, drug use, and addiction, commissioned by the Rosenthal Center and conducted by the Schoen Consulting group, found three out of four Americans reject the notion that addiction is incurable. As for the hard held conviction of most brain scientists that addicts are powerless before their addiction, only 16 percent of the population strongly agrees and 44 percent flatly reject it.

Making Overdoses Safer—Not Necessarily Fewer

It could hardly have been any cuter. Adorable nine-year-old Audrey Stepp was practicing injecting her stuffed lamb with naloxone. The scene was shown on an ABC “20/20” broadcast interview with Audrey and her mother and was picked up by other evening news broadcasts. It wasn’t make-believe. Audrey was practicing how to inject her older brother Sammy who has struggled with heroin addiction for the past six years.

Naloxone is now available, without a prescription, (in nasal spray and hand-held automatic injector) at most pharmacies across the country. NIDA has just created a web section providing “how to” information about the overdose reversal medication for families like Audrey’s. According to the Institute, Naloxone is now “a front line tool used by first responders in preventing opioid overdose deaths”—a laudable goal, when overdose killed some 18 thousand users of opioid painkillers and more than 10 thousand heroin users in 2014.

But what then? What follows? As U.S. News & World Report reported on June 6th, a recent study of prescriptions filled for overdose patients during the thirty days following their hospital release found only 16.7 percent filled prescriptions for addiction treatment medication, and 22.4 percent got opioid painkillers.

While we clearly need to reduce the horrendous incidence of opioid overdose deaths, let’s not mistake a decline in fatalities as a victory over our society’s epidemic of drug misuse.

1st July 2016
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