The Rosenthal Report - December 2016

Rosenthal Reports

The Surgeon General Has Solid Facts But A Flawed Plan To Combat Opioid Addiction

In a fact-packed and ambitious document titled Facing Addiction in America, The Surgeon General’s Report on Alcohol, Drugs, and Health, Dr. Vivek H. Murthy declares, “It is time to change how we as a society address alcohol and drug misuse and substance use disorders,” and indeed it is. But, while the report released last month is filled with useful information about drug use, treatment, and recovery, the public health strategy at the heart of Dr. Murthy's scenario for addressing rising levels of substance misuse and a nationwide epidemic of opioid addiction is fatally flawed. 

What made headlines when the report was released were the statistics—one in seven Americans at risk of addiction and the one in ten lacking the treatment they need. More Americans now use prescription opioids than use tobacco, according to the surgeon general, and more suffer from substance use disorders than from cancer.

Dr. Murthy boils down the recommendations of his 412-page report to a five-point prescription.  Three points are clear and predictable:
•    Expand access to evidence-based treatment;
•    Add more community-based prevention programs;
•    Undertake research that advances development of strategies for treatment, prevention, and support of recovery.

A fourth point—utilizing health reform and parity measures to increase access to substance misuse services—becomes questionable after last month’s election. Nevertheless, as Dr. Murthy says, “Whatever happens, continuing to expand coverage will remain key to addressing addiction.”

It is at the fifth point that the surgeon general’s plan goes off the rails, for he proposes the integration of treatment for substance use disorders with the rest of mainstream health care, which, as detailed in his report, would mean the virtual elimination of today’s network free-standing programs for substance abuse and other behavioral healthcare services.   

The rationale for this proposal derives in part from Dr. Murthy’s own professional experience as a hospitalist (an internist treating hospitalized patient exclusively) and a medical services manager.  But it mostly reflects the orthodoxies that now guide federal substance abuse policy:
•    The alleged ability of “substance use” to “hijack” the normal function of brain circuits;
•    The perception of substance use disorders as a “chronic relapsing condition” no different than such other chronic disorders as             diabetes or hypertension; and
•    The attempt to destigmatize addiction, including such efforts as banning use of the words “abuse, abuser, or addict.”

Please note that:
•    While addiction skews choice it does not eradicate free will.
•    There is more than adequate evidence that, as Dr. Sally Satel puts it, “addiction is an activity that can be altered by its foreseeable       consequences”
•    Shame and stigma are among the most useful of social mechanisms and society’s chief means of modifying negative behaviors. If       it’s okay to employ stigma against smoking, why not against illicit drug use?

“Addiction,” says Dr. Murthy, “isn’t evidence of a character flaw or a moral failure, it’s a chronic disease of the brain that deserves the same compassion that any other chronic illness does, like diabetes or heart disease.” This perception of addiction appears throughout the report. “A substance use disorder is a medical illness,” the report says and, “The primary goal and general management methods of treatment for substance used disorders are the same as those for the treatment of other chronic illnesses.” 

Separation of substance abuse services from the rest of health care, the surgeon general contends, “has contributed to the lack of understanding of the medical nature of these conditions…and the slow adoption of scientifically supported medical treatments by addiction treatment providers.”

Under Murthy’s plan, state funding and licensing policies would be employed to bring about the shotgun marriage of behavioral and general healthcare. 

The fatal flaw in all of this is the politically correct but therapeutically absurd notion that there is truly no difference between substance abuse and other chronic disorders. Nor is there compelling evidence that, save for a few black swans, addiction is in fact a chronic (i.e. incurable) condition. Chronic or not, the behavioral component of addiction goes far beyond the need for compliance in managing diabetes or hypertension. Bad behavior is a fundamental component of addiction and the past fifty years of treatment experience has taught us that changing behavior is not what mainstream medicine does. 

Medication helps, and the Murthy plan calls not only for the expansion of medication assisted treatment (MAT)—the use of methadone, buprenorphine, and naltrexone—but elimination or reduction of “restrictions on how these drugs may be prescribed or dispensed” that he maintains, “have reduced their availability for many people who could benefit from them.” 

Those of us who actually treat addiction recognize that medication is, by itself, not treatment. It is a useful adjunct for the behavioral therapies that help our patients find their way to sustained recovery.  But the most powerful ingredient by far in the treatment of addiction is the joint effort of patients, together with each other and peer counselors in recovery to take control of their own lives.  
Consistent with his call for a public health approach, the surgeon general’s plan includes “harm reduction” programs for those users “who may not be ready to stop substance use,” sanctioning needle exchange programs, overdose prevention education, and access to naloxone. These strategies, he says, “reduce substance misuse and its negative consequences… such as transmission of HIV and other infectious diseases.” They also, as the surgeon general acknowledges, “seek to help individuals engage in treatment to reduce, manage, and stop their substance use when appropriate.” 

When it comes to “the treatment gap” the difference between those substance users who need treatment and those who receive it, the report allows that, “Many factors contribute to this,” and goes on to list “the inability to access or afford care, fear of shame and discrimination, and lack of screening for substance misuse and substance use disorders in general health care settings.” In addition, the report notes that roughly forty percent of those “who know they have an alcohol or drug problem are not ready to stop using, and many others simply feel they do not have a problem or a need for treatment.”

Although it may appear somewhere in the report’s 412 pages, there is no mention in the executive summary or in any of the surgeon general’s interviews of what is surely a critical factor in the inability of our society to bring substance misuse under control. As the number of drug and alcohol users has risen over the past decade, the number of treatment admissions for substance use disorders has fallen.

The report shows illicit drug use rising from 8.3 percent of the population to 10.2 percent between 2002 and 2014. In roughly the same time frame, between 2004 and 2014, as the U.S. population increased by 10 percent, the number of treatment admissions fell by 11 percent, from 1,808,469 to 1,616,358.

Most critical was the precipitous decline of close to 50 percent in teen treatment. “The earlier people try alcohol or drugs, the more likely they are to develop a substance use disorder,” says the surgeon general’s report.  But what it does not say is that adolescents are much less likely than adults to find effective treatment.  Although the report cites one million adolescents (12 to 17) who need but lack treatment, teen admissions plummeted between 2004 and 2014 from 146,423 to 78,018. How or why this has occurred is an issue the demands investigation.

7th December 2016
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The Rosenthal Report - November 2016

Rosenthal Reports
Post-Election Highlights
Victory, Defeat, and Uncertainty for Recreational Marijuana

Pro-pot forces outspent and overwhelmed opponents of recreational marijuana use in California, Massachusetts, Nevada, and Maine, but failed to win in Arizona. Meanwhile, in Alaska, where voters approved recreational use close to two years ago, the first pot shops just opened in Valdez and Fairbanks. These five join Colorado and Washington, states with recreational marijuana already on the books, in the shops, and growing in the fields. This year’s election also saw medical use of marijuana approved by voters in Florida, North Dakota, and Arkansas, making medical use the law in a majority of states.

Legalization champion Ethan Nadelmann, executive director of the Soros-funded Drug Policy Alliance, called the election results “a monumental victory for the marijuana reform movement.”   The Washington Post speculated that adoption of legal marijuana by California, home to roughly 12 percent of nation’s population, might “prompt the federal authorities to rethink their decades-long prohibition on the use of marijuana.” This thought has clearly not escaped President Obama who said, in a recent interview with Bill Mahr, that passage of the legalization proposals could make “untenable” the current federal “hands-off” policy towards legalization efforts at the state level.

It is not likely, however, that the incoming Trump administration, strong for law and order and skeptical of drug reform, would be enthusiastic about keeping their hands off. “The prospect of Rudy Giuliani or Chris Christie as attorney general,” Nadelmann allowed in an interview, “does not bode well. There are various ways in which a hostile White House could trip things up.”

The battle against legalization is clearly not over on the state by state level. “We were outspent greatly in both California and Massachusetts, so this loss is disappointing, but not wholly unexpected,” says Kevin Sabat, president of SAM (Smart Approached to Marijuana), a leader in the fight against legalization. "This is the beginning of the conversation, not the end,” he adds, for SAM will be working with localities within the legalizing states, he says, “to ensure they know their rights and obligations to protect their citizens from pot shops, candies, and advertising."

What Was Lost With Hillary

There was no mention of the nation’s opioid epidemic in the Presidential Debates and Donald Trump’s sole reference to the problem went no farther than the Mexican border where, he declared, “We’re going to build a wall and we’re going to stop that heroin from pouring in.” But Hillary Clinton had a carefully thought out plan to spend ten billion dollars over the next ten years on just about everything other than a wall.

It would have boosted the Substance Abuse Block Grant, (money that regularly goes to the states for drug abuse services), provided blanket provision of naloxone for overdose victims, funded prevention initiatives, promoted prescription monitoring programs, and prioritized treatment over incarceration.

When it came to treatment, Hillary’s plan was committed to comprehensive, ongoing care, and, according to the Associated Press, would promote greater use of medication assisted treatment (MAT).  


The Problem with Medication Assisted Treatment (MAT)

Hillary is not alone in promoting medication assisted treatment. President Obama’s plan, authorized by Congress before the summer recess, also increases funding for MAT programs.

But, at what point does “medication assisted” treatment become “the medication alternative” to treatment, for federal regulations define MAT as “the use of medication in combination with counseling and behavioral therapies.”  This is an issue that troubles health care officials in areas hard hit by the opioid addiction, where the priority has been getting buprenorphine step-down medications to patients in new opioid treatment clinics where they are unlikely to be getting much, if anything, in the way of the “whole patient approach” that federal guidelines say should provide, “a range of services to eliminate, reduce, or prevent the use of illicit drugs.”

Prescription by Decree

When it comes to medically assisted treatment for Medicaid patients, no state is more generous than Vermont.  A number of states demand that Medicaid patients “fail first” at a less costly intervention or, as Kelly Clark, M.D., president-elect of the American Society of Addiction Medicine points out, “require patients to wean off their addiction medication” (which she considers akin to telling a heart patient to taper off of his medication after a year). But not Vermont, where the state’s Medicaid program pays for 68 percent of all the retail prescriptions for buprenorphine, more than any other state in the nation. 

Governor Peter Shumlin, who chose not to run for a fourth term this year, has been determined to end the state’s opioid crisis and is proposing to limit the number of painkilling pills a physician can prescribe for a patient. The issue of setting prescription rules was passed on to the governor and the Vermont State Department when legislators approved an omnibus bill designed to curb the opioid crisis.  

“Limits would be based”, says the governor, “on severity and duration of pain, the complication of the procedure, and the particular medication prescribed.” He contends that rationing the number of pills will reduce the incidence of addiction, “We didn’t have a heroin crisis in America before OxyContin was approved and started being handed out like candy.”

According to the state’s health commissioner, Harry Chen, M.D., the proposal would cap prescriptions for some minor procedures at between nine and twelve pills. The plan, he explained would impose consistency on opioid prescription.  “There is a clear pattern of over-prescribing,” he said, and “tremendous disparity between different doctors on how many painkillers are prescribed for the same surgery.”

Critics of the plan warn that limiting access to legal pain medication was most likely to drive patients to seek illicit drugs. It should also be recalled that over-prescription of pain medication in the recent past was not due entirely to aggressive marketing. It reflected as well the under-treatment of pain that preceded today’s concern about patient satisfaction.

Adderall: Not Just for Kids

After last month’s report on A.D.H.D., Casey Schwartz’s article, “Generation Adderall,” appeared in the Sunday Times Magazine.

Casey wasn’t an A.D.H.D. adolescent. She came to Adderall on her own as a young adult, a sophomore student at Brown University.  It was when she was stuck for a five-page report due the next day on a book she’d only just begun to read that Casey took two Adderall pills from a friend. She spent the rest of the night, she recalls, “in a state of peerless ecstasy. The world fell away; it was only me, locked in a passionate embrace with the book I was reading and the thoughts I was having about it, which tumbled out of nowhere and built into what seemed an amazing pile of riches.” 

She was hooked. It was an experience she was going to have and seek to have repeatedly over the years that followed.  Casey was not unique. As she points out, adults made up the fastest growing group of Adderall users in the mid-2000s.  And, once she realized she needn’t buy overpriced pills from A.D.H.D. kids, and conned her own prescription from an easily hoodwinked psychiatrist, she had access to pills for life.

Does Adderall actually enhance cognitive performance?  Is it, as Casey asks “a smart drug?”  She calls the evidence “more than a little ambiguous.”

In time, she came to realize, she writes, that “I lived in a paradox, believing that the drug was indispensible to my very survival while also knowing that it was nothing short of toxic, poisonous to art, love, and life.” Periodically, she tried to get off Adderall and eventually succeeded. But she found the drug infinitely more difficult to relinquish than various experts assured her it was supposed to be. She also found evidence in the message boards of websites devoted to giving up the drug that she was far from alone in her struggles to quit.

1st November 2016
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The Rosenthal Report - October 2016

Rosenthal Reports
Marijuana Highlights
The Good News

The good news isn't all that good. The initial report from SAMHSA (Substance Abuse and Mental Health Services Administration) on findings of the National Survey of Drug Use and Health for 2015 shows a sharp decline in adolescent use of cigarettes and alcohol. Teen cigarette use has fallen by more than two-thirds since 2002 and alcohol use by nearly half. But at 7.0 percent, current (past month) use of marijuana by adolescents has remained at much the same level over the past decade.

A slight dip in teen use from the previous year and a significant decline from a peak in 2009, along with recent levels of adolescent heroin use, encourage agency officials to describe the current data as offering, "hope that marijuana and heroin use may be slowing down." What has clearly slowed down is the prevalence of adolescents with marijuana use disorders—either dependence on the drug or abuse of it—for the survey found this number falling from 4.3 percent of adolescents to 2.6 percent since 2002.

The Bad News

That's the increase in adult use. For young adults (18 to 25), the level of current (past month) use—now stands at just under 20 percent (19.8)—and has been creeping up from l6.6 percent since 2008. The level of current use for older adults increased by more than half again as much during the same seven-year period from 4.2 percent to 6.5 percent.  Should the increase in adult use concern us? You bet it should. Recent articles and editorials in the American Journal of Psychiatry point to the increase in adult use, with low levels of risk awareness, increased incidence and severity of cannabis use disorder, higher risk of death and psychosis (including schizophrenia), and a troubling low rate of treatment.

Our friends at Smart Approaches to Marijuana (SAM) flagged a new study by Quest Diagnostics, a major drug testing firm that found the rate of workers testing positive for marijuana has increased by 47 percent since 2011. This increase over the past three years followed a long period of declining drug use in the workplace and is clearly a reflection not simply of legalization and the quasi-legalization of medicalized marijuana, but also of what the author of a Journal of Psychiatry article calls "the increasingly accepting social attitudes toward marijuana use."

The Scary News

Psychiatrists are well aware that a connection exists between adolescent marijuana use and psychosis. The article “Concurrent and Sustained Cumulative Effects of Adolescent Marijuana Use on Subclinical Psychotic Symptoms” in the recent American Journal of Psychiatry nailed down some of the specific in a five-year study of more than a thousand teen-age boys.

Researchers at the University of Pittsburgh and Arizona State found that for each year the boys smoked marijuana 52 or more times they increased the risk of persistent subclinical psychotic symptoms by 21 percent. For each year of weekly use the chance of experiencing paranoia rose 133 percent and experiencing hallucinations rose 92 percent. All in all, the study should put "paid" to the notion that pot is pretty harmless stuff.


Risk Raising Synthetics

Complicating the already complex opioid overdose epidemic is the increasing use of powerful synthetic narcotics to boost the potency of heroin. From New England to California, authorities are finding growing numbers of overdose victims dosing themselves with heroin cut with fentanyl, a fast acting, short lasting synthetic painkiller widely used in medicine and 100 times stronger than morphine. In Ohio, the number of fentanyl overdose cases rose from 84 in 2013 to close to 1,500 in 2015.

Recently, carfentanil, a brawny cousin of fentanyl, showed around Cincinnati and in southern Indiana along the Kentucky border. A synthetic opioid used by veterinarians to sedate large animals (including elephants), carfentanil has 10,000 times the strength of morphine. During just one week this past August, it was responsible for close to 200 overdose cases and at least four deaths in the Cincinnati area. The DEA has issued a nationwide warning about carfentanil and NIDA has alerted authorities in both Ohio and Florida.

The danger low-cost, high-powered synthetics pose isn’t only increasing the overdose potential of drugs sold as heroin. They also are being used in counterfeit painkilling pills. The death of singer, songwriter, and musical icon Prince was caused by fentanyl in a counterfeit pill labeled Watson 36 that allegedly contained only hydrocodone and acetaminophen.

Our Medicated Kids

Pioneers in the study of attention deficit hyperactivity disorder (A.D.H.D.) have long decried the growing number of children now being diagnosed with A.D.H.D. That number grew from six hundred thousand in 1990 to six million by 2014. It is still growing, although there are no laboratory tests to confirm the diagnosis, which is based on subjective evaluation and screening for symptoms of inattention, hyperactivity, and impulsive behavior. Medication has become the standard response, and the great majority of the diagnosed are prescribed Ritalin, Adderall, or similar stimulants.


Fewer than one in three receives the behavior therapy that should accompany medication. And only half the diagnosed preschoolers receive the behavior therapy recommended as the first line of treatment by the American Academy of Pediatrics.

Now, New York Times reporter Alan Schwarz tells how all this came about, blowing the whistle on what he describes as one of the world’s most aggressive marketing campaigns. His book ADHD Nation tells how an alliance of drug companies, academic psychiatrists, policy makers, and celebrity pitchmen (what he calls “the A.D.H.D. industrial complex”) has sold the nation and the world, not on drugs, but—in the guise of awareness—on A.D.H.D. itself.

“Attention deficit hyperactivity is real,” says Schwarz, who opens his book with that sentence. But disorders of attention, once thought to be relatively rare (affecting only about three percent of preadolescents) have come to be routinely diagnosed, affecting more than 14 percent of American boys.  And who is it that is diagnosed? In the classroom it’s most often the youngest children in a class.  In the pediatrician’s office it’s likely to be allegedly under-achieving children of parents who believe the right pills will turn them into academic champions. Moreover, the drugs are now being prescribed for two-and-three year olds, which one pediatric critic of practice calls no more than “a quick fix for an unruly child.”

O.D. Fatalities as a Campaign Issue

Under the headline “Why It Matters: Issues at Stake in the Election,” the Associated Press recently listed and briefly described 17 pressing issues facing the nation, putting Iran first on the list and free trade agreements last. In thirteenth place was the article’s capsule summary of the “Opioid Epidemic,” leading with a single sentence citing the nation’s 28,000 opioid overdose deaths in 2014. The cause, according to AP, was the quadrupling of prescription painkiller sales since the start of the millennium. What is needed now are more dollars for “prevention, treatment and recovery services.”

Although the addiction epidemic was prominently featured in the Republican’s early and overcrowded nomination debates, it hasn’t surfaced much since the party conventions and wasn’t mentioned by either candidate in the first of the presidential debates. Summarizing where the candidates stand on the issue, AP cited Donald Trump’s wall along our southern border, which he contends is essential to stopping the flow of illegal drugs into the country, and Hillary Clinton’s pledge to spend ten billion dollars on addiction services.

1st October 2016
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The Rosenthal Report - September 2016

Rosenthal Reports
A Proper Place for Pot

When the Drug Enforcement Administration (D.E.A.) turned down petitions to drop marijuana from the Schedule 1 of the Controlled Substances Act last month, there were cries of anguish and outrage from the pro-pot crowd, plus a plea from The New York Times to “Stop Treating Marijuana Like Heroin.” But this was no hard-hearted rejection of the current reality—widespread decriminalization and quasi-legalization by prescription, plus actual legalization in two states (with upcoming votes in five more come November).  It was simple recognition that, no matter how prevalent the acceptance of toking becomes, pot is still a mind altering substance and, as such, falls under the Controlled Substance Act.

So, legislators clamoring for a category change are stuck with the strictures of the Act’s “eight factor analysis.” It’s not the degree of “actual or potential abuse” that keeps pot in the top category. It’s the lack of any “approved medical use.” That's what's required of drugs in the lower categories.

Although a downgrade of marijuana to a lower category is not in the cards, the D.E.A.—in an even-handed action by the Obama administration—opened wide the doors to marijuana research, allowing universities and even private companies to secure agency approval to grow their own pot for research purposes.  Only the University of Mississippi now enjoys this privilege.

Marijuana’s current clinical credentials, however, are not too impressive. Despite a plethora of anecdotal reports and reputable work on the drug’s ability to alleviate nausea, improve appetite, and ease painful spasms, there is little in the way of hard scientific data to support prescription of smokable marijuana for all the many maladies now being treated with pot in the medical marijuana states. Serious research on components of marijuana, however, is now under way, and the new regulations should accelerate this process.  The Food and Drug Administration has already approved two drugs—Marinol and Casamet that contain synthetic versions of a substance found in marijuana. Both are prescribed for the nausea and vomiting of cancer patients and Marinol is given to aid the appetite of AIDS patients.

It’s true that marijuana is no heroin, but it’s no benign indulgence either.  While most—but far from all—adult users appear to avoid serious consequence, the same is not true of kids.  Adolescents are twice as likely as adults to become addicted to marijuana (and, yes, pot is addictive). More significantly marijuana impairs perception and judgment, shrinks attention span and compromises the ability to learn, all of which impedes the maturation and socialization that should be occurring throughout the adolescent years. 

The most recent and disturbing discoveries about marijuana have found heavy use in adolescence resulting in lasting changes to “working memory,” altering brain structures critical to memory and reasoning, impeding problem solving and the retention of information needed for everyday tasks.

What I find particularly troubling, if predictable, is how casually many parents now regard marijuana use. Our recent survey of public perceptions of drug abuse found that more parents would rather see their children smoking pot than smoking cigarettes.

Today, it is legalization that gets the headlines, but the real issue is society’s increasing acceptance of marijuana use and the burden this places on families. Parents now, more than ever, need be aware of just how dangerous and damaging marijuana can be for their kids and must deal with the threat without the level of support from law, society, and the community that they once enjoyed.

Take the Pledge & Turn the Tide

That’s the message that Vivek H. Murthy, M.D., the U.S. Surgeon General, sent to 2.4 million physicians and other health care professionals at the end of August, urging them to go online to the Turn the Tide website, sign up, and commit themselves to the campaign’s three-point program:

Educate ourselves to treat pain safely and effectively.
Screen our patients for opioid use disorder and provide or connect them with evidence-based treatment.
Talk about and treat addiction as a chronic illness, not a moral failing. 

There’s no doubting the impact of the opioid addiction epidemic that has been growing since the start of the current millennium. Between 1999 and 2014, as prescription of opioid medications (such as Percocet, Vicodin, and OxyContin) quadrupled, more than 165,000 Americans died from opioid-related overdoses.  And today, more and more addicted men and women who can no longer secure the drugs they crave by prescription are turning to the more accessible and less costly option of heroin.

The surgeon general is hardly the first to sound the alarm.  By 2008 more Americans were dying from drug overdose than from motor vehicle accidents. The Center for Disease Control designated the spread of addiction as “epidemic” in 2010 and issued guidelines for a far more restrained approach to the prescription of opioids this past March.  (The surgeon general’s letter includes a pocket card copy of the CDC guidelines). It was also in 2010 that my colleague Andrew Kolodny, M.D. and his Physicians for Responsible Opioid Prescribing organization began advocating for restraint and controls in the use of opioids. 

Although I don’t argue with the need to respond aggressively to the addiction epidemic and to address the over-prescription of potent painkillers, I am concerned about over-responding.  After all, much of the problem we face today came about because of over-responding to the under-treatment of pain.  It was not only aggressive marketing of prescription opioids that led to over-prescription. It was also a newfound concern about patient satisfaction in the 1980s. That’s, when patient pain came to matter, as patients were recognized as “health care consumers,” physicians as “providers,” and the federal government started keeping track of patient satisfaction.  When I turned to the Turn the Tide website I was struck by one of the factoids that crossed the screen in the site’s numerical display. It read: “As many as 1 in 4 receiving long-term opioid therapy (in primary care settings) struggle with opioid addiction.”

What, I wondered, about the other three? What, for that matter, about all the patients with chronic pain whose caregivers will now feel pressure to follow the CDC guidelines that encourage such alternatives to opioids as exercise, cognitive behavioral therapy or the use of aspirin, ibuprofen and other anti-inflammatory medications. (Other sources also recommend acupuncture and meditation). When opioids are to be used, the rule is go slow and low—low dosage, and a strictly limited number of pills—only immediate release pills too, not the extended release, long-acting kind.  Will this reduce the incidence of addiction and overdose?  It certainly should, but I suspect there’ll be a world of hurt that goes untreated as well.

There is a wry twist to one aspect of Surgeon General’s pledge. It’s the requirement of those who sign up to connect patients with opioid use disorders with evidence based treatment. Since the overwhelming majority of new treatment capacity authorized by Congress (but yet to be funded) is specifically for medically assisted treatment (MAT), we can be fairly certain that these patients will have ready access to buprenorphine, suboxone and similar semi-synthetic opioid derivatives.

When the Enemy is Us

Yes, former drug users are stigmatized. That’s true. It is also true that stigma flourishes, in part, because of efforts by the very folks who protest most ardently against it. Whether or not it inhibits addicts from seeking treatment, stigma has profound and negative effects on the lives of men and women in recovery.  A recent survey of public perceptions of addiction and drug abuse conducted by Schoen Consulting for the Rosenthal Center, found that three quarters of Americans find social drinkers trustworthy enough to hire, while barely half consider recovering addicts that trustworthy. When it comes to approving a potential husband or wife for their children, our survey respondents put the totally abstinent at the top of their list, with social drinkers close behind. Barely 30 percent would bless the union of their son or daughter to an addict in recovery.

What the survey also revealed was widespread misunderstanding of addiction. Seventy percent of respondents agreed that addiction was a disease, 67 percent that it was a chronic condition, and slightly more than half that relapse was a built-in aspect of the disorder.  They split almost evenly over whether or not addicts were powerless to resist their addiction (with a slight edge on the pro-powerless side). Nevertheless three out of four maintained that this chronic relapsing condition is curable. 

As for stigma, close to two-thirds of Americans hold it to be a useful social tool, and stigmatization they agree might well reduce the use of marijuana, as it has the use of cigarettes. A key finding about stigma, however, is the belief by better than two thirds of respondents that defining relapse as integral to addiction contributes to stigmatizing people in recovery. There is a lesson in this for those vested most firmly in the “chronic relapsing” disease model. Rather than bowdlerizing the language of addiction (banning the use of “addicts,”  “abuse,” or “abusers”) what is more likely to destigmatize recovery is ceasing to insist that addiction is incurable, and indeed the evidence is mounting that, for most (if not all) addicts, this is not necessarily true.                            

1st September 2016
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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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The Rosenthal Report - June 2016

Rosenthal Reports
Good News and Bad

Good news for kids comes from the Journal of Clinical Child & Adolescent Psychology, reporting research findings that show children with attention-deficit problems improve faster when they first receive behavioral treatment (i.e. talk therapy) rather than the current standard practice of starting with prescription stimulants such as Adderall or Ritalin (which more than four million children and adolescents now receive).  The bad news comes from Washington where $920 million of the $1.1 billion President Obama wants to fight the nation’s opioid addiction epidemic is earmarked specifically for medication-assisted treatment. Resorting to drugs (methadone, buprenorphine, LAAM, and naltrexone)—not as aids to treatment but more often as treatment itself and subsequent maintenance—means that we will create an ever-growing population of permanently addicted men and women.


More News Good and Bad

Here the good news comes from the DEA crediting tighter control of hydrocodone prescriptions for reducing the prescription rate for this highly addictive opioid painkiller by 26.3% and reducing the number of pills consumed by roughly one billion. The bad news however, is the simultaneous rise in overdose deaths reported in just about every one of the nation’s counties as former oxycodone addicts turned to heroin. Looking ahead, it is not unreasonable to expect the CDC’s “Start Low and Go Slow” guidelines, recommending nonopioid alternatives for chronic pain to be accompanied by similar boosts in heroin consumption and overdose deaths.

Keeping Pot at Arm’s Length—Not Quite

Marijuana may be legal in Colorado, but not within 1,000 feet of a school.  That’s the law. But it’s not the practice. Reporters for the Denver Post have found 25 marijuana shops operating well within the thousand-foot exclusion zone.

Heroin Injection Sites: Good Intentions Often Go Awry

What should thoughtful policy makers make of proposals to open legally sanctioned heroin injection sites in San Francisco, New York City, and Ithaca? While the sites can provide access to treatment, direct evidence of harm reduction is scant. Studies of legal injection sites in Vancouver, Sydney, and throughout Europe have found no significant reductions in HIV or hepatitis infection or the sharing of syringes. More significantly, the evaluations found no solid evidence of overdoses being averted. As Toronto, Ottawa, and Montreal, plan to follow Vancouver’s example with programs of their own, one journalist for the Toronto Star reported on the program in Oslo, Europe’s overdose capital with the continent’s highest overdose death rate. In Oslo, he writes, “the existence of safe injection sites has neither discouraged users to take it off the streets nor significantly persuaded users to avail themselves of rehabilitation.’  Ten years after the Oslo program began, the overall mortality rate is just where it was a decade ago. “Good intentions,” he writes, “can lead to bad consequences. One need look no further than the Slab, an area leading from the Oslo train station directly to the city’s main street. Emaciated addicts gather in the area every day, every night, slumping against the walls of derelict warehouses around the docks, openly injecting heroin, knowing police won't move in unless it becomes necessary to quell a significant public disturbance.”

1st June 2016
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