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Career Choices: Addiction psychiatry
Editor’s note: Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.
In this Career Choices, Saeed Ahmed, MD, talked with Cornel Stanciu, MD. Dr. Stanciu is an addiction psychiatrist at Dartmouth’s Geisel School of Medicine, where he is an Assistant Professor, and serves as the Director of Addiction Services at New Hampshire Hospital. He provides support to clinicians managing patients with addictive disorders in a multitude of settings, and also assists with policy making and delivery of addiction care at the state level. He is also the author of Deciphering the Addicted Brain, a guide to help families and the general public better understand addictive disorders.
Dr. Ahmed: What attracted you to pursue subspecialty training in addictive disorders?
Dr. Stanciu: In the early stages of my training, I frequently encountered individuals with medical and mental health disorders whose treatment was impacted by underlying substance use. I soon came to realize any attempts at (for example) managing hypertension in someone with cocaine use disorder, or managing schizophrenia in someone with ongoing cannabis use, were futile. Almost all of my patients receiving treatment for mental health disorders were dependent on tobacco or other substances, and most were interested in cessation. Through mentorship from addiction-trained residency faculty members, I was able to get a taste of the neurobiologic complexities of the disease, something that left me with a desire to develop a deeper understanding of the disease process. Witnessing strikingly positive outcomes with implementation of evidence-based treatment modalities further solidified my path to subspecialty training. Even during that early phase, because I expressed interest in managing these conditions, I was immediately put in a position to share and disseminate any newly acquired knowledge to other specialties as well as the public.
Dr. Ahmed: Could one manage addictive disorders with just general psychiatry training, and what are the differences between the different paths to certification that a resident could undertake?
Dr. Stanciu: Addictive disorders fall under the general umbrella of psychiatric care. Most individuals with these disorders exhibit some degree of mental illness. Medical school curriculum offers on average 2 hours of addiction-related didactics during 4 years. General psychiatry training programs vary significantly in the type of exposure to addiction—some residencies have an affiliated addiction fellowship, others have addiction-trained psychiatrists on staff, but most have none. Ultimately, there is great variability in the degree of comfort in working with individuals with addictive disorders post-residency. Being able to prescribe medications for the treatment of addictive disorders is very different from being familiar with the latest evidence-based recommendations and guidelines; the latter is
Addiction medicine is a fairly new route initially intended to allow non-psychiatric specialties access to addictive disorders training and certification. This is offered through the American Board of Preventive Medicine. There are currently 2 routes to sitting for the exam: through completion of a 1-year addiction medicine fellowship, or through the “practice pathway” still available until 2020. To be eligible for the latter, individuals must provide documentation of clinical experience post-residency, which is quantified as number of hours spent treating patients with addictions, plus any additional courses or training, and must be endorsed by a certified addictionologist.
Continue to: What was your fellowship experience link...
Dr. Ahmed: What was your fellowship experience like, and what should one consider when choosing a program?
Dr. Stanciu: I completed my fellowship training through Dartmouth’s Geisel School of Medicine, and the experience was tremendously valuable. In evaluating programs, one of the starting points is whether you have interest in a formal research track, because several programs include an optional year for that. Most programs tend to provide exposure to the Veterans Affairs system. The 1 year should provide you with broad exposure to all possible settings, all addictive disorders and patient populations, and all treatment modalities, in addition to rigorous didactic sessions. The ideal program should include rotations through methadone treatment centers, intensive outpatient programs, pain and interdisciplinary clinics, detoxification units, and centers for treatment of adolescent and young adults, as well as general medical settings and infectious disease clinics. There should also be close collaboration with psychologists who can provide training in evidence-based therapeutic modalities. During this year, it is vital to expand your knowledge of the ethical and legal regulations of treatment programs, state and federal requirements, insurance complexities, and requirements for privacy and protection of health information. The size of these programs can vary significantly, which may limit the one-on-one time devoted to your training, which is something I personally valued. My faculty was very supportive of academic endeavors, providing guidance, funding, and encouragement for attending and presenting at conferences, publishing papers, and other academic pursuits. Additionally, faculty should be current with emerging literature and willing to develop or implement new protocols and evaluate new pharmacologic therapies.
Dr. Ahmed: What are some of the career options and work settings for addiction psychiatrists?
Dr. Stanciu: Addiction psychiatrists work in numerous settings and various capacities. They can provide subspecialty care directly by seeing patients in outpatient clinics or inpatient addiction treatment centers for detoxification or rehabilitation, or they can work with dual-diagnosis populations in inpatient units. The expansion of telemedicine also holds promise for a role through virtual services. Indirectly, they can serve as a resource for expertise in the field through consultations in medical and psychiatric settings, or through policy making by working with the legislature and public health departments. Additionally, they can help create and integrate new knowledge into practice and educate future generations of physicians and the public.
Dr. Ahmed: What are some of the prevalent disorders and reasons for consultation that you encounter in your daily practice?
Continue to: Dr. Stanciu's response...
Dr. Stanciu: This can vary significantly depending on the setting, geographical region, and demographics of the population. My main non-administrative responsibilities are primarily consultative assisting clinicians at a 200-bed psychiatric hospital to address co-occurring addictive disorders. In short-term units, I am primarily asked to provide input on issues related to various toxidromes and withdrawals and the use of relapse prevention medications for alcohol use disorders as well as the use of buprenorphine or other forms of medication-assisted treatment. I work closely with licensed drug and alcohol counselors in implementing brief interventions as well as facilitating outpatient treatment referrals. Clinicians in longer term units may consult on issues related to pain management in individuals who have addictive disorders, the use of evidence-based pharmacologic agents to address cravings, or the use of relapse prevention medications for someone close to discharge. In terms of specific drugs of abuse, although opioids have recently received a tremendous amount of attention due to the visible costs through overdose deaths, the magnitude of individuals who are losing years of quality life through the use of alcohol and tobacco is significant, and hence this is a large portion of the conditions I encounter. I have also seen an abundance of marijuana use due to decreased perception of harm and increased access.
Dr. Ahmed: What are some of the challenges in working in this field?
Dr. Stanciu: Historically, funding for services has been an issue for clinicians working primarily with addictive disorders from the standpoint of reimbursement, patient access to evidence-based pharmacotherapy, and ability to collaborate with existing levels of care. In recent years, federal funding and policies have changed this, and after numerous studies have found increased cost savings, commercial insurances are providing coverage. A significant challenge also has been public stigma and dealing with a condition that is relapsing-remitting, poorly understood by other specialties and the general public, and sometimes labeled as a defect of character. Several efforts in education have lessened this; however, the impact still takes a toll on patients, who may feel ashamed of their disorder and sometimes are hesitant to take medications because they may believe that they are not “clean” if they depend on a medication for remission. Lastly, recent changes in marijuana policies make conversations about this drug quite difficult because patients often view it as harmless, and the laws governing legality and indications for therapeutic use are slightly ahead of the evidence.
Dr. Ahmed: In what direction do you believe the subspecialty is headed?
Dr. Stanciu: Currently, there are approximately 1,000 certified addiction psychiatrists for the 45 million Americans who have addictive disorders. Smoking and other forms of tobacco use pose significant threats to the 2020 Healthy People Tobacco Use objectives. There is a significant demand for addictionologists in both public and private sectors. As with mental health, demand exceeds supply, and efforts are underway to expand downstream education and increase access to specialists. Several federal laws have been put in place to remove barriers and expand access to care and have paved the way to a brighter future. One is the Affordable Care Act, which requires all insurances including Medicaid to cover the cost of treatment. Second is the Mental Health Parity and Addiction Equity Act, which ensures that the duration and dollar amount of coverage for substance use disorders is comparable to that of medical and surgical care.
Continue to: Another exciting possibility...
Another exciting possibility comes from the world of pharmaceuticals. Some medications have modest efficacy for addressing addictive disorders; however, historically these have been poorly utilized. Enhanced understanding of the neurobiology combined with increased insurance reimbursement should prompt research and new drug development. Some promising agents are already in the pipeline. Research into molecular and gene therapy as a way to better individualize care is also underway.
Going forward, I think we will also encounter a different landscape of drugs. Synthetic agents are emerging and increasing in popularity. Alarmingly, public perception of harm is decreasing. When it comes to cannabis use, I see a rise in pathologic use and the ramifications of this will have a drastic impact, particularly on patients with mental health conditions. We will need to undertake better efforts in monitoring, staying updated, and providing public education campaigns.
Dr. Ahmed: What advice do you have for trainees contemplating subspecialty training in addiction psychiatry?
Dr. Stanciu: I cannot emphasize enough the importance of mentorship. The American Academy of Addiction Psychiatry has a robust system for connecting mentees with mentors at all stages in their careers. This can be extremely helpful, especially in situations where the residency program does not have addiction-trained faculty or rotations through treatment centers. Joining such an organization also grants you access to resources that can help further your enthusiasm. Those interested should also familiarize themselves with currently available pharmacotherapeutic treatments that have evidence supporting efficacy for various addictive disorders, and begin to incorporate these medications into general mental health practice, along with attempts at motivational interviewing. For example, begin discussing naltrexone with patients who have comorbid alcohol use disorders and are interested in reducing their drinking; and varenicline with patients who smoke and are interested in quitting. The outcomes should automatically elicit an interest in pursuing further training in the field!
Editor’s note: Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.
In this Career Choices, Saeed Ahmed, MD, talked with Cornel Stanciu, MD. Dr. Stanciu is an addiction psychiatrist at Dartmouth’s Geisel School of Medicine, where he is an Assistant Professor, and serves as the Director of Addiction Services at New Hampshire Hospital. He provides support to clinicians managing patients with addictive disorders in a multitude of settings, and also assists with policy making and delivery of addiction care at the state level. He is also the author of Deciphering the Addicted Brain, a guide to help families and the general public better understand addictive disorders.
Dr. Ahmed: What attracted you to pursue subspecialty training in addictive disorders?
Dr. Stanciu: In the early stages of my training, I frequently encountered individuals with medical and mental health disorders whose treatment was impacted by underlying substance use. I soon came to realize any attempts at (for example) managing hypertension in someone with cocaine use disorder, or managing schizophrenia in someone with ongoing cannabis use, were futile. Almost all of my patients receiving treatment for mental health disorders were dependent on tobacco or other substances, and most were interested in cessation. Through mentorship from addiction-trained residency faculty members, I was able to get a taste of the neurobiologic complexities of the disease, something that left me with a desire to develop a deeper understanding of the disease process. Witnessing strikingly positive outcomes with implementation of evidence-based treatment modalities further solidified my path to subspecialty training. Even during that early phase, because I expressed interest in managing these conditions, I was immediately put in a position to share and disseminate any newly acquired knowledge to other specialties as well as the public.
Dr. Ahmed: Could one manage addictive disorders with just general psychiatry training, and what are the differences between the different paths to certification that a resident could undertake?
Dr. Stanciu: Addictive disorders fall under the general umbrella of psychiatric care. Most individuals with these disorders exhibit some degree of mental illness. Medical school curriculum offers on average 2 hours of addiction-related didactics during 4 years. General psychiatry training programs vary significantly in the type of exposure to addiction—some residencies have an affiliated addiction fellowship, others have addiction-trained psychiatrists on staff, but most have none. Ultimately, there is great variability in the degree of comfort in working with individuals with addictive disorders post-residency. Being able to prescribe medications for the treatment of addictive disorders is very different from being familiar with the latest evidence-based recommendations and guidelines; the latter is
Addiction medicine is a fairly new route initially intended to allow non-psychiatric specialties access to addictive disorders training and certification. This is offered through the American Board of Preventive Medicine. There are currently 2 routes to sitting for the exam: through completion of a 1-year addiction medicine fellowship, or through the “practice pathway” still available until 2020. To be eligible for the latter, individuals must provide documentation of clinical experience post-residency, which is quantified as number of hours spent treating patients with addictions, plus any additional courses or training, and must be endorsed by a certified addictionologist.
Continue to: What was your fellowship experience link...
Dr. Ahmed: What was your fellowship experience like, and what should one consider when choosing a program?
Dr. Stanciu: I completed my fellowship training through Dartmouth’s Geisel School of Medicine, and the experience was tremendously valuable. In evaluating programs, one of the starting points is whether you have interest in a formal research track, because several programs include an optional year for that. Most programs tend to provide exposure to the Veterans Affairs system. The 1 year should provide you with broad exposure to all possible settings, all addictive disorders and patient populations, and all treatment modalities, in addition to rigorous didactic sessions. The ideal program should include rotations through methadone treatment centers, intensive outpatient programs, pain and interdisciplinary clinics, detoxification units, and centers for treatment of adolescent and young adults, as well as general medical settings and infectious disease clinics. There should also be close collaboration with psychologists who can provide training in evidence-based therapeutic modalities. During this year, it is vital to expand your knowledge of the ethical and legal regulations of treatment programs, state and federal requirements, insurance complexities, and requirements for privacy and protection of health information. The size of these programs can vary significantly, which may limit the one-on-one time devoted to your training, which is something I personally valued. My faculty was very supportive of academic endeavors, providing guidance, funding, and encouragement for attending and presenting at conferences, publishing papers, and other academic pursuits. Additionally, faculty should be current with emerging literature and willing to develop or implement new protocols and evaluate new pharmacologic therapies.
Dr. Ahmed: What are some of the career options and work settings for addiction psychiatrists?
Dr. Stanciu: Addiction psychiatrists work in numerous settings and various capacities. They can provide subspecialty care directly by seeing patients in outpatient clinics or inpatient addiction treatment centers for detoxification or rehabilitation, or they can work with dual-diagnosis populations in inpatient units. The expansion of telemedicine also holds promise for a role through virtual services. Indirectly, they can serve as a resource for expertise in the field through consultations in medical and psychiatric settings, or through policy making by working with the legislature and public health departments. Additionally, they can help create and integrate new knowledge into practice and educate future generations of physicians and the public.
Dr. Ahmed: What are some of the prevalent disorders and reasons for consultation that you encounter in your daily practice?
Continue to: Dr. Stanciu's response...
Dr. Stanciu: This can vary significantly depending on the setting, geographical region, and demographics of the population. My main non-administrative responsibilities are primarily consultative assisting clinicians at a 200-bed psychiatric hospital to address co-occurring addictive disorders. In short-term units, I am primarily asked to provide input on issues related to various toxidromes and withdrawals and the use of relapse prevention medications for alcohol use disorders as well as the use of buprenorphine or other forms of medication-assisted treatment. I work closely with licensed drug and alcohol counselors in implementing brief interventions as well as facilitating outpatient treatment referrals. Clinicians in longer term units may consult on issues related to pain management in individuals who have addictive disorders, the use of evidence-based pharmacologic agents to address cravings, or the use of relapse prevention medications for someone close to discharge. In terms of specific drugs of abuse, although opioids have recently received a tremendous amount of attention due to the visible costs through overdose deaths, the magnitude of individuals who are losing years of quality life through the use of alcohol and tobacco is significant, and hence this is a large portion of the conditions I encounter. I have also seen an abundance of marijuana use due to decreased perception of harm and increased access.
Dr. Ahmed: What are some of the challenges in working in this field?
Dr. Stanciu: Historically, funding for services has been an issue for clinicians working primarily with addictive disorders from the standpoint of reimbursement, patient access to evidence-based pharmacotherapy, and ability to collaborate with existing levels of care. In recent years, federal funding and policies have changed this, and after numerous studies have found increased cost savings, commercial insurances are providing coverage. A significant challenge also has been public stigma and dealing with a condition that is relapsing-remitting, poorly understood by other specialties and the general public, and sometimes labeled as a defect of character. Several efforts in education have lessened this; however, the impact still takes a toll on patients, who may feel ashamed of their disorder and sometimes are hesitant to take medications because they may believe that they are not “clean” if they depend on a medication for remission. Lastly, recent changes in marijuana policies make conversations about this drug quite difficult because patients often view it as harmless, and the laws governing legality and indications for therapeutic use are slightly ahead of the evidence.
Dr. Ahmed: In what direction do you believe the subspecialty is headed?
Dr. Stanciu: Currently, there are approximately 1,000 certified addiction psychiatrists for the 45 million Americans who have addictive disorders. Smoking and other forms of tobacco use pose significant threats to the 2020 Healthy People Tobacco Use objectives. There is a significant demand for addictionologists in both public and private sectors. As with mental health, demand exceeds supply, and efforts are underway to expand downstream education and increase access to specialists. Several federal laws have been put in place to remove barriers and expand access to care and have paved the way to a brighter future. One is the Affordable Care Act, which requires all insurances including Medicaid to cover the cost of treatment. Second is the Mental Health Parity and Addiction Equity Act, which ensures that the duration and dollar amount of coverage for substance use disorders is comparable to that of medical and surgical care.
Continue to: Another exciting possibility...
Another exciting possibility comes from the world of pharmaceuticals. Some medications have modest efficacy for addressing addictive disorders; however, historically these have been poorly utilized. Enhanced understanding of the neurobiology combined with increased insurance reimbursement should prompt research and new drug development. Some promising agents are already in the pipeline. Research into molecular and gene therapy as a way to better individualize care is also underway.
Going forward, I think we will also encounter a different landscape of drugs. Synthetic agents are emerging and increasing in popularity. Alarmingly, public perception of harm is decreasing. When it comes to cannabis use, I see a rise in pathologic use and the ramifications of this will have a drastic impact, particularly on patients with mental health conditions. We will need to undertake better efforts in monitoring, staying updated, and providing public education campaigns.
Dr. Ahmed: What advice do you have for trainees contemplating subspecialty training in addiction psychiatry?
Dr. Stanciu: I cannot emphasize enough the importance of mentorship. The American Academy of Addiction Psychiatry has a robust system for connecting mentees with mentors at all stages in their careers. This can be extremely helpful, especially in situations where the residency program does not have addiction-trained faculty or rotations through treatment centers. Joining such an organization also grants you access to resources that can help further your enthusiasm. Those interested should also familiarize themselves with currently available pharmacotherapeutic treatments that have evidence supporting efficacy for various addictive disorders, and begin to incorporate these medications into general mental health practice, along with attempts at motivational interviewing. For example, begin discussing naltrexone with patients who have comorbid alcohol use disorders and are interested in reducing their drinking; and varenicline with patients who smoke and are interested in quitting. The outcomes should automatically elicit an interest in pursuing further training in the field!
Editor’s note: Career Choices features a psychiatry resident/fellow interviewing a psychiatrist about why he or she has chosen a specific career path. The goal is to inform trainees about the various psychiatric career options, and to give them a feel for the pros and cons of the various paths.
In this Career Choices, Saeed Ahmed, MD, talked with Cornel Stanciu, MD. Dr. Stanciu is an addiction psychiatrist at Dartmouth’s Geisel School of Medicine, where he is an Assistant Professor, and serves as the Director of Addiction Services at New Hampshire Hospital. He provides support to clinicians managing patients with addictive disorders in a multitude of settings, and also assists with policy making and delivery of addiction care at the state level. He is also the author of Deciphering the Addicted Brain, a guide to help families and the general public better understand addictive disorders.
Dr. Ahmed: What attracted you to pursue subspecialty training in addictive disorders?
Dr. Stanciu: In the early stages of my training, I frequently encountered individuals with medical and mental health disorders whose treatment was impacted by underlying substance use. I soon came to realize any attempts at (for example) managing hypertension in someone with cocaine use disorder, or managing schizophrenia in someone with ongoing cannabis use, were futile. Almost all of my patients receiving treatment for mental health disorders were dependent on tobacco or other substances, and most were interested in cessation. Through mentorship from addiction-trained residency faculty members, I was able to get a taste of the neurobiologic complexities of the disease, something that left me with a desire to develop a deeper understanding of the disease process. Witnessing strikingly positive outcomes with implementation of evidence-based treatment modalities further solidified my path to subspecialty training. Even during that early phase, because I expressed interest in managing these conditions, I was immediately put in a position to share and disseminate any newly acquired knowledge to other specialties as well as the public.
Dr. Ahmed: Could one manage addictive disorders with just general psychiatry training, and what are the differences between the different paths to certification that a resident could undertake?
Dr. Stanciu: Addictive disorders fall under the general umbrella of psychiatric care. Most individuals with these disorders exhibit some degree of mental illness. Medical school curriculum offers on average 2 hours of addiction-related didactics during 4 years. General psychiatry training programs vary significantly in the type of exposure to addiction—some residencies have an affiliated addiction fellowship, others have addiction-trained psychiatrists on staff, but most have none. Ultimately, there is great variability in the degree of comfort in working with individuals with addictive disorders post-residency. Being able to prescribe medications for the treatment of addictive disorders is very different from being familiar with the latest evidence-based recommendations and guidelines; the latter is
Addiction medicine is a fairly new route initially intended to allow non-psychiatric specialties access to addictive disorders training and certification. This is offered through the American Board of Preventive Medicine. There are currently 2 routes to sitting for the exam: through completion of a 1-year addiction medicine fellowship, or through the “practice pathway” still available until 2020. To be eligible for the latter, individuals must provide documentation of clinical experience post-residency, which is quantified as number of hours spent treating patients with addictions, plus any additional courses or training, and must be endorsed by a certified addictionologist.
Continue to: What was your fellowship experience link...
Dr. Ahmed: What was your fellowship experience like, and what should one consider when choosing a program?
Dr. Stanciu: I completed my fellowship training through Dartmouth’s Geisel School of Medicine, and the experience was tremendously valuable. In evaluating programs, one of the starting points is whether you have interest in a formal research track, because several programs include an optional year for that. Most programs tend to provide exposure to the Veterans Affairs system. The 1 year should provide you with broad exposure to all possible settings, all addictive disorders and patient populations, and all treatment modalities, in addition to rigorous didactic sessions. The ideal program should include rotations through methadone treatment centers, intensive outpatient programs, pain and interdisciplinary clinics, detoxification units, and centers for treatment of adolescent and young adults, as well as general medical settings and infectious disease clinics. There should also be close collaboration with psychologists who can provide training in evidence-based therapeutic modalities. During this year, it is vital to expand your knowledge of the ethical and legal regulations of treatment programs, state and federal requirements, insurance complexities, and requirements for privacy and protection of health information. The size of these programs can vary significantly, which may limit the one-on-one time devoted to your training, which is something I personally valued. My faculty was very supportive of academic endeavors, providing guidance, funding, and encouragement for attending and presenting at conferences, publishing papers, and other academic pursuits. Additionally, faculty should be current with emerging literature and willing to develop or implement new protocols and evaluate new pharmacologic therapies.
Dr. Ahmed: What are some of the career options and work settings for addiction psychiatrists?
Dr. Stanciu: Addiction psychiatrists work in numerous settings and various capacities. They can provide subspecialty care directly by seeing patients in outpatient clinics or inpatient addiction treatment centers for detoxification or rehabilitation, or they can work with dual-diagnosis populations in inpatient units. The expansion of telemedicine also holds promise for a role through virtual services. Indirectly, they can serve as a resource for expertise in the field through consultations in medical and psychiatric settings, or through policy making by working with the legislature and public health departments. Additionally, they can help create and integrate new knowledge into practice and educate future generations of physicians and the public.
Dr. Ahmed: What are some of the prevalent disorders and reasons for consultation that you encounter in your daily practice?
Continue to: Dr. Stanciu's response...
Dr. Stanciu: This can vary significantly depending on the setting, geographical region, and demographics of the population. My main non-administrative responsibilities are primarily consultative assisting clinicians at a 200-bed psychiatric hospital to address co-occurring addictive disorders. In short-term units, I am primarily asked to provide input on issues related to various toxidromes and withdrawals and the use of relapse prevention medications for alcohol use disorders as well as the use of buprenorphine or other forms of medication-assisted treatment. I work closely with licensed drug and alcohol counselors in implementing brief interventions as well as facilitating outpatient treatment referrals. Clinicians in longer term units may consult on issues related to pain management in individuals who have addictive disorders, the use of evidence-based pharmacologic agents to address cravings, or the use of relapse prevention medications for someone close to discharge. In terms of specific drugs of abuse, although opioids have recently received a tremendous amount of attention due to the visible costs through overdose deaths, the magnitude of individuals who are losing years of quality life through the use of alcohol and tobacco is significant, and hence this is a large portion of the conditions I encounter. I have also seen an abundance of marijuana use due to decreased perception of harm and increased access.
Dr. Ahmed: What are some of the challenges in working in this field?
Dr. Stanciu: Historically, funding for services has been an issue for clinicians working primarily with addictive disorders from the standpoint of reimbursement, patient access to evidence-based pharmacotherapy, and ability to collaborate with existing levels of care. In recent years, federal funding and policies have changed this, and after numerous studies have found increased cost savings, commercial insurances are providing coverage. A significant challenge also has been public stigma and dealing with a condition that is relapsing-remitting, poorly understood by other specialties and the general public, and sometimes labeled as a defect of character. Several efforts in education have lessened this; however, the impact still takes a toll on patients, who may feel ashamed of their disorder and sometimes are hesitant to take medications because they may believe that they are not “clean” if they depend on a medication for remission. Lastly, recent changes in marijuana policies make conversations about this drug quite difficult because patients often view it as harmless, and the laws governing legality and indications for therapeutic use are slightly ahead of the evidence.
Dr. Ahmed: In what direction do you believe the subspecialty is headed?
Dr. Stanciu: Currently, there are approximately 1,000 certified addiction psychiatrists for the 45 million Americans who have addictive disorders. Smoking and other forms of tobacco use pose significant threats to the 2020 Healthy People Tobacco Use objectives. There is a significant demand for addictionologists in both public and private sectors. As with mental health, demand exceeds supply, and efforts are underway to expand downstream education and increase access to specialists. Several federal laws have been put in place to remove barriers and expand access to care and have paved the way to a brighter future. One is the Affordable Care Act, which requires all insurances including Medicaid to cover the cost of treatment. Second is the Mental Health Parity and Addiction Equity Act, which ensures that the duration and dollar amount of coverage for substance use disorders is comparable to that of medical and surgical care.
Continue to: Another exciting possibility...
Another exciting possibility comes from the world of pharmaceuticals. Some medications have modest efficacy for addressing addictive disorders; however, historically these have been poorly utilized. Enhanced understanding of the neurobiology combined with increased insurance reimbursement should prompt research and new drug development. Some promising agents are already in the pipeline. Research into molecular and gene therapy as a way to better individualize care is also underway.
Going forward, I think we will also encounter a different landscape of drugs. Synthetic agents are emerging and increasing in popularity. Alarmingly, public perception of harm is decreasing. When it comes to cannabis use, I see a rise in pathologic use and the ramifications of this will have a drastic impact, particularly on patients with mental health conditions. We will need to undertake better efforts in monitoring, staying updated, and providing public education campaigns.
Dr. Ahmed: What advice do you have for trainees contemplating subspecialty training in addiction psychiatry?
Dr. Stanciu: I cannot emphasize enough the importance of mentorship. The American Academy of Addiction Psychiatry has a robust system for connecting mentees with mentors at all stages in their careers. This can be extremely helpful, especially in situations where the residency program does not have addiction-trained faculty or rotations through treatment centers. Joining such an organization also grants you access to resources that can help further your enthusiasm. Those interested should also familiarize themselves with currently available pharmacotherapeutic treatments that have evidence supporting efficacy for various addictive disorders, and begin to incorporate these medications into general mental health practice, along with attempts at motivational interviewing. For example, begin discussing naltrexone with patients who have comorbid alcohol use disorders and are interested in reducing their drinking; and varenicline with patients who smoke and are interested in quitting. The outcomes should automatically elicit an interest in pursuing further training in the field!
Teens likely to mimic parents’ opioid use
reported Pamela C. Griesler, PhD, of Columbia University, New York, and her associates.
Given the significant link between parental and adolescent smoking and adolescent nonmedical prescription opioid (NMPO) use, smoking also should be included in targeted interventions, they wrote in Pediatrics.
Dr. Griesler and her colleagues noted that there actually are three classes of factors influencing the association between parent and adolescent NMPO use: phenotypic heritability, parental role modeling, and parental socialization and other environmental influences.
In the first known study to explore the relationship of parent-adolescent NMPO use within a nationally representative sampling of parent-child dyads taken from the National Surveys on Drug Use and Health, Dr. Griesler and her colleagues examined the intergenerational association of lifetime NMPO use among 35,000 parent-adolescent dyads (21,200 mothers, 13,800 fathers). Of the 35,000 children aged 12-17 years included in the sample, 90% were biological, 8% were stepchildren, and 2% were adopted.
Given the absence of previous studies exploring the relationship between parent-adolescent NMPO use, Dr. Griesler and her associates used established findings for smoking and substance use to hypothesize that there would be stronger associations for mothers than fathers, daughters than sons, and for whites than African Americans.
The investigators posed three questions that formed the basis of their research: 1) What is the association between lifetime parental and child NMPO use? 2) What is the unique association between parental and child NMPO use, controlling for other factors? 3) Do parental/adolescent NMPO use associations differ by parent/child gender and race and/or ethnicity?
About 14% of parents reported ever using an NMPO; fathers (14%) had slightly higher rates of usage than mothers (13%), and white parents had higher rates of use (16%) than African American (10%) or Hispanic (9%) parents. Among adolescents, 9% reported ever having used an NMPO; this included similar rates for boys (9%) and girls (9%), as well as whites (9%), Hispanics (9%), and African Americans (8%). Use increased with age over time, from 4% among 12-year-olds to 15% among 17-year-olds.
Dr. Griesler and her colleagues did find “a significant positive association between NMPO use by parents and adolescents.” Adolescents were more likely to use an NMPO in their lifetime (14%) if a parent had a history of any use than adolescents whose parents did not have a history (8%). This association persisted even when controlling for other factors (adjusted odds ratio, 1.3).
Adolescent reporting identified low levels of parental support and monitoring, as well as parent approval of drug use, as the primary factors contributing to perceptions of subpar parent-child relationship quality and subsequent NMPO use. Additional adolescent behaviors contributing to increased risk of drug use included delinquency, depression, anxiety, reduced academic and religious involvement, and perceptions around peer drug use and approval of drug use, as well as being older.
Consistent with their original hypothesis, “only maternal NMPO use was significantly associated with adolescent NMPO use,” the investigators wrote (aOR, 1.62), which was not correlated either way concerning the gender of the child. The authors did note, however, “a marginally significant negative association among sons, [aOR, 0.71],” even though no overall paternal-child NMPO correlation was found (aOR, 0.98). They speculated that this negative association might be explained “by the father’s use of other drugs, particularly marijuana.”
Parental factors independently associated with adolescent NMPO use included smoking, alcohol and/or marijuana use, as well as other illicit drug use. When controlling for their use of different drugs and other covariates, only smoking remained associated with adolescent NMPO use (aOR, 1.24). Importantly, higher NMPO usage was observed in cases of poor parenting quality, especially for low levels of monitoring and high incidence of conflict between parents and adolescents. Adolescent NMPO usage were conversely lower in cases where parents self-reported their belief that drug use was risky.
Adolescent behaviors that predicted lifetime NMPO use included starting to smoke cigarettes or marijuana before using NMPO, being depressed or delinquent, having the perception that most peers use drugs, and being older in age. Dr. Griesler and her associates also observed that adolescents who began using alcohol before NMPO were likely to experiment first with smoking cigarettes and marijuana before NMPO.
The lack of differences observed with regard to child gender, race, or ethnicity warrants further investigation, but the authors speculated that “such differences might be detected with measures of current or heavy use.”
One limitation of the study was the focus on lifetime use, Dr. Griesler and her colleagues wrote. Observing patterns of current or heavy use, as well as disorder and “genetically informative samples,” might shed light on the role that familial environmental and genetic influences could play. Additionally, limiting households to one parent and one adolescent discounts the possible combined influence of mother and father NMPO usage on adolescent usage. The research also did not explore the role that adolescent NMPO use could play in influencing “parent-child interactions.”
The authors reported no financial relationships or potential conflicts of interest. The study was supported by grants from the National Institute on Drug Abuse and the New York State Psychiatric Institute; it was funded by the National Institutes of Health.
SOURCE: Griesler PC et al. Pediatrics. 2019;143(3):e20182354.
reported Pamela C. Griesler, PhD, of Columbia University, New York, and her associates.
Given the significant link between parental and adolescent smoking and adolescent nonmedical prescription opioid (NMPO) use, smoking also should be included in targeted interventions, they wrote in Pediatrics.
Dr. Griesler and her colleagues noted that there actually are three classes of factors influencing the association between parent and adolescent NMPO use: phenotypic heritability, parental role modeling, and parental socialization and other environmental influences.
In the first known study to explore the relationship of parent-adolescent NMPO use within a nationally representative sampling of parent-child dyads taken from the National Surveys on Drug Use and Health, Dr. Griesler and her colleagues examined the intergenerational association of lifetime NMPO use among 35,000 parent-adolescent dyads (21,200 mothers, 13,800 fathers). Of the 35,000 children aged 12-17 years included in the sample, 90% were biological, 8% were stepchildren, and 2% were adopted.
Given the absence of previous studies exploring the relationship between parent-adolescent NMPO use, Dr. Griesler and her associates used established findings for smoking and substance use to hypothesize that there would be stronger associations for mothers than fathers, daughters than sons, and for whites than African Americans.
The investigators posed three questions that formed the basis of their research: 1) What is the association between lifetime parental and child NMPO use? 2) What is the unique association between parental and child NMPO use, controlling for other factors? 3) Do parental/adolescent NMPO use associations differ by parent/child gender and race and/or ethnicity?
About 14% of parents reported ever using an NMPO; fathers (14%) had slightly higher rates of usage than mothers (13%), and white parents had higher rates of use (16%) than African American (10%) or Hispanic (9%) parents. Among adolescents, 9% reported ever having used an NMPO; this included similar rates for boys (9%) and girls (9%), as well as whites (9%), Hispanics (9%), and African Americans (8%). Use increased with age over time, from 4% among 12-year-olds to 15% among 17-year-olds.
Dr. Griesler and her colleagues did find “a significant positive association between NMPO use by parents and adolescents.” Adolescents were more likely to use an NMPO in their lifetime (14%) if a parent had a history of any use than adolescents whose parents did not have a history (8%). This association persisted even when controlling for other factors (adjusted odds ratio, 1.3).
Adolescent reporting identified low levels of parental support and monitoring, as well as parent approval of drug use, as the primary factors contributing to perceptions of subpar parent-child relationship quality and subsequent NMPO use. Additional adolescent behaviors contributing to increased risk of drug use included delinquency, depression, anxiety, reduced academic and religious involvement, and perceptions around peer drug use and approval of drug use, as well as being older.
Consistent with their original hypothesis, “only maternal NMPO use was significantly associated with adolescent NMPO use,” the investigators wrote (aOR, 1.62), which was not correlated either way concerning the gender of the child. The authors did note, however, “a marginally significant negative association among sons, [aOR, 0.71],” even though no overall paternal-child NMPO correlation was found (aOR, 0.98). They speculated that this negative association might be explained “by the father’s use of other drugs, particularly marijuana.”
Parental factors independently associated with adolescent NMPO use included smoking, alcohol and/or marijuana use, as well as other illicit drug use. When controlling for their use of different drugs and other covariates, only smoking remained associated with adolescent NMPO use (aOR, 1.24). Importantly, higher NMPO usage was observed in cases of poor parenting quality, especially for low levels of monitoring and high incidence of conflict between parents and adolescents. Adolescent NMPO usage were conversely lower in cases where parents self-reported their belief that drug use was risky.
Adolescent behaviors that predicted lifetime NMPO use included starting to smoke cigarettes or marijuana before using NMPO, being depressed or delinquent, having the perception that most peers use drugs, and being older in age. Dr. Griesler and her associates also observed that adolescents who began using alcohol before NMPO were likely to experiment first with smoking cigarettes and marijuana before NMPO.
The lack of differences observed with regard to child gender, race, or ethnicity warrants further investigation, but the authors speculated that “such differences might be detected with measures of current or heavy use.”
One limitation of the study was the focus on lifetime use, Dr. Griesler and her colleagues wrote. Observing patterns of current or heavy use, as well as disorder and “genetically informative samples,” might shed light on the role that familial environmental and genetic influences could play. Additionally, limiting households to one parent and one adolescent discounts the possible combined influence of mother and father NMPO usage on adolescent usage. The research also did not explore the role that adolescent NMPO use could play in influencing “parent-child interactions.”
The authors reported no financial relationships or potential conflicts of interest. The study was supported by grants from the National Institute on Drug Abuse and the New York State Psychiatric Institute; it was funded by the National Institutes of Health.
SOURCE: Griesler PC et al. Pediatrics. 2019;143(3):e20182354.
reported Pamela C. Griesler, PhD, of Columbia University, New York, and her associates.
Given the significant link between parental and adolescent smoking and adolescent nonmedical prescription opioid (NMPO) use, smoking also should be included in targeted interventions, they wrote in Pediatrics.
Dr. Griesler and her colleagues noted that there actually are three classes of factors influencing the association between parent and adolescent NMPO use: phenotypic heritability, parental role modeling, and parental socialization and other environmental influences.
In the first known study to explore the relationship of parent-adolescent NMPO use within a nationally representative sampling of parent-child dyads taken from the National Surveys on Drug Use and Health, Dr. Griesler and her colleagues examined the intergenerational association of lifetime NMPO use among 35,000 parent-adolescent dyads (21,200 mothers, 13,800 fathers). Of the 35,000 children aged 12-17 years included in the sample, 90% were biological, 8% were stepchildren, and 2% were adopted.
Given the absence of previous studies exploring the relationship between parent-adolescent NMPO use, Dr. Griesler and her associates used established findings for smoking and substance use to hypothesize that there would be stronger associations for mothers than fathers, daughters than sons, and for whites than African Americans.
The investigators posed three questions that formed the basis of their research: 1) What is the association between lifetime parental and child NMPO use? 2) What is the unique association between parental and child NMPO use, controlling for other factors? 3) Do parental/adolescent NMPO use associations differ by parent/child gender and race and/or ethnicity?
About 14% of parents reported ever using an NMPO; fathers (14%) had slightly higher rates of usage than mothers (13%), and white parents had higher rates of use (16%) than African American (10%) or Hispanic (9%) parents. Among adolescents, 9% reported ever having used an NMPO; this included similar rates for boys (9%) and girls (9%), as well as whites (9%), Hispanics (9%), and African Americans (8%). Use increased with age over time, from 4% among 12-year-olds to 15% among 17-year-olds.
Dr. Griesler and her colleagues did find “a significant positive association between NMPO use by parents and adolescents.” Adolescents were more likely to use an NMPO in their lifetime (14%) if a parent had a history of any use than adolescents whose parents did not have a history (8%). This association persisted even when controlling for other factors (adjusted odds ratio, 1.3).
Adolescent reporting identified low levels of parental support and monitoring, as well as parent approval of drug use, as the primary factors contributing to perceptions of subpar parent-child relationship quality and subsequent NMPO use. Additional adolescent behaviors contributing to increased risk of drug use included delinquency, depression, anxiety, reduced academic and religious involvement, and perceptions around peer drug use and approval of drug use, as well as being older.
Consistent with their original hypothesis, “only maternal NMPO use was significantly associated with adolescent NMPO use,” the investigators wrote (aOR, 1.62), which was not correlated either way concerning the gender of the child. The authors did note, however, “a marginally significant negative association among sons, [aOR, 0.71],” even though no overall paternal-child NMPO correlation was found (aOR, 0.98). They speculated that this negative association might be explained “by the father’s use of other drugs, particularly marijuana.”
Parental factors independently associated with adolescent NMPO use included smoking, alcohol and/or marijuana use, as well as other illicit drug use. When controlling for their use of different drugs and other covariates, only smoking remained associated with adolescent NMPO use (aOR, 1.24). Importantly, higher NMPO usage was observed in cases of poor parenting quality, especially for low levels of monitoring and high incidence of conflict between parents and adolescents. Adolescent NMPO usage were conversely lower in cases where parents self-reported their belief that drug use was risky.
Adolescent behaviors that predicted lifetime NMPO use included starting to smoke cigarettes or marijuana before using NMPO, being depressed or delinquent, having the perception that most peers use drugs, and being older in age. Dr. Griesler and her associates also observed that adolescents who began using alcohol before NMPO were likely to experiment first with smoking cigarettes and marijuana before NMPO.
The lack of differences observed with regard to child gender, race, or ethnicity warrants further investigation, but the authors speculated that “such differences might be detected with measures of current or heavy use.”
One limitation of the study was the focus on lifetime use, Dr. Griesler and her colleagues wrote. Observing patterns of current or heavy use, as well as disorder and “genetically informative samples,” might shed light on the role that familial environmental and genetic influences could play. Additionally, limiting households to one parent and one adolescent discounts the possible combined influence of mother and father NMPO usage on adolescent usage. The research also did not explore the role that adolescent NMPO use could play in influencing “parent-child interactions.”
The authors reported no financial relationships or potential conflicts of interest. The study was supported by grants from the National Institute on Drug Abuse and the New York State Psychiatric Institute; it was funded by the National Institutes of Health.
SOURCE: Griesler PC et al. Pediatrics. 2019;143(3):e20182354.
FROM PEDIATRICS
Alcohol abstinence questioned as addiction treatment goal
BONITA SPRINGS, FLA. – Reductions in alcohol use bring about significant improvement in adverse consequences, mental health status, and quality of life, even if the reductions do not reach the level of abstinence, according to recent research presented at the annual meeting of the American Academy of Addiction Psychiatry.
The findings, experts say, demonstrate how a fixation on abstinence or elimination of all heavy drinking – the endpoints the Food and Drug Administration now require in pivotal clinical trials on alcohol use disorder (AUD) treatments – is shortsighted and can unnecessarily discourage people with alcohol use disorder from pursuing treatment.
“We need to think a little differently, or a little out of the box, from the way we’ve been thinking in the past,” said Raymond F. Anton, MD, professor of psychiatry at the Medical University of South Carolina in Charleston and chair of the Alcohol Clinical Trials Initiative (ACTIVE), a group advocating for a new endpoint that recognizes the benefits of lesser reductions in alcohol intake.
In a new analysis using data from the COMBINE study, researchers looked at the associations between reduction in World Health Organization drinking risk levels of alcohol consumption and clinically meaningful outcomes among people in treatment.
There are four levels: very high (more than 7.1 14-g drinks a day for men and more than 4.3 for women); high (4.3-7.1 or 2.9-4.3, respectively); moderate (2.9-4.3 or 1.4-2.9); and low (less than 2.9 or less than 1.4).
Researchers assessed responses to treatment with acamprosate, naltrexone, and psychological intervention in patients an average of 44 years old with 71% of their days being heavy drinking days. They found significant improvement in consequences tied to drinking, according to the Drinker Inventory of Consequences, and in mental health according to the Short Form Health Survey and the WHO Quality of Life assessment – even when the improvement was only by one WHO risk level – or just a few drinks a day – and did not involve abstaining (P less than .001 for all improvement categories).
“Reductions in WHO drinking risk levels are predictive of clinical benefit” or how the patient feels and functions, said Daniel Falk, PhD, health scientist administrator at the National Institute on Alcohol Abuse and Alcoholism.
The ACTIVE group he chairs, Dr. Anton said, is proposing that the FDA add a new endpoint for phase 3 trials: percentage of subjects who attain a 1- or 2-level reduction in WHO drinking risk levels.
Stephanie O’Malley, PhD, professor of psychiatry at Yale University in New Haven, Conn., said a 30-year-old with a moderate drinking problem – occasionally missing a family function, but never letting it interfere with work, say – might be turned off by a treatment plan that preaches abstinence, she said. Varenicline, for example, results in abstinence just 7% of the time, with some risk of suicidality and nausea. That person might not want to stop drinking entirely for the rest of his or her life, but could benefit by reducing the drinking, she said.
But 55% of the time, varenicline produces a reduction of one level of risk, which is associated with clinically meaningful results. That will sound much more appealing to a prospective patient, she said.
“From a clinical perspective, these WHO outcomes have some advantages,” she said. “I think you’re going to, one, encourage more people to accept treatment, and … be more optimistic about the outcomes.”
Dr. Anton reported consulting and/or funding from Alkermes, Allergan, Indivior, Insys Life Epigenetics, and Laboratori Farmaceutico CT. Dr. O’Malley reported consulting and/or funding from Alkermes, Amygdala, Indivior, Mistubishi Tanabe, Opiant, and other sources. Dr. Falk reported no disclosures.
BONITA SPRINGS, FLA. – Reductions in alcohol use bring about significant improvement in adverse consequences, mental health status, and quality of life, even if the reductions do not reach the level of abstinence, according to recent research presented at the annual meeting of the American Academy of Addiction Psychiatry.
The findings, experts say, demonstrate how a fixation on abstinence or elimination of all heavy drinking – the endpoints the Food and Drug Administration now require in pivotal clinical trials on alcohol use disorder (AUD) treatments – is shortsighted and can unnecessarily discourage people with alcohol use disorder from pursuing treatment.
“We need to think a little differently, or a little out of the box, from the way we’ve been thinking in the past,” said Raymond F. Anton, MD, professor of psychiatry at the Medical University of South Carolina in Charleston and chair of the Alcohol Clinical Trials Initiative (ACTIVE), a group advocating for a new endpoint that recognizes the benefits of lesser reductions in alcohol intake.
In a new analysis using data from the COMBINE study, researchers looked at the associations between reduction in World Health Organization drinking risk levels of alcohol consumption and clinically meaningful outcomes among people in treatment.
There are four levels: very high (more than 7.1 14-g drinks a day for men and more than 4.3 for women); high (4.3-7.1 or 2.9-4.3, respectively); moderate (2.9-4.3 or 1.4-2.9); and low (less than 2.9 or less than 1.4).
Researchers assessed responses to treatment with acamprosate, naltrexone, and psychological intervention in patients an average of 44 years old with 71% of their days being heavy drinking days. They found significant improvement in consequences tied to drinking, according to the Drinker Inventory of Consequences, and in mental health according to the Short Form Health Survey and the WHO Quality of Life assessment – even when the improvement was only by one WHO risk level – or just a few drinks a day – and did not involve abstaining (P less than .001 for all improvement categories).
“Reductions in WHO drinking risk levels are predictive of clinical benefit” or how the patient feels and functions, said Daniel Falk, PhD, health scientist administrator at the National Institute on Alcohol Abuse and Alcoholism.
The ACTIVE group he chairs, Dr. Anton said, is proposing that the FDA add a new endpoint for phase 3 trials: percentage of subjects who attain a 1- or 2-level reduction in WHO drinking risk levels.
Stephanie O’Malley, PhD, professor of psychiatry at Yale University in New Haven, Conn., said a 30-year-old with a moderate drinking problem – occasionally missing a family function, but never letting it interfere with work, say – might be turned off by a treatment plan that preaches abstinence, she said. Varenicline, for example, results in abstinence just 7% of the time, with some risk of suicidality and nausea. That person might not want to stop drinking entirely for the rest of his or her life, but could benefit by reducing the drinking, she said.
But 55% of the time, varenicline produces a reduction of one level of risk, which is associated with clinically meaningful results. That will sound much more appealing to a prospective patient, she said.
“From a clinical perspective, these WHO outcomes have some advantages,” she said. “I think you’re going to, one, encourage more people to accept treatment, and … be more optimistic about the outcomes.”
Dr. Anton reported consulting and/or funding from Alkermes, Allergan, Indivior, Insys Life Epigenetics, and Laboratori Farmaceutico CT. Dr. O’Malley reported consulting and/or funding from Alkermes, Amygdala, Indivior, Mistubishi Tanabe, Opiant, and other sources. Dr. Falk reported no disclosures.
BONITA SPRINGS, FLA. – Reductions in alcohol use bring about significant improvement in adverse consequences, mental health status, and quality of life, even if the reductions do not reach the level of abstinence, according to recent research presented at the annual meeting of the American Academy of Addiction Psychiatry.
The findings, experts say, demonstrate how a fixation on abstinence or elimination of all heavy drinking – the endpoints the Food and Drug Administration now require in pivotal clinical trials on alcohol use disorder (AUD) treatments – is shortsighted and can unnecessarily discourage people with alcohol use disorder from pursuing treatment.
“We need to think a little differently, or a little out of the box, from the way we’ve been thinking in the past,” said Raymond F. Anton, MD, professor of psychiatry at the Medical University of South Carolina in Charleston and chair of the Alcohol Clinical Trials Initiative (ACTIVE), a group advocating for a new endpoint that recognizes the benefits of lesser reductions in alcohol intake.
In a new analysis using data from the COMBINE study, researchers looked at the associations between reduction in World Health Organization drinking risk levels of alcohol consumption and clinically meaningful outcomes among people in treatment.
There are four levels: very high (more than 7.1 14-g drinks a day for men and more than 4.3 for women); high (4.3-7.1 or 2.9-4.3, respectively); moderate (2.9-4.3 or 1.4-2.9); and low (less than 2.9 or less than 1.4).
Researchers assessed responses to treatment with acamprosate, naltrexone, and psychological intervention in patients an average of 44 years old with 71% of their days being heavy drinking days. They found significant improvement in consequences tied to drinking, according to the Drinker Inventory of Consequences, and in mental health according to the Short Form Health Survey and the WHO Quality of Life assessment – even when the improvement was only by one WHO risk level – or just a few drinks a day – and did not involve abstaining (P less than .001 for all improvement categories).
“Reductions in WHO drinking risk levels are predictive of clinical benefit” or how the patient feels and functions, said Daniel Falk, PhD, health scientist administrator at the National Institute on Alcohol Abuse and Alcoholism.
The ACTIVE group he chairs, Dr. Anton said, is proposing that the FDA add a new endpoint for phase 3 trials: percentage of subjects who attain a 1- or 2-level reduction in WHO drinking risk levels.
Stephanie O’Malley, PhD, professor of psychiatry at Yale University in New Haven, Conn., said a 30-year-old with a moderate drinking problem – occasionally missing a family function, but never letting it interfere with work, say – might be turned off by a treatment plan that preaches abstinence, she said. Varenicline, for example, results in abstinence just 7% of the time, with some risk of suicidality and nausea. That person might not want to stop drinking entirely for the rest of his or her life, but could benefit by reducing the drinking, she said.
But 55% of the time, varenicline produces a reduction of one level of risk, which is associated with clinically meaningful results. That will sound much more appealing to a prospective patient, she said.
“From a clinical perspective, these WHO outcomes have some advantages,” she said. “I think you’re going to, one, encourage more people to accept treatment, and … be more optimistic about the outcomes.”
Dr. Anton reported consulting and/or funding from Alkermes, Allergan, Indivior, Insys Life Epigenetics, and Laboratori Farmaceutico CT. Dr. O’Malley reported consulting and/or funding from Alkermes, Amygdala, Indivior, Mistubishi Tanabe, Opiant, and other sources. Dr. Falk reported no disclosures.
REPORTING FROM AAAP 2018
E-cigarettes beat nicotine patch for smoking cessation
E-cigarettes might be more effective for smoking cessation than nicotine replacement therapy, results of a randomized study of almost 900 adults suggest.
Rates of abstinence at 1 year were 18% for adults who used refillable e-cigarettes to wean themselves off smoking, according to the reported results, compared with about 10% for those who tried nicotine replacement therapies.
“This is particularly noteworthy given that nicotine replacement was used under expert guidance, with access to the full range of nicotine replacement products, and with 88.1% of participants using combination treatments,” said investigator Peter Hajek, PhD, of Queen Mary University of London, and his coauthors in the New England Journal of Medicine.
The findings contrast with those of earlier studies, which showed a lesser effect of e-cigarettes as a stop-smoking strategy, Dr. Hajek and coauthors wrote.
In previous studies, participants used first-generation cartridge-based e-cigarettes, while in the present study, they were given second-generation refillable e-cigarettes and free choice of e-liquids, the authors noted. Moreover, those previous studies provided limited face-to-face support, they said, but
The randomized study by Dr. Hajek and his colleagues included 886 adults in the United Kingdom attending stop-smoking services provided by the U.K. National Health Service. They were randomized to receive either an e-cigarette starter pack and one bottle of nicotine-containing e-liquid, or 3 months’ worth of nicotine replacement products of their own choosing. At the 52-week validation visits, the study participants received about the equivalence of about $26 U.S. dollars for their travel and time.
Abstinence from smoking at 52 weeks, which was verified by measuring expired carbon monoxide levels, was achieved in 18.0% of the e-cigarette group and 9.9% of the nicotine replacement group (relative risk, 1.83; 95% confidence interval, 1.30-2.58; P less than .001), according to the report.
However, the rate of continued e-cigarette use was “fairly high,” investigators wrote. Eighty percent of the e-cigarette group was still using their assigned product at 52 weeks, compared with just 9% in the nicotine replacement group.
“This can be seen as problematic if e-cigarette use for a year signals long-term use, which may pose as-yet-unknown health risks,” they said.
Tobacco withdrawal symptoms were less severe and satisfaction ratings were higher with e-cigarettes versus nicotine replacement therapy, similar to what had been observed in previous studies, investigators said.
They cited several limitations. For example, product assignments were not blinded. However, the investigators said they tried to “limit expectation effects by recruiting only participants with no strong product preference.”
Dr. Hajek reported grants and fees from Pfizer unrelated to the present study. Coauthors reported disclosures related to Pfizer and Johnson and Johnson, along with grants from the U.K. National Institute for Health Research.
SOURCE: Hajek P et al. N Engl J Med. 2019;380:629-37. doi: 10.1056/NEJMoa1808779.
Any smoking cessation benefit of e-cigarettes needs to be balanced against short- and long-term safety risks of using these products, according to authors of an editorial.
In the study by Hajek et al., the 1-year abstinence rate of 18% in the e-cigarette group compares favorably to what has been reported for Food and Drug Administration–approved smoking cessation treatments, according to Belinda Borelli, PhD, and George T. O’Connor, MD.
The short-term safety data in the trial are “reassuring,” with a low incidence of oropharyngeal irritation, no excess wheezing or dyspnea, and greater declines in cough and phlegm production versus the nicotine replacement group, Dr. Borelli and Dr. O’Connor said.
However, a notable finding was that 80% of participants in the e-cigarette group were still using the product at 1 year, versus just 9% in the nicotine replacement group. “This differential pattern of long-term use raises concerns about the health consequences of long-term e-cigarette use,” they said.
E-cigarette vapor generally has lower levels of toxins and fewer biologic effects than does tobacco smoke, but it has produced adverse biologic effects in animal models and human cells in vitro, according to the authors.
“These findings argue against complacency in accepting the transition from tobacco smoking to indefinite e-cigarette use as a completely successful smoking cessation outcome,” they wrote. Policy analysts need to be careful and do their due diligence to ensure all consequences of the policy options are fully understood, especially as pharmaceuticals account for greater costs in the Medicare program. Future policy analyses must account for changes to Medicare costs as well as beneficiary costs to understand the overall effects of policy changes.
Dr. Borelli is with the Center for Behavioral Science Research, department of health policy and health services research at the Henry M. Goldman School of Dental Medicine, Boston University. Dr. O’Connor is with the Pulmonary Center at Boston University and with the division of pulmonary, allergy, sleep, and critical care medicine at Boston Medical Center. Dr. Borelli had no disclosures; Dr. O’Connor reported disclosures with AstraZeneca and Janssen Pharmaceuticals. They made these comments in an accompanying editorial (N Eng J Med. 2019. doi: 10.1056/NEJMe1816406).
Any smoking cessation benefit of e-cigarettes needs to be balanced against short- and long-term safety risks of using these products, according to authors of an editorial.
In the study by Hajek et al., the 1-year abstinence rate of 18% in the e-cigarette group compares favorably to what has been reported for Food and Drug Administration–approved smoking cessation treatments, according to Belinda Borelli, PhD, and George T. O’Connor, MD.
The short-term safety data in the trial are “reassuring,” with a low incidence of oropharyngeal irritation, no excess wheezing or dyspnea, and greater declines in cough and phlegm production versus the nicotine replacement group, Dr. Borelli and Dr. O’Connor said.
However, a notable finding was that 80% of participants in the e-cigarette group were still using the product at 1 year, versus just 9% in the nicotine replacement group. “This differential pattern of long-term use raises concerns about the health consequences of long-term e-cigarette use,” they said.
E-cigarette vapor generally has lower levels of toxins and fewer biologic effects than does tobacco smoke, but it has produced adverse biologic effects in animal models and human cells in vitro, according to the authors.
“These findings argue against complacency in accepting the transition from tobacco smoking to indefinite e-cigarette use as a completely successful smoking cessation outcome,” they wrote. Policy analysts need to be careful and do their due diligence to ensure all consequences of the policy options are fully understood, especially as pharmaceuticals account for greater costs in the Medicare program. Future policy analyses must account for changes to Medicare costs as well as beneficiary costs to understand the overall effects of policy changes.
Dr. Borelli is with the Center for Behavioral Science Research, department of health policy and health services research at the Henry M. Goldman School of Dental Medicine, Boston University. Dr. O’Connor is with the Pulmonary Center at Boston University and with the division of pulmonary, allergy, sleep, and critical care medicine at Boston Medical Center. Dr. Borelli had no disclosures; Dr. O’Connor reported disclosures with AstraZeneca and Janssen Pharmaceuticals. They made these comments in an accompanying editorial (N Eng J Med. 2019. doi: 10.1056/NEJMe1816406).
Any smoking cessation benefit of e-cigarettes needs to be balanced against short- and long-term safety risks of using these products, according to authors of an editorial.
In the study by Hajek et al., the 1-year abstinence rate of 18% in the e-cigarette group compares favorably to what has been reported for Food and Drug Administration–approved smoking cessation treatments, according to Belinda Borelli, PhD, and George T. O’Connor, MD.
The short-term safety data in the trial are “reassuring,” with a low incidence of oropharyngeal irritation, no excess wheezing or dyspnea, and greater declines in cough and phlegm production versus the nicotine replacement group, Dr. Borelli and Dr. O’Connor said.
However, a notable finding was that 80% of participants in the e-cigarette group were still using the product at 1 year, versus just 9% in the nicotine replacement group. “This differential pattern of long-term use raises concerns about the health consequences of long-term e-cigarette use,” they said.
E-cigarette vapor generally has lower levels of toxins and fewer biologic effects than does tobacco smoke, but it has produced adverse biologic effects in animal models and human cells in vitro, according to the authors.
“These findings argue against complacency in accepting the transition from tobacco smoking to indefinite e-cigarette use as a completely successful smoking cessation outcome,” they wrote. Policy analysts need to be careful and do their due diligence to ensure all consequences of the policy options are fully understood, especially as pharmaceuticals account for greater costs in the Medicare program. Future policy analyses must account for changes to Medicare costs as well as beneficiary costs to understand the overall effects of policy changes.
Dr. Borelli is with the Center for Behavioral Science Research, department of health policy and health services research at the Henry M. Goldman School of Dental Medicine, Boston University. Dr. O’Connor is with the Pulmonary Center at Boston University and with the division of pulmonary, allergy, sleep, and critical care medicine at Boston Medical Center. Dr. Borelli had no disclosures; Dr. O’Connor reported disclosures with AstraZeneca and Janssen Pharmaceuticals. They made these comments in an accompanying editorial (N Eng J Med. 2019. doi: 10.1056/NEJMe1816406).
E-cigarettes might be more effective for smoking cessation than nicotine replacement therapy, results of a randomized study of almost 900 adults suggest.
Rates of abstinence at 1 year were 18% for adults who used refillable e-cigarettes to wean themselves off smoking, according to the reported results, compared with about 10% for those who tried nicotine replacement therapies.
“This is particularly noteworthy given that nicotine replacement was used under expert guidance, with access to the full range of nicotine replacement products, and with 88.1% of participants using combination treatments,” said investigator Peter Hajek, PhD, of Queen Mary University of London, and his coauthors in the New England Journal of Medicine.
The findings contrast with those of earlier studies, which showed a lesser effect of e-cigarettes as a stop-smoking strategy, Dr. Hajek and coauthors wrote.
In previous studies, participants used first-generation cartridge-based e-cigarettes, while in the present study, they were given second-generation refillable e-cigarettes and free choice of e-liquids, the authors noted. Moreover, those previous studies provided limited face-to-face support, they said, but
The randomized study by Dr. Hajek and his colleagues included 886 adults in the United Kingdom attending stop-smoking services provided by the U.K. National Health Service. They were randomized to receive either an e-cigarette starter pack and one bottle of nicotine-containing e-liquid, or 3 months’ worth of nicotine replacement products of their own choosing. At the 52-week validation visits, the study participants received about the equivalence of about $26 U.S. dollars for their travel and time.
Abstinence from smoking at 52 weeks, which was verified by measuring expired carbon monoxide levels, was achieved in 18.0% of the e-cigarette group and 9.9% of the nicotine replacement group (relative risk, 1.83; 95% confidence interval, 1.30-2.58; P less than .001), according to the report.
However, the rate of continued e-cigarette use was “fairly high,” investigators wrote. Eighty percent of the e-cigarette group was still using their assigned product at 52 weeks, compared with just 9% in the nicotine replacement group.
“This can be seen as problematic if e-cigarette use for a year signals long-term use, which may pose as-yet-unknown health risks,” they said.
Tobacco withdrawal symptoms were less severe and satisfaction ratings were higher with e-cigarettes versus nicotine replacement therapy, similar to what had been observed in previous studies, investigators said.
They cited several limitations. For example, product assignments were not blinded. However, the investigators said they tried to “limit expectation effects by recruiting only participants with no strong product preference.”
Dr. Hajek reported grants and fees from Pfizer unrelated to the present study. Coauthors reported disclosures related to Pfizer and Johnson and Johnson, along with grants from the U.K. National Institute for Health Research.
SOURCE: Hajek P et al. N Engl J Med. 2019;380:629-37. doi: 10.1056/NEJMoa1808779.
E-cigarettes might be more effective for smoking cessation than nicotine replacement therapy, results of a randomized study of almost 900 adults suggest.
Rates of abstinence at 1 year were 18% for adults who used refillable e-cigarettes to wean themselves off smoking, according to the reported results, compared with about 10% for those who tried nicotine replacement therapies.
“This is particularly noteworthy given that nicotine replacement was used under expert guidance, with access to the full range of nicotine replacement products, and with 88.1% of participants using combination treatments,” said investigator Peter Hajek, PhD, of Queen Mary University of London, and his coauthors in the New England Journal of Medicine.
The findings contrast with those of earlier studies, which showed a lesser effect of e-cigarettes as a stop-smoking strategy, Dr. Hajek and coauthors wrote.
In previous studies, participants used first-generation cartridge-based e-cigarettes, while in the present study, they were given second-generation refillable e-cigarettes and free choice of e-liquids, the authors noted. Moreover, those previous studies provided limited face-to-face support, they said, but
The randomized study by Dr. Hajek and his colleagues included 886 adults in the United Kingdom attending stop-smoking services provided by the U.K. National Health Service. They were randomized to receive either an e-cigarette starter pack and one bottle of nicotine-containing e-liquid, or 3 months’ worth of nicotine replacement products of their own choosing. At the 52-week validation visits, the study participants received about the equivalence of about $26 U.S. dollars for their travel and time.
Abstinence from smoking at 52 weeks, which was verified by measuring expired carbon monoxide levels, was achieved in 18.0% of the e-cigarette group and 9.9% of the nicotine replacement group (relative risk, 1.83; 95% confidence interval, 1.30-2.58; P less than .001), according to the report.
However, the rate of continued e-cigarette use was “fairly high,” investigators wrote. Eighty percent of the e-cigarette group was still using their assigned product at 52 weeks, compared with just 9% in the nicotine replacement group.
“This can be seen as problematic if e-cigarette use for a year signals long-term use, which may pose as-yet-unknown health risks,” they said.
Tobacco withdrawal symptoms were less severe and satisfaction ratings were higher with e-cigarettes versus nicotine replacement therapy, similar to what had been observed in previous studies, investigators said.
They cited several limitations. For example, product assignments were not blinded. However, the investigators said they tried to “limit expectation effects by recruiting only participants with no strong product preference.”
Dr. Hajek reported grants and fees from Pfizer unrelated to the present study. Coauthors reported disclosures related to Pfizer and Johnson and Johnson, along with grants from the U.K. National Institute for Health Research.
SOURCE: Hajek P et al. N Engl J Med. 2019;380:629-37. doi: 10.1056/NEJMoa1808779.
FROM THE NEW ENGLAND JOURNAL OF MEDICINE
Key clinical point: The rate of smokers who continued to use e-cigarettes after 1 year was “fairly high,” which might be problematic.
Major finding: Abstinence from smoking at 52 weeks was achieved in 18.0% of the e-cigarette group and 9.9% of the nicotine replacement group (relative risk, 1.83; 95% confidence interval, 1.30-2.58; P less than .001).
Study details: Randomized study of 886 adults in the United Kingdom attending stop-smoking services provided by the U.K. National Health Service.
Disclosures: Dr. Hajek reported grants and fees from Pfizer unrelated to the present study.The coauthors reported disclosures related to Pfizer, and Johnson and Johnson, along with grants from the U.K. National Institute for Health Research.
Source: Hajek P et al. N Engl J Med. 2019;380:629-37. doi: 10.1056/NEJMoa1808779.
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, the United States now has more than 100 measles cases for the year, e-cigarette use reverses progress in reducing teens’ tobacco use, and consider adopting the MESA 10-year coronary heart disease risk calculator.
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In California, opioids most often prescribed in low-income, mostly white areas
There is a higher prevalence of opioid prescribing and opioid-related overdose deaths concentrated in regions with mostly low-income, white residents, compared with regions with high income and the lowest proportion of white residents, according to a new analysis of data on people living in California.
The findings of this study provide further evidence that the opioid epidemic affects a large proportion of low-income white communities (JAMA Intern Med. 2019 Feb 11. doi: 10.1001/jamainternmed.2018.6721).
“Whereas most epidemics predominate within social minority groups and previous US drug epidemics have typically been concentrated in nonwhite communities, Joseph Friedman, MPH, from the University of California, Los Angeles, and his colleagues wrote in their study. “Our analysis suggests that, at least in California, an important determinant of this phenomenon may be that white individuals have a higher level of exposure than nonwhite individuals to opioid prescriptions on a per capita basis through the health care system.”
Mr. Friedman and his colleagues analyzed 29.7 million prescription drug records from California’s Controlled Substance Utilization Review and Evaluation System in and examined the prevalence of opioids, benzodiazepines, and stimulants by race, ethnicity, and income level in 1,760 zip codes during 2011-2015. The researchers estimated the prevalence of opioid prescriptions in each zip code by calculating the number of people per zip code receiving an opioid prescription divided by the population of the zip code during each year.
Overall, 23.6% of California residents received at least one opioid prescription each year of the study. The researchers found 44.2% of individuals in zip codes with the lowest income but highest proportion of white residents and 16.1% of individuals in areas with the highest income and lowest proportion of white residents had received a minimum of one opioid prescription each year. The prevalence of stimulant prescriptions was 3.8% in zip codes with high income, and a high proportion of white population, compared with a prevalence of 0.6% in areas with low income and a low proportion of white residents. The researchers noted there was no association between income and benzodiazepine prescription, but the prevalence of benzodiazepine prescriptions was 15.7% in zip codes with the highest proportion of white residents, compared with 7.0% in zip codes with a low proportion of white residents.
During the same time period, there were 9,534 opioid overdose deaths in California from causes such as fentanyl, synthetic opioids, and prescription opioids. “Overdose deaths were highly concentrated in lower-income and mostly white areas,” Mr. Friedman and his colleagues wrote. “We observed an approximate 10-fold difference in overdose rates across the race/ethnicity–income gradient in California.”
Although the number of opioids prescribed each year has decreased since 2012, in a research letter published in the same issue noted that the rate of prescribing is still higher than it was in 1999 (JAMA Intern Med. 2019 Feb 11. doi: 10.1001/jamainternmed.2018.6989). The authors also pointed out increases in the duration of opioid prescriptions and wide regional variations in opioid prescribing rates.
In their study, Gery P. Guy Jr., PhD, and his colleagues used data from the IQVIA Xponent database from approximately 50,400 retail pharmacies and discovered the average morphine milligram equivalent (MME) per capita had decreased from 641.4 MME per capita in 2015 to 512.6 MME per capita in 2017 (20.1%). The number of opioid prescriptions also decreased from 6.7 per 100 persons in 2015 to 5.0 per 100 persons in 2017 (25.3%). However, during 2015-2017, the average duration of opioid prescriptions increased from 17.7 days to 18.3 days (3.4%), while the median duration increased during the same time from 15.0 days to 20.0 days (33.3%).
While 74.7% of counties reduced the number of opioids prescribed during 2015-2017 and there also were reductions in the rate of high-dose prescribing (76.6%) and overall prescribing rates (74.7%), Dr. Guy of the Centers for Disease Control and Prevention and his colleagues found “substantial variation” in 2017 prescription rates at the county level, with opioids prescribed at 1,061.0 MME per capita at the highest quartile, compared with 182.8 MME per capita at the lowest quartile.
“Recent reductions could be related to policies and strategies aimed at reducing inappropriate prescribing, increased awareness of the risks associated with opioids, and release of the CDC Guideline for Prescribing Opioids for Chronic Pain–United States, 2016,” Dr. Guy and his colleagues noted.
In an additional article published in the same JAMA Internal Medicine issue, Bennett Allen, a research associate at the New York City Department of Health and Mental Hygiene and his colleagues examined the rate of opioid overdose deaths for non-Hispanic white, non-Hispanic black, Hispanic, and undefined other races in New York (JAMA Intern Med. 2019 Feb 11. doi: 10.1001/jamainternmed.2018.7700). They identified 1,487 deaths in 2017, which included 556 white (37.0%), 421 black (28.0%), 455 Hispanic (31.0%), and 55 undefined (4.0%) opioid overdose deaths. There was a higher rate of fentanyl and/or heroin overdose deaths from younger (aged 15-34 years) white New Yorkers (22.2/100,000 persons; 95% confidence interval, 19.0-25.5), compared with younger black New Yorkers (5.8/100,000; 95% CI, 4.0-8.2) and Hispanic (9.7/100,000; 95% CI, 7.6-12.1).
Among older residents (aged 55-84 years), Mr. Allen and his colleagues found higher rates of fentanyl and/or heroin overdose for black New Yorkers (25.4/100,000 persons; 95% CI, 20.9-30.0), compared with older white New Yorkers (9.4/100,000 persons; 95% CI, 7.3-11.8), as well as significantly higher rates of cocaine overdose (25.4/100,000 persons; 95% CI, 20.9-30.0), compared with white (5.1/100,000 persons; 95% CI, 3.6-7.0) and Hispanic residents (11.8/100,000 persons; 95% CI, 8.9-15.4).
“The distinct age distribution and drug involvement of overdose deaths among New York City blacks, Latinos, and whites, along with complementary evidence about drug use trajectories, highlight the need for heterogeneous approaches to treatment and the equitable allocation of treatment and health care resources to reach diverse populations at risk of overdose,” Mr. Allen and his colleagues wrote.
Dr. Schriger reported support from Korein Foundation for his time working on the study by Friedman et al. The other authors reported no conflicts of interest.
The results published by Friedman et al. are a reminder that we can use regional prescribing trends to identify communities most susceptible to the opioid epidemic and give them the resources they need to combat opioid addiction, Vice Adm. Jerome M. Adams, MD, MPH, and Adm. Brett P. Giroir, MD, wrote in a related editorial.
“Discussion of overdose risks and coprescribing of naloxone must become routine if we are to make opioid prescribing safer,” the authors wrote.
Physicians also can help respond to the opioid epidemic outside of prescribing by promoting evidence-based nonopioid and nonpharmaceutical pain treatments, screening their patients for OUD and OUD risks, and acknowledging “that the problem cannot be solved by medical interventions alone.” Individual, environmental, and societal factors also contribute to the opioid epidemic, and physicians are uniquely suited to spearhead efforts aimed at addressing comprehensive opioid misuse.
“Physicians stand out as natural leaders to help solve the crises because of the depth of their knowledge, immediacy of their contact with patients, and relatively high level of respect their profession enjoys,” Dr. Adams and Dr. Giroir wrote. “We thereby call on our nation’s doctors to embrace their roles in the clinic and beyond to help educate communities, bring together stakeholders, and be part of the cultural change to support people living free from addiction.”
Dr. Adams is the 20th surgeon general of the United States at the U.S. Public Health Service and HHS; Dr. Giroir is the 16th U.S. assistant secretary for health at the U.S. Public Health Service and HHS. They reported no relevant conflicts of interest. Their invited commentary accompanied the three related articles in the publication (JAMA Intern Med. 2019 Feb 11. doi: 10.1001/jamainternmed.2018.7934 ).
The results published by Friedman et al. are a reminder that we can use regional prescribing trends to identify communities most susceptible to the opioid epidemic and give them the resources they need to combat opioid addiction, Vice Adm. Jerome M. Adams, MD, MPH, and Adm. Brett P. Giroir, MD, wrote in a related editorial.
“Discussion of overdose risks and coprescribing of naloxone must become routine if we are to make opioid prescribing safer,” the authors wrote.
Physicians also can help respond to the opioid epidemic outside of prescribing by promoting evidence-based nonopioid and nonpharmaceutical pain treatments, screening their patients for OUD and OUD risks, and acknowledging “that the problem cannot be solved by medical interventions alone.” Individual, environmental, and societal factors also contribute to the opioid epidemic, and physicians are uniquely suited to spearhead efforts aimed at addressing comprehensive opioid misuse.
“Physicians stand out as natural leaders to help solve the crises because of the depth of their knowledge, immediacy of their contact with patients, and relatively high level of respect their profession enjoys,” Dr. Adams and Dr. Giroir wrote. “We thereby call on our nation’s doctors to embrace their roles in the clinic and beyond to help educate communities, bring together stakeholders, and be part of the cultural change to support people living free from addiction.”
Dr. Adams is the 20th surgeon general of the United States at the U.S. Public Health Service and HHS; Dr. Giroir is the 16th U.S. assistant secretary for health at the U.S. Public Health Service and HHS. They reported no relevant conflicts of interest. Their invited commentary accompanied the three related articles in the publication (JAMA Intern Med. 2019 Feb 11. doi: 10.1001/jamainternmed.2018.7934 ).
The results published by Friedman et al. are a reminder that we can use regional prescribing trends to identify communities most susceptible to the opioid epidemic and give them the resources they need to combat opioid addiction, Vice Adm. Jerome M. Adams, MD, MPH, and Adm. Brett P. Giroir, MD, wrote in a related editorial.
“Discussion of overdose risks and coprescribing of naloxone must become routine if we are to make opioid prescribing safer,” the authors wrote.
Physicians also can help respond to the opioid epidemic outside of prescribing by promoting evidence-based nonopioid and nonpharmaceutical pain treatments, screening their patients for OUD and OUD risks, and acknowledging “that the problem cannot be solved by medical interventions alone.” Individual, environmental, and societal factors also contribute to the opioid epidemic, and physicians are uniquely suited to spearhead efforts aimed at addressing comprehensive opioid misuse.
“Physicians stand out as natural leaders to help solve the crises because of the depth of their knowledge, immediacy of their contact with patients, and relatively high level of respect their profession enjoys,” Dr. Adams and Dr. Giroir wrote. “We thereby call on our nation’s doctors to embrace their roles in the clinic and beyond to help educate communities, bring together stakeholders, and be part of the cultural change to support people living free from addiction.”
Dr. Adams is the 20th surgeon general of the United States at the U.S. Public Health Service and HHS; Dr. Giroir is the 16th U.S. assistant secretary for health at the U.S. Public Health Service and HHS. They reported no relevant conflicts of interest. Their invited commentary accompanied the three related articles in the publication (JAMA Intern Med. 2019 Feb 11. doi: 10.1001/jamainternmed.2018.7934 ).
There is a higher prevalence of opioid prescribing and opioid-related overdose deaths concentrated in regions with mostly low-income, white residents, compared with regions with high income and the lowest proportion of white residents, according to a new analysis of data on people living in California.
The findings of this study provide further evidence that the opioid epidemic affects a large proportion of low-income white communities (JAMA Intern Med. 2019 Feb 11. doi: 10.1001/jamainternmed.2018.6721).
“Whereas most epidemics predominate within social minority groups and previous US drug epidemics have typically been concentrated in nonwhite communities, Joseph Friedman, MPH, from the University of California, Los Angeles, and his colleagues wrote in their study. “Our analysis suggests that, at least in California, an important determinant of this phenomenon may be that white individuals have a higher level of exposure than nonwhite individuals to opioid prescriptions on a per capita basis through the health care system.”
Mr. Friedman and his colleagues analyzed 29.7 million prescription drug records from California’s Controlled Substance Utilization Review and Evaluation System in and examined the prevalence of opioids, benzodiazepines, and stimulants by race, ethnicity, and income level in 1,760 zip codes during 2011-2015. The researchers estimated the prevalence of opioid prescriptions in each zip code by calculating the number of people per zip code receiving an opioid prescription divided by the population of the zip code during each year.
Overall, 23.6% of California residents received at least one opioid prescription each year of the study. The researchers found 44.2% of individuals in zip codes with the lowest income but highest proportion of white residents and 16.1% of individuals in areas with the highest income and lowest proportion of white residents had received a minimum of one opioid prescription each year. The prevalence of stimulant prescriptions was 3.8% in zip codes with high income, and a high proportion of white population, compared with a prevalence of 0.6% in areas with low income and a low proportion of white residents. The researchers noted there was no association between income and benzodiazepine prescription, but the prevalence of benzodiazepine prescriptions was 15.7% in zip codes with the highest proportion of white residents, compared with 7.0% in zip codes with a low proportion of white residents.
During the same time period, there were 9,534 opioid overdose deaths in California from causes such as fentanyl, synthetic opioids, and prescription opioids. “Overdose deaths were highly concentrated in lower-income and mostly white areas,” Mr. Friedman and his colleagues wrote. “We observed an approximate 10-fold difference in overdose rates across the race/ethnicity–income gradient in California.”
Although the number of opioids prescribed each year has decreased since 2012, in a research letter published in the same issue noted that the rate of prescribing is still higher than it was in 1999 (JAMA Intern Med. 2019 Feb 11. doi: 10.1001/jamainternmed.2018.6989). The authors also pointed out increases in the duration of opioid prescriptions and wide regional variations in opioid prescribing rates.
In their study, Gery P. Guy Jr., PhD, and his colleagues used data from the IQVIA Xponent database from approximately 50,400 retail pharmacies and discovered the average morphine milligram equivalent (MME) per capita had decreased from 641.4 MME per capita in 2015 to 512.6 MME per capita in 2017 (20.1%). The number of opioid prescriptions also decreased from 6.7 per 100 persons in 2015 to 5.0 per 100 persons in 2017 (25.3%). However, during 2015-2017, the average duration of opioid prescriptions increased from 17.7 days to 18.3 days (3.4%), while the median duration increased during the same time from 15.0 days to 20.0 days (33.3%).
While 74.7% of counties reduced the number of opioids prescribed during 2015-2017 and there also were reductions in the rate of high-dose prescribing (76.6%) and overall prescribing rates (74.7%), Dr. Guy of the Centers for Disease Control and Prevention and his colleagues found “substantial variation” in 2017 prescription rates at the county level, with opioids prescribed at 1,061.0 MME per capita at the highest quartile, compared with 182.8 MME per capita at the lowest quartile.
“Recent reductions could be related to policies and strategies aimed at reducing inappropriate prescribing, increased awareness of the risks associated with opioids, and release of the CDC Guideline for Prescribing Opioids for Chronic Pain–United States, 2016,” Dr. Guy and his colleagues noted.
In an additional article published in the same JAMA Internal Medicine issue, Bennett Allen, a research associate at the New York City Department of Health and Mental Hygiene and his colleagues examined the rate of opioid overdose deaths for non-Hispanic white, non-Hispanic black, Hispanic, and undefined other races in New York (JAMA Intern Med. 2019 Feb 11. doi: 10.1001/jamainternmed.2018.7700). They identified 1,487 deaths in 2017, which included 556 white (37.0%), 421 black (28.0%), 455 Hispanic (31.0%), and 55 undefined (4.0%) opioid overdose deaths. There was a higher rate of fentanyl and/or heroin overdose deaths from younger (aged 15-34 years) white New Yorkers (22.2/100,000 persons; 95% confidence interval, 19.0-25.5), compared with younger black New Yorkers (5.8/100,000; 95% CI, 4.0-8.2) and Hispanic (9.7/100,000; 95% CI, 7.6-12.1).
Among older residents (aged 55-84 years), Mr. Allen and his colleagues found higher rates of fentanyl and/or heroin overdose for black New Yorkers (25.4/100,000 persons; 95% CI, 20.9-30.0), compared with older white New Yorkers (9.4/100,000 persons; 95% CI, 7.3-11.8), as well as significantly higher rates of cocaine overdose (25.4/100,000 persons; 95% CI, 20.9-30.0), compared with white (5.1/100,000 persons; 95% CI, 3.6-7.0) and Hispanic residents (11.8/100,000 persons; 95% CI, 8.9-15.4).
“The distinct age distribution and drug involvement of overdose deaths among New York City blacks, Latinos, and whites, along with complementary evidence about drug use trajectories, highlight the need for heterogeneous approaches to treatment and the equitable allocation of treatment and health care resources to reach diverse populations at risk of overdose,” Mr. Allen and his colleagues wrote.
Dr. Schriger reported support from Korein Foundation for his time working on the study by Friedman et al. The other authors reported no conflicts of interest.
There is a higher prevalence of opioid prescribing and opioid-related overdose deaths concentrated in regions with mostly low-income, white residents, compared with regions with high income and the lowest proportion of white residents, according to a new analysis of data on people living in California.
The findings of this study provide further evidence that the opioid epidemic affects a large proportion of low-income white communities (JAMA Intern Med. 2019 Feb 11. doi: 10.1001/jamainternmed.2018.6721).
“Whereas most epidemics predominate within social minority groups and previous US drug epidemics have typically been concentrated in nonwhite communities, Joseph Friedman, MPH, from the University of California, Los Angeles, and his colleagues wrote in their study. “Our analysis suggests that, at least in California, an important determinant of this phenomenon may be that white individuals have a higher level of exposure than nonwhite individuals to opioid prescriptions on a per capita basis through the health care system.”
Mr. Friedman and his colleagues analyzed 29.7 million prescription drug records from California’s Controlled Substance Utilization Review and Evaluation System in and examined the prevalence of opioids, benzodiazepines, and stimulants by race, ethnicity, and income level in 1,760 zip codes during 2011-2015. The researchers estimated the prevalence of opioid prescriptions in each zip code by calculating the number of people per zip code receiving an opioid prescription divided by the population of the zip code during each year.
Overall, 23.6% of California residents received at least one opioid prescription each year of the study. The researchers found 44.2% of individuals in zip codes with the lowest income but highest proportion of white residents and 16.1% of individuals in areas with the highest income and lowest proportion of white residents had received a minimum of one opioid prescription each year. The prevalence of stimulant prescriptions was 3.8% in zip codes with high income, and a high proportion of white population, compared with a prevalence of 0.6% in areas with low income and a low proportion of white residents. The researchers noted there was no association between income and benzodiazepine prescription, but the prevalence of benzodiazepine prescriptions was 15.7% in zip codes with the highest proportion of white residents, compared with 7.0% in zip codes with a low proportion of white residents.
During the same time period, there were 9,534 opioid overdose deaths in California from causes such as fentanyl, synthetic opioids, and prescription opioids. “Overdose deaths were highly concentrated in lower-income and mostly white areas,” Mr. Friedman and his colleagues wrote. “We observed an approximate 10-fold difference in overdose rates across the race/ethnicity–income gradient in California.”
Although the number of opioids prescribed each year has decreased since 2012, in a research letter published in the same issue noted that the rate of prescribing is still higher than it was in 1999 (JAMA Intern Med. 2019 Feb 11. doi: 10.1001/jamainternmed.2018.6989). The authors also pointed out increases in the duration of opioid prescriptions and wide regional variations in opioid prescribing rates.
In their study, Gery P. Guy Jr., PhD, and his colleagues used data from the IQVIA Xponent database from approximately 50,400 retail pharmacies and discovered the average morphine milligram equivalent (MME) per capita had decreased from 641.4 MME per capita in 2015 to 512.6 MME per capita in 2017 (20.1%). The number of opioid prescriptions also decreased from 6.7 per 100 persons in 2015 to 5.0 per 100 persons in 2017 (25.3%). However, during 2015-2017, the average duration of opioid prescriptions increased from 17.7 days to 18.3 days (3.4%), while the median duration increased during the same time from 15.0 days to 20.0 days (33.3%).
While 74.7% of counties reduced the number of opioids prescribed during 2015-2017 and there also were reductions in the rate of high-dose prescribing (76.6%) and overall prescribing rates (74.7%), Dr. Guy of the Centers for Disease Control and Prevention and his colleagues found “substantial variation” in 2017 prescription rates at the county level, with opioids prescribed at 1,061.0 MME per capita at the highest quartile, compared with 182.8 MME per capita at the lowest quartile.
“Recent reductions could be related to policies and strategies aimed at reducing inappropriate prescribing, increased awareness of the risks associated with opioids, and release of the CDC Guideline for Prescribing Opioids for Chronic Pain–United States, 2016,” Dr. Guy and his colleagues noted.
In an additional article published in the same JAMA Internal Medicine issue, Bennett Allen, a research associate at the New York City Department of Health and Mental Hygiene and his colleagues examined the rate of opioid overdose deaths for non-Hispanic white, non-Hispanic black, Hispanic, and undefined other races in New York (JAMA Intern Med. 2019 Feb 11. doi: 10.1001/jamainternmed.2018.7700). They identified 1,487 deaths in 2017, which included 556 white (37.0%), 421 black (28.0%), 455 Hispanic (31.0%), and 55 undefined (4.0%) opioid overdose deaths. There was a higher rate of fentanyl and/or heroin overdose deaths from younger (aged 15-34 years) white New Yorkers (22.2/100,000 persons; 95% confidence interval, 19.0-25.5), compared with younger black New Yorkers (5.8/100,000; 95% CI, 4.0-8.2) and Hispanic (9.7/100,000; 95% CI, 7.6-12.1).
Among older residents (aged 55-84 years), Mr. Allen and his colleagues found higher rates of fentanyl and/or heroin overdose for black New Yorkers (25.4/100,000 persons; 95% CI, 20.9-30.0), compared with older white New Yorkers (9.4/100,000 persons; 95% CI, 7.3-11.8), as well as significantly higher rates of cocaine overdose (25.4/100,000 persons; 95% CI, 20.9-30.0), compared with white (5.1/100,000 persons; 95% CI, 3.6-7.0) and Hispanic residents (11.8/100,000 persons; 95% CI, 8.9-15.4).
“The distinct age distribution and drug involvement of overdose deaths among New York City blacks, Latinos, and whites, along with complementary evidence about drug use trajectories, highlight the need for heterogeneous approaches to treatment and the equitable allocation of treatment and health care resources to reach diverse populations at risk of overdose,” Mr. Allen and his colleagues wrote.
Dr. Schriger reported support from Korein Foundation for his time working on the study by Friedman et al. The other authors reported no conflicts of interest.
FROM JAMA INTERNAL MEDICINE
Key clinical point: The most common users of opioids according to prescription drug records are residents of mostly low-income, white neighborhoods.
Major finding: Compared with 23.6% of all Californians, 44.2% of individuals in zip codes containing mostly low-income, white residents had at least one opioid prescription each year, compared with 16.1% of individuals in high-income zip codes with the lowest population of white residents.
Study details: An analysis of 29.7 million opioid prescription drug records by race and income in California during 2011-2015.
Disclosures: Dr. Schriger reported support from the Korein Foundation for his time working on the study by Friedman et al. The other authors from Friedman et al. reported no conflicts of interest.
E-cig use reverses progress in reducing tobacco use in teens
A significant increase during 2017-2018 in e-cigarette use among U.S. youths has erased recent progress in reducing overall tobacco product use in this age group, a study from the Centers for Disease Control and Prevention has found.
E-cigarettes are driving the trend. About 4 million high school students in the United States reported using any tobacco product in the last 30 days, and 3 million of them reported using e-cigarettes, according to a Vital Signs document published by the CDC on Feb. 11 in its Morbidity and Mortality Weekly Report.*
In addition, many high school students who use e-cigarettes use them often; 28% reported using the products at least 20 times in the past 28 days, up from 20% in 2017.
“Any use of any tobacco product is unsafe for teens,” Anne Schuchat, MD, principal deputy director of the CDC, said in a teleconference to present the findings. Nicotine is highly addictive and can harm brain development in youth, including capacity for learning, memory, and attention, she said.
The rise in e-cigarette use corresponds with the rise in marketing and availability of e-cigarette devices such as JUUL, which dispense nicotine via liquid refill pods available in flavors including strawberry and cotton candy, said Brian King, MPH, PhD, deputy director for research translation at the CDC’s Office on Smoking and Health.
“The advertising will lead a horse to water, the flavors will make them drink, and the nicotine will keep them coming back for more,” said Dr. King.
Approximately 27.1% of high school students and 7.2% of middle school students used a tobacco product in 2018, a significant increase from 2017 data, and with a major increase in e-cigarette use.
No change was noted in the use of other tobacco products, including cigarettes, from 2017 to 2018, according to the report. However, conventional cigarettes remained the most common companion product to e-cigarettes for youth who use two or more tobacco products (two in five high school students and one in three middle school students in 2018). From a demographic standpoint, e-cigarette use was highest among males, whites, and high school students.
Tobacco use in teens is trending in the direction of wiping out the progress made in recent years to reduce exposure to youths. The report noted, “The prevalence of e-cigarette use by U.S. high school students had peaked in 2015 before declining by 29% during 2015-2016 (from 16% to 11.3%); this decline was the first ever recorded for e-cigarette use among youths in the NYTS since monitoring began, and it was subsequently sustained during 2016-2017). However, current e-cigarette use increased by 77.8% among high school students and 48.5% among middle school students during 2017-2018, erasing the progress in reducing e-cigarette use, as well as any tobacco product use, that had occurred in prior years.”
The CDC and the Food and Drug Administration are taking action to curb the rise in e-cigarette use in youth in particular by seeking regulations to make the products less accessible, raising prices, and banning most flavorings, said Dr. Schuchat.
“We have targeted companies engaged in kid friendly marketing,” said Mitch Zeller, JD, director of the Center for Tobacco Products for the FDA.
In a statement published simultaneously with the Vital Signs study, FDA Commissioner Scott Gottlieb, MD, emphasized the link between e-cigarette use in teens and the potential for future tobacco use. “The kids using e-cigarettes are children who rejected conventional cigarettes, but don’t see the same stigma associated with the use of e-cigarettes. But now, having become exposed to nicotine through e-cigs, they will be more likely to smoke.” Dr. Gottlieb declared, “I will not allow a generation of children to become addicted to nicotine through e-cigarettes. We must stop the trends of youth e-cigarette use from continuing to build and will take whatever action is necessary to ensure these kids don’t become future smokers.” He reviewed steps taken in the past year by the FDA to counter tobacco use in teens but he warned of future actions that may need to be taken: “If these youth use trends continue, we’ll be forced to consider regulatory steps that could constrain or even foreclose the opportunities for currently addicted adult smokers to have the same level of access to these products that they now enjoy. I recognize that such a move could come with significant impacts to adult smokers.”
In the meantime, however, parents, teachers, community leaders, and health care providers are on the front lines and can make a difference in protecting youth and curbing nicotine use, Dr. King said.
One of the most important things clinicians can do is to ask young patients specifically about e-cigarette use, he emphasized. Learn and use the terminology the kids are using; ask, “Do you use JUUL?” If they are using these products, “make sure they know they are dangerous,” and can harm the developing brain, he said.
Although there are no currently approved medications to treat nicotine addiction in youth, research suggests that behavioral counseling, as well as reinforcement of the danger of nicotine from parents and other people of influence, can help, Dr. King said.
The Vital Signs report is based on data from the 2011-2018 National Youth Tobacco Survey, which assesses current use of cigarettes, cigars, smokeless tobacco, e-cigarettes, hookahs, pipe tobacco, and bidis among a nationally representative sample of middle and high school students in the United States. The findings were analyzed by the CDC, FDA, and the National Cancer Institute.
SOURCE: Gentzke AS et al. MMWR 2019 Feb 11. doi: 10.15585/mmwr.mm6806e1.
*Correction 2/13/2019 An earlier version of this article misstated the number of students using e-cigarettes as a proportion of all teen tobacco users.
A significant increase during 2017-2018 in e-cigarette use among U.S. youths has erased recent progress in reducing overall tobacco product use in this age group, a study from the Centers for Disease Control and Prevention has found.
E-cigarettes are driving the trend. About 4 million high school students in the United States reported using any tobacco product in the last 30 days, and 3 million of them reported using e-cigarettes, according to a Vital Signs document published by the CDC on Feb. 11 in its Morbidity and Mortality Weekly Report.*
In addition, many high school students who use e-cigarettes use them often; 28% reported using the products at least 20 times in the past 28 days, up from 20% in 2017.
“Any use of any tobacco product is unsafe for teens,” Anne Schuchat, MD, principal deputy director of the CDC, said in a teleconference to present the findings. Nicotine is highly addictive and can harm brain development in youth, including capacity for learning, memory, and attention, she said.
The rise in e-cigarette use corresponds with the rise in marketing and availability of e-cigarette devices such as JUUL, which dispense nicotine via liquid refill pods available in flavors including strawberry and cotton candy, said Brian King, MPH, PhD, deputy director for research translation at the CDC’s Office on Smoking and Health.
“The advertising will lead a horse to water, the flavors will make them drink, and the nicotine will keep them coming back for more,” said Dr. King.
Approximately 27.1% of high school students and 7.2% of middle school students used a tobacco product in 2018, a significant increase from 2017 data, and with a major increase in e-cigarette use.
No change was noted in the use of other tobacco products, including cigarettes, from 2017 to 2018, according to the report. However, conventional cigarettes remained the most common companion product to e-cigarettes for youth who use two or more tobacco products (two in five high school students and one in three middle school students in 2018). From a demographic standpoint, e-cigarette use was highest among males, whites, and high school students.
Tobacco use in teens is trending in the direction of wiping out the progress made in recent years to reduce exposure to youths. The report noted, “The prevalence of e-cigarette use by U.S. high school students had peaked in 2015 before declining by 29% during 2015-2016 (from 16% to 11.3%); this decline was the first ever recorded for e-cigarette use among youths in the NYTS since monitoring began, and it was subsequently sustained during 2016-2017). However, current e-cigarette use increased by 77.8% among high school students and 48.5% among middle school students during 2017-2018, erasing the progress in reducing e-cigarette use, as well as any tobacco product use, that had occurred in prior years.”
The CDC and the Food and Drug Administration are taking action to curb the rise in e-cigarette use in youth in particular by seeking regulations to make the products less accessible, raising prices, and banning most flavorings, said Dr. Schuchat.
“We have targeted companies engaged in kid friendly marketing,” said Mitch Zeller, JD, director of the Center for Tobacco Products for the FDA.
In a statement published simultaneously with the Vital Signs study, FDA Commissioner Scott Gottlieb, MD, emphasized the link between e-cigarette use in teens and the potential for future tobacco use. “The kids using e-cigarettes are children who rejected conventional cigarettes, but don’t see the same stigma associated with the use of e-cigarettes. But now, having become exposed to nicotine through e-cigs, they will be more likely to smoke.” Dr. Gottlieb declared, “I will not allow a generation of children to become addicted to nicotine through e-cigarettes. We must stop the trends of youth e-cigarette use from continuing to build and will take whatever action is necessary to ensure these kids don’t become future smokers.” He reviewed steps taken in the past year by the FDA to counter tobacco use in teens but he warned of future actions that may need to be taken: “If these youth use trends continue, we’ll be forced to consider regulatory steps that could constrain or even foreclose the opportunities for currently addicted adult smokers to have the same level of access to these products that they now enjoy. I recognize that such a move could come with significant impacts to adult smokers.”
In the meantime, however, parents, teachers, community leaders, and health care providers are on the front lines and can make a difference in protecting youth and curbing nicotine use, Dr. King said.
One of the most important things clinicians can do is to ask young patients specifically about e-cigarette use, he emphasized. Learn and use the terminology the kids are using; ask, “Do you use JUUL?” If they are using these products, “make sure they know they are dangerous,” and can harm the developing brain, he said.
Although there are no currently approved medications to treat nicotine addiction in youth, research suggests that behavioral counseling, as well as reinforcement of the danger of nicotine from parents and other people of influence, can help, Dr. King said.
The Vital Signs report is based on data from the 2011-2018 National Youth Tobacco Survey, which assesses current use of cigarettes, cigars, smokeless tobacco, e-cigarettes, hookahs, pipe tobacco, and bidis among a nationally representative sample of middle and high school students in the United States. The findings were analyzed by the CDC, FDA, and the National Cancer Institute.
SOURCE: Gentzke AS et al. MMWR 2019 Feb 11. doi: 10.15585/mmwr.mm6806e1.
*Correction 2/13/2019 An earlier version of this article misstated the number of students using e-cigarettes as a proportion of all teen tobacco users.
A significant increase during 2017-2018 in e-cigarette use among U.S. youths has erased recent progress in reducing overall tobacco product use in this age group, a study from the Centers for Disease Control and Prevention has found.
E-cigarettes are driving the trend. About 4 million high school students in the United States reported using any tobacco product in the last 30 days, and 3 million of them reported using e-cigarettes, according to a Vital Signs document published by the CDC on Feb. 11 in its Morbidity and Mortality Weekly Report.*
In addition, many high school students who use e-cigarettes use them often; 28% reported using the products at least 20 times in the past 28 days, up from 20% in 2017.
“Any use of any tobacco product is unsafe for teens,” Anne Schuchat, MD, principal deputy director of the CDC, said in a teleconference to present the findings. Nicotine is highly addictive and can harm brain development in youth, including capacity for learning, memory, and attention, she said.
The rise in e-cigarette use corresponds with the rise in marketing and availability of e-cigarette devices such as JUUL, which dispense nicotine via liquid refill pods available in flavors including strawberry and cotton candy, said Brian King, MPH, PhD, deputy director for research translation at the CDC’s Office on Smoking and Health.
“The advertising will lead a horse to water, the flavors will make them drink, and the nicotine will keep them coming back for more,” said Dr. King.
Approximately 27.1% of high school students and 7.2% of middle school students used a tobacco product in 2018, a significant increase from 2017 data, and with a major increase in e-cigarette use.
No change was noted in the use of other tobacco products, including cigarettes, from 2017 to 2018, according to the report. However, conventional cigarettes remained the most common companion product to e-cigarettes for youth who use two or more tobacco products (two in five high school students and one in three middle school students in 2018). From a demographic standpoint, e-cigarette use was highest among males, whites, and high school students.
Tobacco use in teens is trending in the direction of wiping out the progress made in recent years to reduce exposure to youths. The report noted, “The prevalence of e-cigarette use by U.S. high school students had peaked in 2015 before declining by 29% during 2015-2016 (from 16% to 11.3%); this decline was the first ever recorded for e-cigarette use among youths in the NYTS since monitoring began, and it was subsequently sustained during 2016-2017). However, current e-cigarette use increased by 77.8% among high school students and 48.5% among middle school students during 2017-2018, erasing the progress in reducing e-cigarette use, as well as any tobacco product use, that had occurred in prior years.”
The CDC and the Food and Drug Administration are taking action to curb the rise in e-cigarette use in youth in particular by seeking regulations to make the products less accessible, raising prices, and banning most flavorings, said Dr. Schuchat.
“We have targeted companies engaged in kid friendly marketing,” said Mitch Zeller, JD, director of the Center for Tobacco Products for the FDA.
In a statement published simultaneously with the Vital Signs study, FDA Commissioner Scott Gottlieb, MD, emphasized the link between e-cigarette use in teens and the potential for future tobacco use. “The kids using e-cigarettes are children who rejected conventional cigarettes, but don’t see the same stigma associated with the use of e-cigarettes. But now, having become exposed to nicotine through e-cigs, they will be more likely to smoke.” Dr. Gottlieb declared, “I will not allow a generation of children to become addicted to nicotine through e-cigarettes. We must stop the trends of youth e-cigarette use from continuing to build and will take whatever action is necessary to ensure these kids don’t become future smokers.” He reviewed steps taken in the past year by the FDA to counter tobacco use in teens but he warned of future actions that may need to be taken: “If these youth use trends continue, we’ll be forced to consider regulatory steps that could constrain or even foreclose the opportunities for currently addicted adult smokers to have the same level of access to these products that they now enjoy. I recognize that such a move could come with significant impacts to adult smokers.”
In the meantime, however, parents, teachers, community leaders, and health care providers are on the front lines and can make a difference in protecting youth and curbing nicotine use, Dr. King said.
One of the most important things clinicians can do is to ask young patients specifically about e-cigarette use, he emphasized. Learn and use the terminology the kids are using; ask, “Do you use JUUL?” If they are using these products, “make sure they know they are dangerous,” and can harm the developing brain, he said.
Although there are no currently approved medications to treat nicotine addiction in youth, research suggests that behavioral counseling, as well as reinforcement of the danger of nicotine from parents and other people of influence, can help, Dr. King said.
The Vital Signs report is based on data from the 2011-2018 National Youth Tobacco Survey, which assesses current use of cigarettes, cigars, smokeless tobacco, e-cigarettes, hookahs, pipe tobacco, and bidis among a nationally representative sample of middle and high school students in the United States. The findings were analyzed by the CDC, FDA, and the National Cancer Institute.
SOURCE: Gentzke AS et al. MMWR 2019 Feb 11. doi: 10.15585/mmwr.mm6806e1.
*Correction 2/13/2019 An earlier version of this article misstated the number of students using e-cigarettes as a proportion of all teen tobacco users.
FROM CDC VITAL SIGNS REPORT
The Underrecognized Risk for Drug Overdose Deaths
The numbers are stunning: 1,643% increase in rates of deaths involving synthetic opioids. A 915% increase for heroin, 830% for benzodiazepines. Even more stunning: Those are the increases only in overdose death rates for women aged 30 to 64 years.
According to CDC data, between 1999 and 2010, the largest percentage change in the rates of overall drug overdose deaths was among women aged between 45 and 64 years. But that research did not account for trends in specific drugs or consider changes in age group distributions, say researchers from the CDC’s National Center for Injury Prevention and Control.
They examined overdose death rates among women aged 30 to 64 years between 1999 and 2017. The unadjusted death rate jumped 260%, from 4,314 deaths to 18,110 deaths. Among women aged 55 to 59 years, the number of deaths involving antidepressants increased approximately 300%; among women aged 60 to 64 years, nearly 400%. The crude rate of deaths involving prescription opioids skyrocketed > 1,000%.
The drug epidemic is “evolving,” the researchers note. In 1999, overdose death rates were highest among women aged 40 to 44 years. In 2017, they were highest among women aged 50 to 54 years. And as demographics shift, prevention programs need to shift as well. As women age, the researchers say, individual experiences can change the type of substance used or misused and in the experiences of pain that might result in an opioid prescription.
The researchers note that “substantial work” has focused on informing women of childbearing age about the risks and benefits of certain drugs. The current analysis demonstrates “the remaining need” to consider middle-aged women who are at risk.
Targeted efforts are needed, and the researchers suggest interventions: Medicaid and other health insurance programs can review records of controlled substance prescribing. States and local communities can expand capacity of drug use disorder treatments and links to care, particularly adding “gender-responsive” substance use disorder treatment centers.
A “multifaceted approach involving the full spectrum of care services is likely necessary,” the researchers say. Health care practitioners who treat women for pain, depression, or anxiety can discuss treatment options that consider the unique biopsychosocial needs of women.
Health care practitioners also can consider implementing the CDC Guideline for Prescribing Opioids for Chronic Pain, which says “Opioids are not first-line or routine therapy for chronic pain.” The guideline also says before starting and periodically during opioid therapy, clinicians should discuss with patients the “known risks and realistic benefits of opioid therapy.” In other words, listen to the women and prescribe carefully.
The numbers are stunning: 1,643% increase in rates of deaths involving synthetic opioids. A 915% increase for heroin, 830% for benzodiazepines. Even more stunning: Those are the increases only in overdose death rates for women aged 30 to 64 years.
According to CDC data, between 1999 and 2010, the largest percentage change in the rates of overall drug overdose deaths was among women aged between 45 and 64 years. But that research did not account for trends in specific drugs or consider changes in age group distributions, say researchers from the CDC’s National Center for Injury Prevention and Control.
They examined overdose death rates among women aged 30 to 64 years between 1999 and 2017. The unadjusted death rate jumped 260%, from 4,314 deaths to 18,110 deaths. Among women aged 55 to 59 years, the number of deaths involving antidepressants increased approximately 300%; among women aged 60 to 64 years, nearly 400%. The crude rate of deaths involving prescription opioids skyrocketed > 1,000%.
The drug epidemic is “evolving,” the researchers note. In 1999, overdose death rates were highest among women aged 40 to 44 years. In 2017, they were highest among women aged 50 to 54 years. And as demographics shift, prevention programs need to shift as well. As women age, the researchers say, individual experiences can change the type of substance used or misused and in the experiences of pain that might result in an opioid prescription.
The researchers note that “substantial work” has focused on informing women of childbearing age about the risks and benefits of certain drugs. The current analysis demonstrates “the remaining need” to consider middle-aged women who are at risk.
Targeted efforts are needed, and the researchers suggest interventions: Medicaid and other health insurance programs can review records of controlled substance prescribing. States and local communities can expand capacity of drug use disorder treatments and links to care, particularly adding “gender-responsive” substance use disorder treatment centers.
A “multifaceted approach involving the full spectrum of care services is likely necessary,” the researchers say. Health care practitioners who treat women for pain, depression, or anxiety can discuss treatment options that consider the unique biopsychosocial needs of women.
Health care practitioners also can consider implementing the CDC Guideline for Prescribing Opioids for Chronic Pain, which says “Opioids are not first-line or routine therapy for chronic pain.” The guideline also says before starting and periodically during opioid therapy, clinicians should discuss with patients the “known risks and realistic benefits of opioid therapy.” In other words, listen to the women and prescribe carefully.
The numbers are stunning: 1,643% increase in rates of deaths involving synthetic opioids. A 915% increase for heroin, 830% for benzodiazepines. Even more stunning: Those are the increases only in overdose death rates for women aged 30 to 64 years.
According to CDC data, between 1999 and 2010, the largest percentage change in the rates of overall drug overdose deaths was among women aged between 45 and 64 years. But that research did not account for trends in specific drugs or consider changes in age group distributions, say researchers from the CDC’s National Center for Injury Prevention and Control.
They examined overdose death rates among women aged 30 to 64 years between 1999 and 2017. The unadjusted death rate jumped 260%, from 4,314 deaths to 18,110 deaths. Among women aged 55 to 59 years, the number of deaths involving antidepressants increased approximately 300%; among women aged 60 to 64 years, nearly 400%. The crude rate of deaths involving prescription opioids skyrocketed > 1,000%.
The drug epidemic is “evolving,” the researchers note. In 1999, overdose death rates were highest among women aged 40 to 44 years. In 2017, they were highest among women aged 50 to 54 years. And as demographics shift, prevention programs need to shift as well. As women age, the researchers say, individual experiences can change the type of substance used or misused and in the experiences of pain that might result in an opioid prescription.
The researchers note that “substantial work” has focused on informing women of childbearing age about the risks and benefits of certain drugs. The current analysis demonstrates “the remaining need” to consider middle-aged women who are at risk.
Targeted efforts are needed, and the researchers suggest interventions: Medicaid and other health insurance programs can review records of controlled substance prescribing. States and local communities can expand capacity of drug use disorder treatments and links to care, particularly adding “gender-responsive” substance use disorder treatment centers.
A “multifaceted approach involving the full spectrum of care services is likely necessary,” the researchers say. Health care practitioners who treat women for pain, depression, or anxiety can discuss treatment options that consider the unique biopsychosocial needs of women.
Health care practitioners also can consider implementing the CDC Guideline for Prescribing Opioids for Chronic Pain, which says “Opioids are not first-line or routine therapy for chronic pain.” The guideline also says before starting and periodically during opioid therapy, clinicians should discuss with patients the “known risks and realistic benefits of opioid therapy.” In other words, listen to the women and prescribe carefully.
Loan Repayment Plan for Substance Use Clinicians
The opioid emergency claims > 130 lives every day, says Health Resources and Services Administration (HRSA) Administrator George Sigounas, MS, PhD. By strengthening the health workforce, HRSA hopes to ensure that there are enough clinicians to cope with the growing epidemic.
That is why, in December 2018, HRSA launched a program that Sigounas says is “critical to HHS’ response to the opioid crisis.” The new National Health Service Corps (NHSC) Substance Use Disorder (SUD) Workforce Loan Repayment Program (LRP) will provide eligible health care clinicians with student loan repayment assistance in exchange for service in underserved communities.
A clinician may be awarded up to $75,000 for 3 years of full-time service at an NHSC-approved SUD site and $37,500 for part-time. Eligible providers use evidence-based treatment models to treat SUDs and must be trained and licensed to provide SUD treatment at NHSC-approved facilities. Qualification criteria are available at https://nhsc.hrsa.gov/loan-repayment/nhsc-sud-workforce-loan-repayment-program.html.
Clinicians also can apply to the NHSC Loan Repayment Program for primary care, dental, and behavioral health professionals. If accepted, they may receive up to $50,000 for 2 years of full-time service, $25,000 for part-time.
Military reservists also are eligible to participate in either the NHSC LRP or the NHSC Students to Service Loan Repayment Program. (Military training or service will not satisfy the NHSC service commitment.) More information is available at https://nhsc.hrsa.gov/loan-repayment/military-reservists.html.
Clinicians can only apply for 1 program. Sigounas says, “I am grateful to the clinicians who will apply and are looking to make a positive impact on patients, caregivers, and hard-hit communities throughout the country.”
The opioid emergency claims > 130 lives every day, says Health Resources and Services Administration (HRSA) Administrator George Sigounas, MS, PhD. By strengthening the health workforce, HRSA hopes to ensure that there are enough clinicians to cope with the growing epidemic.
That is why, in December 2018, HRSA launched a program that Sigounas says is “critical to HHS’ response to the opioid crisis.” The new National Health Service Corps (NHSC) Substance Use Disorder (SUD) Workforce Loan Repayment Program (LRP) will provide eligible health care clinicians with student loan repayment assistance in exchange for service in underserved communities.
A clinician may be awarded up to $75,000 for 3 years of full-time service at an NHSC-approved SUD site and $37,500 for part-time. Eligible providers use evidence-based treatment models to treat SUDs and must be trained and licensed to provide SUD treatment at NHSC-approved facilities. Qualification criteria are available at https://nhsc.hrsa.gov/loan-repayment/nhsc-sud-workforce-loan-repayment-program.html.
Clinicians also can apply to the NHSC Loan Repayment Program for primary care, dental, and behavioral health professionals. If accepted, they may receive up to $50,000 for 2 years of full-time service, $25,000 for part-time.
Military reservists also are eligible to participate in either the NHSC LRP or the NHSC Students to Service Loan Repayment Program. (Military training or service will not satisfy the NHSC service commitment.) More information is available at https://nhsc.hrsa.gov/loan-repayment/military-reservists.html.
Clinicians can only apply for 1 program. Sigounas says, “I am grateful to the clinicians who will apply and are looking to make a positive impact on patients, caregivers, and hard-hit communities throughout the country.”
The opioid emergency claims > 130 lives every day, says Health Resources and Services Administration (HRSA) Administrator George Sigounas, MS, PhD. By strengthening the health workforce, HRSA hopes to ensure that there are enough clinicians to cope with the growing epidemic.
That is why, in December 2018, HRSA launched a program that Sigounas says is “critical to HHS’ response to the opioid crisis.” The new National Health Service Corps (NHSC) Substance Use Disorder (SUD) Workforce Loan Repayment Program (LRP) will provide eligible health care clinicians with student loan repayment assistance in exchange for service in underserved communities.
A clinician may be awarded up to $75,000 for 3 years of full-time service at an NHSC-approved SUD site and $37,500 for part-time. Eligible providers use evidence-based treatment models to treat SUDs and must be trained and licensed to provide SUD treatment at NHSC-approved facilities. Qualification criteria are available at https://nhsc.hrsa.gov/loan-repayment/nhsc-sud-workforce-loan-repayment-program.html.
Clinicians also can apply to the NHSC Loan Repayment Program for primary care, dental, and behavioral health professionals. If accepted, they may receive up to $50,000 for 2 years of full-time service, $25,000 for part-time.
Military reservists also are eligible to participate in either the NHSC LRP or the NHSC Students to Service Loan Repayment Program. (Military training or service will not satisfy the NHSC service commitment.) More information is available at https://nhsc.hrsa.gov/loan-repayment/military-reservists.html.
Clinicians can only apply for 1 program. Sigounas says, “I am grateful to the clinicians who will apply and are looking to make a positive impact on patients, caregivers, and hard-hit communities throughout the country.”
Legal marijuana may complicate SUD treatment in adolescents
BROOKLYN, N.Y. – The legalization of marijuana almost certainly will complicate the treatment of substance use disorder in adolescents, particularly when SUD occurs as a comorbidity of bipolar disorder or other psychiatric diseases, according to an expert review at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
The full effects of marijuana legalization on SUD have not yet been comprehensively studied in children or adults, but the consequences of easier access, diminished stigma, and potential for a diminished sense of harm are widely considered to be an important obstacle to successful therapy in children, said Timothy E. Wilens, MD, chief of the division of child and adolescent psychiatry at Massachusetts General Hospital, Boston.
Comorbid substance use in children with mood disorders or ADHD has long been understood as a form of self-medication. However, use of marijuana, alcohol, or other mood-altering drugs also are known to interfere with treatment, Dr. Wilens said.
The problem is common among adults as well, but adolescents pose a greater challenge.
“Youths are more vulnerable to developing a substance use disorder because reward pathways develop before control pathways,” Dr. Wilens said. He cited data showing that about half of individuals who develop SUD, many of whom have other psychiatric diagnoses, do so by age 18 years, and 80% do so by age 26 years.
“Substance use disorder is a pediatric issue,” he emphasized.
The problem with legalization of marijuana is that adolescents are likely to conclude that what is safe for adults is safe for children. Citing a study that associated increased use of marijuana with reduced perception of harm (and the opposite), Dr. Wilens predicted that adolescents with comorbid SUD would resist treatment.
Because of those concerns, Massachusetts General Hospital, which is based in a state where recreational marijuana use is permitted, has issued a position statement. The statement endorses the study of marijuana for benefit and for harm but expresses specific concern about “the recreational use of marijuana at any age because of the potential downstream effects on children.”
Dr. Wilens expressed particular concern about parental use of marijuana in front of children because of the implication that it is safe and acceptable. For children at risk of comorbid substance use because of a mood disorder, he cautioned parents against even concealed use of marijuana because of the low likelihood that it will go unnoticed.
“Substance use disorders are associated with a more pernicious and longer course in adolescents than children,” said Dr. Wilens, paraphrasing one of the bullet points from the Massachusetts General position statement, which outlines the potential harms for children. Another of the bullet points maintains, “there are known structural and functional brain changes” that have been documented when marijuana use begins in childhood.
Citing a correlation between parental and adolescent marijuana use, He noted that a very high proportion of adolescents with or without mood disorders experiment with marijuana at some point in high school, so there already is resistance to a characterization that it is harmful.
A realistic approach is therefore required in helping adolescents with comorbid substance use to curb this form of self-medication. It is essential to set priorities, he said, when treating adolescents with SUD and comorbid psychiatric disorders. “Don’t even think about treating substance use disorder until you treat the bipolar disease,” he said.
As the symptoms are relieved, the need for self-medication is likely to diminish, but Dr. Wilens cautioned against being too rigid when helping adolescents move away from marijuana and alcohol. He believes a zero tolerance approach can be counterproductive. Rather, he advocates a “harm reduction” approach in which adolescents agree to reasonable reductions, like avoiding marijuana during the week, while they eliminate dependence.
In an overview of pharmacotherapy to reduce cravings for drugs, he cited evidence, as well as personal experience, that over-the-counter N-acetylcysteine can be a useful tool. However, adolescents in particular should be warned about the pungent smell, which has been a barrier to adherence. He also suggested that psychotherapy, with or without pharmacotherapy, is helpful.
Treatment of comorbid SUD is a critical part of achieving control of accompanying psychiatric diseases, but this task might be complicated by legalized recreational marijuana, Dr. Wilens concluded. He encouraged clinicians to recognize that challenge.
Dr. Wilens reported financial relationships with Ironshore Pharmaceuticals, Janssen, KemPharm, and Otsuka Pharmaceutical.
BROOKLYN, N.Y. – The legalization of marijuana almost certainly will complicate the treatment of substance use disorder in adolescents, particularly when SUD occurs as a comorbidity of bipolar disorder or other psychiatric diseases, according to an expert review at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
The full effects of marijuana legalization on SUD have not yet been comprehensively studied in children or adults, but the consequences of easier access, diminished stigma, and potential for a diminished sense of harm are widely considered to be an important obstacle to successful therapy in children, said Timothy E. Wilens, MD, chief of the division of child and adolescent psychiatry at Massachusetts General Hospital, Boston.
Comorbid substance use in children with mood disorders or ADHD has long been understood as a form of self-medication. However, use of marijuana, alcohol, or other mood-altering drugs also are known to interfere with treatment, Dr. Wilens said.
The problem is common among adults as well, but adolescents pose a greater challenge.
“Youths are more vulnerable to developing a substance use disorder because reward pathways develop before control pathways,” Dr. Wilens said. He cited data showing that about half of individuals who develop SUD, many of whom have other psychiatric diagnoses, do so by age 18 years, and 80% do so by age 26 years.
“Substance use disorder is a pediatric issue,” he emphasized.
The problem with legalization of marijuana is that adolescents are likely to conclude that what is safe for adults is safe for children. Citing a study that associated increased use of marijuana with reduced perception of harm (and the opposite), Dr. Wilens predicted that adolescents with comorbid SUD would resist treatment.
Because of those concerns, Massachusetts General Hospital, which is based in a state where recreational marijuana use is permitted, has issued a position statement. The statement endorses the study of marijuana for benefit and for harm but expresses specific concern about “the recreational use of marijuana at any age because of the potential downstream effects on children.”
Dr. Wilens expressed particular concern about parental use of marijuana in front of children because of the implication that it is safe and acceptable. For children at risk of comorbid substance use because of a mood disorder, he cautioned parents against even concealed use of marijuana because of the low likelihood that it will go unnoticed.
“Substance use disorders are associated with a more pernicious and longer course in adolescents than children,” said Dr. Wilens, paraphrasing one of the bullet points from the Massachusetts General position statement, which outlines the potential harms for children. Another of the bullet points maintains, “there are known structural and functional brain changes” that have been documented when marijuana use begins in childhood.
Citing a correlation between parental and adolescent marijuana use, He noted that a very high proportion of adolescents with or without mood disorders experiment with marijuana at some point in high school, so there already is resistance to a characterization that it is harmful.
A realistic approach is therefore required in helping adolescents with comorbid substance use to curb this form of self-medication. It is essential to set priorities, he said, when treating adolescents with SUD and comorbid psychiatric disorders. “Don’t even think about treating substance use disorder until you treat the bipolar disease,” he said.
As the symptoms are relieved, the need for self-medication is likely to diminish, but Dr. Wilens cautioned against being too rigid when helping adolescents move away from marijuana and alcohol. He believes a zero tolerance approach can be counterproductive. Rather, he advocates a “harm reduction” approach in which adolescents agree to reasonable reductions, like avoiding marijuana during the week, while they eliminate dependence.
In an overview of pharmacotherapy to reduce cravings for drugs, he cited evidence, as well as personal experience, that over-the-counter N-acetylcysteine can be a useful tool. However, adolescents in particular should be warned about the pungent smell, which has been a barrier to adherence. He also suggested that psychotherapy, with or without pharmacotherapy, is helpful.
Treatment of comorbid SUD is a critical part of achieving control of accompanying psychiatric diseases, but this task might be complicated by legalized recreational marijuana, Dr. Wilens concluded. He encouraged clinicians to recognize that challenge.
Dr. Wilens reported financial relationships with Ironshore Pharmaceuticals, Janssen, KemPharm, and Otsuka Pharmaceutical.
BROOKLYN, N.Y. – The legalization of marijuana almost certainly will complicate the treatment of substance use disorder in adolescents, particularly when SUD occurs as a comorbidity of bipolar disorder or other psychiatric diseases, according to an expert review at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
The full effects of marijuana legalization on SUD have not yet been comprehensively studied in children or adults, but the consequences of easier access, diminished stigma, and potential for a diminished sense of harm are widely considered to be an important obstacle to successful therapy in children, said Timothy E. Wilens, MD, chief of the division of child and adolescent psychiatry at Massachusetts General Hospital, Boston.
Comorbid substance use in children with mood disorders or ADHD has long been understood as a form of self-medication. However, use of marijuana, alcohol, or other mood-altering drugs also are known to interfere with treatment, Dr. Wilens said.
The problem is common among adults as well, but adolescents pose a greater challenge.
“Youths are more vulnerable to developing a substance use disorder because reward pathways develop before control pathways,” Dr. Wilens said. He cited data showing that about half of individuals who develop SUD, many of whom have other psychiatric diagnoses, do so by age 18 years, and 80% do so by age 26 years.
“Substance use disorder is a pediatric issue,” he emphasized.
The problem with legalization of marijuana is that adolescents are likely to conclude that what is safe for adults is safe for children. Citing a study that associated increased use of marijuana with reduced perception of harm (and the opposite), Dr. Wilens predicted that adolescents with comorbid SUD would resist treatment.
Because of those concerns, Massachusetts General Hospital, which is based in a state where recreational marijuana use is permitted, has issued a position statement. The statement endorses the study of marijuana for benefit and for harm but expresses specific concern about “the recreational use of marijuana at any age because of the potential downstream effects on children.”
Dr. Wilens expressed particular concern about parental use of marijuana in front of children because of the implication that it is safe and acceptable. For children at risk of comorbid substance use because of a mood disorder, he cautioned parents against even concealed use of marijuana because of the low likelihood that it will go unnoticed.
“Substance use disorders are associated with a more pernicious and longer course in adolescents than children,” said Dr. Wilens, paraphrasing one of the bullet points from the Massachusetts General position statement, which outlines the potential harms for children. Another of the bullet points maintains, “there are known structural and functional brain changes” that have been documented when marijuana use begins in childhood.
Citing a correlation between parental and adolescent marijuana use, He noted that a very high proportion of adolescents with or without mood disorders experiment with marijuana at some point in high school, so there already is resistance to a characterization that it is harmful.
A realistic approach is therefore required in helping adolescents with comorbid substance use to curb this form of self-medication. It is essential to set priorities, he said, when treating adolescents with SUD and comorbid psychiatric disorders. “Don’t even think about treating substance use disorder until you treat the bipolar disease,” he said.
As the symptoms are relieved, the need for self-medication is likely to diminish, but Dr. Wilens cautioned against being too rigid when helping adolescents move away from marijuana and alcohol. He believes a zero tolerance approach can be counterproductive. Rather, he advocates a “harm reduction” approach in which adolescents agree to reasonable reductions, like avoiding marijuana during the week, while they eliminate dependence.
In an overview of pharmacotherapy to reduce cravings for drugs, he cited evidence, as well as personal experience, that over-the-counter N-acetylcysteine can be a useful tool. However, adolescents in particular should be warned about the pungent smell, which has been a barrier to adherence. He also suggested that psychotherapy, with or without pharmacotherapy, is helpful.
Treatment of comorbid SUD is a critical part of achieving control of accompanying psychiatric diseases, but this task might be complicated by legalized recreational marijuana, Dr. Wilens concluded. He encouraged clinicians to recognize that challenge.
Dr. Wilens reported financial relationships with Ironshore Pharmaceuticals, Janssen, KemPharm, and Otsuka Pharmaceutical.
EXPERT ANALYSIS FROM THE PSYCHOPHARMACOLOGY UPDATE INSTITUTE