Addiction Policy Forum Blog

7 min read

Physician substance use disorders: contingency management encourages recovery?

By Mark Gold, MD on December 26, 2019

“Imagine if,” write the authors of a review in The New England Journal of Medicine, “the medical profession barred anyone being treated with pharmacotherapy for depression from returning to practice, insisting that only physicians who had achieved remission with cognitive behavioral therapy were fit to practice.” Why might readers imagine this? Physicians and nurses with opioid use disorder (OUD) are encouraged or required to participate in physician health programs, or PHPs, state-based treatment programs studied by experts like McLellan, Dupont, and Merlo, among others.1 These programs are often focused on abstinence and have defined 5-year outcomes, including fitness for duty and return to work. This New England Journal of Medicine article makes a case for lifting bans on medication-assisted treatment (MAT) in some PHPs and orienting the programs around structural health challenges faced by medical professionals. 

It is certainly true that PHPs have a history of successful recovery, return-to-work rates, and premorbid function outcomes for physicians who are monitored and active in such programs. But all physicians are not the same. Substance Use Disorders (SUDs) are not the same, either, and physician specialties have different risks.2 Before the public heard of fentanyl, for example, it was a dangerous substance for anesthesiologists.3 And health care professionals and business executives can become political footballs in the MAT vs non-MAT dichotomy. 

I like to frame this discussion around personalized medicine. We do not currently have tests or other predictors gauging which person with OUD will best recover at 5 years, and with which treatment. Some studies on PHPs suggest that health care professionals have the best 5-year return-to-work and premorbid function outcomes reported. This may be due to the generally late onset of SUDs in physicians. It could be that a given PHP works because of contingency management—follow the program and you can continue to be a physician. Contingency management is one of the most effective behavioral interventions for OUD and used much more frequently in PHPs than in non-PHP treatment settings. But few psychiatrists or addiction specialists understand the overall utility and efficacy.4 

We need more research to figure this out, but physician intervention, treatment, and recovery has been a model for successful 5-year outcomes and multidisciplinary treatment.5 Some programs are strictly oriented around a non-medication approach, but others are more flexible. Some programs have mandated MAT, like those requiring naltrexone for anesthesiologists6 returning to work, but others may prohibit MAT. Merlo has reported on outcomes and on MAT utilization in this population. She found that “individuals with opioid use disorders managed by PHPs can achieve long-term abstinence from opioids, alcohol, and other drugs without opioid substitution therapy (OST ) through participation in abstinence-based psychosocial treatment with extended, intensive care management following discharge.”7

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7 min read

We know vaping can cause serious lung problems. A new study says it might also cause cancer.

By Mark Gold, MD on December 19, 2019

In a study published this week, researchers asked tens of thousands of individuals over 12 years of age about their use of tobacco products, e-cigarettes, and their health, and conducted follow-up questions over three years.1 They found the development of lung problems like emphysema, bronchitis, asthma, and chronic obstructive pulmonary disease in individuals who had used e-cigarettes in the past or currently use them. Combined use of e-cigarette and tobacco products dramatically increased lung disease risks by an incredible 330 percent. The researchers concluded that, “Use of e-cigarettes is an independent risk factor for respiratory disease in addition to combustible tobacco smoking.” The study’s senior author, Stanton Glantz, told CNN, "I was a little surprised that we could find evidence on incident lung disease in the longitudinal study, because three years is a while but most studies that look at the development of lung disease go over 10 to 20 years.”

The Centers for Disease Control (CDC) reports that, as of December 10, 2019, there are 2,409 hospitalization cases of vaping-related lung injuries in the U.S., resulting in 52 deaths across 26 states and Washington, D.C.2 The FDA has found THC in most of the samples it’s studying from these cases and has highlighted Vitamin E acetate as a chemical linked to some of the lung injuries. But the CDC warns that it still does not know how many other chemicals and products may be involved, and says that, “the best way for people to ensure that they are not at risk while the investigation continues is to consider refraining from the use of all e-cigarette, or vaping, products.” NIDA just reported that 3.5 percent of 12th graders and 3 percent of 10th graders say they vape on a daily basis, with 14 percent of 12th graders also saying that they vaped marijuana in the previous month. That figure is twice as large as it was last year. 

Though federal officials have reportedly backed away from banning flavored vaping products3, some states have implemented such restrictions. And other national lawmakers are still considering similar options to confront the vaping epidemic.4 Dr. Scott Gottlieb, the former FDA Commissioner, has now recommended banning all cartridge-based e-cigarette products, which would include popular devices like Juul.5 Gottlieb, along with other experts, is worried about the epidemic of youth vaping, nicotine use and dependence which can lead to the use of tobacco-based products, the number one cause of preventable death, and other substances later in life. 

Stories about vaping-related severe lung diseases, the epidemic of youth use, and public policy responses are important for patients, families, medical professionals, and consumers to follow. But we should also continue to monitor research that paints an even more distressing picture of e-cigarette products. In a recent study, researchers looked at the association between e-cigarette use and cancer.

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7 min read

Suicide might be a root cause of more opioid overdoses than we thought

By Mark Gold, MD on December 12, 2019

An “intentional” suicide attempt by fatal drug overdose refers to an individual seeking to overdose in order to end her life. This may sound straightforward enough. But the issue is much more nuanced, related to how we understand and respond to the opioid overdose epidemic. If all overdoses are considered “accidental” until proven otherwise, we may be missing higher rates of suicide and depression, and different approaches to prevention, identification, and treatment. 

How exactly can coroners and officials who write on death certificates determine whether someone “intentionally” wanted to die by overdose or “unintentionally” died by overdose, without any desire to die at all? The Directors of the National Institute of Mental Health (NIMH) and National Institute on Drug Abuse (NIDA) recently reviewed the literature linking overdose and suicide.1 Up to 30 percent of all accidental overdoses are actually suicides. They observed that, controlling for other conditions, suicidal thoughts are 40-50 percent higher among individuals misusing prescription opioids, and that, “people with a prescription opioid use disorder were also twice as likely to attempt suicide as individuals who did not misuse prescription opioids.”

In the U.S., suicide rates are increasing, overdoses are increasing, and life expectancy is decreasing—“deaths of despair”, they are often called. Between 1999 and 2009, opioid-related suicide rates doubled.2 Opioid-related overdose deaths among Americans and adolescents have also surged. And both opioid-related deaths and suicides have increased to epidemic levels in the United States. Doctors Nora D. Volkow and Maria A. Oquendo3 have written that declining motivation to live can range “from engagement in increasingly risky behaviors despite a lack of conscious suicidal intent to frank suicidal ideation and intent.” Most of what we used to think as leading causes of death have been decreasing. Deaths due to cardiovascular disease, cancer, stroke, and lung disease have all been steadily decreasing since 2000. But deaths from drugs, alcohol, and suicide have been increasing. Things have changed so much and so fast that more U.S. deaths now result from self-harm than even diabetes.4 Suicide is more than twice as common as homicide in the United States. Accidents, which may sometimes be covert suicide, make up the other leading causes of death. The major default manner-of-death assignment for injury cases contain misclassified suicides.5

Yet little attention has been paid to these deaths’ contributions to overdoses, suicide, and addiction.6 In a recent study, nationally recognized research leaders explore the connection between opioid-related overdoses and the spectrum of suicidal motivation.

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1 min read

Download the latest research in the Research You Can Use newsletter!

By Mark Gold, MD on December 5, 2019

Stay up-to-date on the latest and most important addiction research with Research You Can Use, Dr. Mark Gold's weekly analysis of compelling evidence from the field. Dr. Gold is a renowned addiction expert and psychiatrist providing critical expertise on a range of subjects. 

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7 min read

Alcohol use disorders are complex, but new research should improve practice

By Mark Gold, MD on November 14, 2019

 

Alcohol use disorders (AUDs) are one of the most common and least-treated health conditions in the world. Some AUDs decline in severity or even get better without treatment.1 AUDs often accompany depression, anxiety, fears and phobias, sleep disorders, liver problems, and other diseases. They may be caused by shared genes underlying other psychiatric conditions, especially depression.2 And while there’s a strong genetic component in many AUD cases, there are a host of contributing factors, from cultural and regulatory environments to psychological disposition to brain circuitry and anxiety, that can play important roles in the development of the condition—or, at least, that can play anything from a substantial role to a very limited one. It all depends. 

As any patient, involved health care practitioner, and/or expert would be quick to point out, AUD is a highly complicated condition, sometimes frustratingly so. According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), 6.2 percent of adults over 18 in the U.S. have an AUD, including over 9 million men and 5 million women.3 These numbers can be difficult to gauge in part because of the condition’s complexity—if we had a blood test that a physician could perform or a throat culture that could be sent to the lab, it would establish a diagnosis to everyone’s satisfaction. AUD is the most prevalent substance use disorder in the world, and from a public health perspective, it’s important not to let the complexity of AUD get in the way of sound policies and treatment practices. A comprehensive seminar recently published in The Lancet offered an updated discussion of the state of research on AUD, covering diagnosis, treatment, epidemiology, risk factors, environmental issues, and other considerations, as a guide to what we’ve learned about the condition.

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9 min read

Is our addiction crisis fueling the all-time high in reported STD cases?

By Mark Gold, MD on November 7, 2019

The French and Italians once blamed each other for the creation of syphilis, officials viewed it as a moral incentive to maintain sexual propriety, and California required cases to be reported by number rather than name to conceal the identities of “ sinful” sufferers.1 The infection often went undetected, causing neurological and psychiatric problems chronicled in the lives of the rich and famous: Eduard Manet, Paul Gauguin, Vincent van Gogh, Ludwig van Beethoven, Robert Schumann, Franz Schubert, Al Capone, Keats, Baudelaire, Dostoyevsky, and Oscar Wilde.2 Later, diagnosis and treatment changed. Advances in science and medicine, if not in the reduction of stigma, dramatically cut reported rates of syphilis,3 and public health authorities had major successes in curbing Sexually Transmitted Diseases (STDs) over the second half of the twentieth century. In 2018, 1,306 infants in the United States contracted syphilis, a 185 percent rise since 2014. 

The CDC, in a recent report, is now sounding the alarm over astonishingly large increases in the prevalence of STDs. Cases have now increased for the fifth straight year and reached another all-time high. One contributing factor is substance use and substance use disorders (SUDs), which are linked to unprotected sex, sex with multiple partners, and other behaviors increasing the risk of STDs. As the CDC predicted, needle use and substance-seeking sex have had major impacts on STD rates: a 2016 report spotlighted 220 counties at elevated risk of HIV from high levels of intravenous drug use. Drinking and use of other substances, which can alter judgment and risk calculations, are also associated with increased chances of contracting STDs. 

But in some STD cases, the problem is not a complex one linked to a variety of nuanced and complicatedly intertwined variables. It’s simply a function of not trying. As the CDC’s Director of STD Prevention Gail Bolan notes of infants with syphilis, “This goes beyond data and surveillance, beyond numbers and calculations—we lost 94 lives before they began to an entirely preventable infection.”4

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