Buprenorphine Use In the US

The First Three Years of Buprenorphine in the United States: Experience to Date and Future Directions.

Review Article, Journal of Addiction Medicine. 1(2):62-67, June 2007. Fiellin, David A. MD

Abstract: Buprenorphine, primarily as the buprenorphine/naloxone combination, has been available in the United States for office and specialty treatment program-based care since 2003. The existing evidence, collected primarily from federal sources, indicates that access to this type of treatment has expanded, that more than 50% of the 12,000 physicians able to provide this care are not addiction specialists, that buprenorphine diversion is low, that physician scrutiny by federal agents is infrequent, and among those receiving treatment patient acceptance is high. Implementation has been slowed because of physician training and support needs, reimbursement, and limits on the number of patients each physician can treat. As a result there are geographic variations in access and unmet treatment needs. The United States Congress has moved twice to loosen numerical limitations, now allowing each physician to treat up to 100 patients. Future research and evaluation are needed to ensure that opioid-dependent patients receive optimal care with buprenorphine.

(C) 2007 American Society of Addiction Medicine

Buprenorphine: The Basic Pharmacology Revisited.

Invited Review
Journal of Addiction Medicine. 1(2):68-72, June 2007.
Cowan, Alan PhD

Abstract:
The historical background leading to the current use of buprenorphine as an analgesic and its role in the management of opioid dependence is summarized. The popular description of buprenorphine as a "partial agonist" is discussed in relation to efficacy in animal models of antinociception and clinical analgesia. The latest information on the respiratory depressant effects of buprenorphine and its N-dealkylated metabolite (norbuprenorphine) is presented. New data on the buprenorphine withdrawal syndrome in rats are described.

(C) 2007 American Society of Addiction Medicine

Is Compulsive Gambling an Addiction?

AMA Won't Call Compulsive Gaming 'Addictive'
June 25, 2007


There's not enough evidence to suggest that compulsive video-game playing rises to the level of addiction as with alcohol or other drugs, according to the American Medical Association (AMA).

Reuters reported June 24 that an AMA panel dropped a proposal to include video game addiction in the American Diagnostic and Statistical Manual of Mental Disorders (DSM).

"There is nothing here to suggest that this is a complex physiological disease state akin to alcoholism or other substance abuse disorders, and it doesn't get to have the word addiction attached to it," said Stuart Gitlow of the American Society of Addiction Medicine and Mt. Sinai School of Medicine in New York.

The proposal was debated at the recent AMA annual meeting in Chicago. The study panel recommended that the issue of video-game addiction be revisited when the next revision of the DSM is due, in five years.

Some doctors argued strongly for inclusion of video-game addiction. "Working with this problem is no different than working with alcoholic patients. The same denial, the same rationalization, the same inability to give it up," said Thomas Allen of the Osler Medical Center in Towson, Md.

FSAM Resolutions Gain Support

Dear Friends and Colleagues:
GOOD NEWS!!!!!
I presented the FSAM to the South Florida Caucus, representing an influential and sizeable voting block of ~50 delegates .
All resolution were adopted and will be supported by the three largest county medical societies in Florida (Dade, Broward, Palm Beach).
Now we have to continue the political battle at the state medical society meeting in Miami in August.
I will attend the AMA Annual meeting in Chicago this weekend and (among many other issues) will lobby support for the ABAM (American Board of Addiction Medicine) .
As of tomorrow our resolutions will be part of the FMA Delegates handbook and listed as sponsored by FSAM, Dade, Broward and Palm Beach Medical Societies. Stacy is trying to gain the support of the Orange County Medical Society.

Yours
Bernd

PS: Attached you find some more information about my book, which was featured today on the frontpage of the Miami Herald http://www.miamiherald.com/460/story/144059.html .

Web Site: www.agermanlife.com

UDDL Repeal In Florida

Dear Friends and Colleagues;
Attached some background info regarding the UDDL status in Florida:
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Section 627.629,Florida Statutes (2000), permits an insurance company to include the following exclusion in a health insurance contract "Intoxicants and Narcotics: The insurer will not be liable for any loss resulting from the insured being drunk or under the influence of any narcotic unless taken on the advice of a physician."A person is "drunk" when operating a motor vehicle if he or she has a blood alcohol level of .08 gram per alcohol per 100 milliliters of blood. See § 316.193, Fla. Stat. (2000). Even though driving under the influence is a crime in Florida, there currently is no statutory authorization for an alcohol exclusion in a Florida No-fault Automobile Insurance PIP policy. See § 627.736(2), Fla. Stat. (2000). When the no-fault laws were first enacted, the legislature did permit an alcohol exclusion in a PIP policy if the circumstances involved a conviction for DUI. See ch. 71-252, § 7, Laws of Fla. See also Travelers Indem. Co. of Am. v. McInroy, 342 So. 2d 842 (Fla. 1st DCA 1977). Experience with that exclusion caused the legislature to withdraw its authorization in 1982. See ch. 82-243, § 554, Laws of Fla. Unfortunately, a Florida Supreme Court decision from 2001 is blocking the UDDL repeal:
"CONCLUSION: Ms. Steck had a blood alcohol level more than three times the legal limit for driving while intoxicated when she walked into Dale Mabry Highway, a major Tampa thoroughfare, and was struck by a car. Any reasonable, disinterested third party would agree that her injuries suffered in the accident resulted from her drunkenness.
The polestar for interpreting statutes is legislative intent. Statev. Webb,398 So.2d 820, 824 (Fla. 1981). The Legislature permits health insurers to exclude losses,which result from the commission of felonies or engaging in an illegal occupation. Can anyone reasonably believe that when Section 627.629 was enacted to permit exclusions“for any loss resulting from the insured being drunk,” the Legislature intended for this
exclusion to be limited only to biological effects upon the body from the use of intoxicants?
This Court should follow Harris, should specifically reverse Mason II, and should hold that the drunkenness exclusion authorized by Section 627.629, Florida Statutes and included in Ms. Steck’s policy excludes coverage for all expenses caused, either directly or indirectly, by her walking into the path of oncoming traffic while drunk. The summary judgment on liability in favor of Ms. Steck should be reversed, and this case should be remanded with directions that summary judgment be entered in favor of BCBSF in regard to all expenses incurred to treat injuries sustained
in the June 29, 1997 accident.
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Looking forward to your comments.
Bernd

Is Alcohol Cardioprotective?

Drink to your health - is alcohol really cardioprotective?

In the April 2007 edition of the New Zealand Family Physician is a clinical review Drink to your health is alcohol really cardioprotective? by Graham Gulbransen and Ross McCormick which begins: A convenient and widely held belief is that a few drinks are good for the heart. This view is based largely on epidemiological studies similar to those that mistakenly showed that menopausal hormone replacement therapy (HRT) was cardioprotective. Because of confounding and misclassification, non-randomised uncontrolled studies can never confirm such beliefs. This article reviews the medical literature on alcohol and coronary heart disease (CHD), looking at evidence for and against cardioprotection.

The review starts with an introduction:
"In 1926 Raymond Pearl first described the J-shaped alcohol-mortality curve: moderately alcoholised fowls had the lowest mortality, followed by those not exposed, with heavily alcoholised fowls having the highest mortality!

"In the past 30 years more than 100 epidemiological studies have suggested that moderate alcohol consumption (in humans!) is cardioprotective. In New Zealand we follow the Alcohol Advisory Council of New Zealand guidelines that define safer or moderate drinking as up to 20 grams of alcohol daily for women and 30 grams for men. However, a 1987 Lancet editorial, Dying for a Drink urged caution, The higher mortality among abstainers has not been fully explained but may well be a spurious finding in a group of men who may be at higher risk for other reasons The U [J] shaped curve has been interpreted uncritically The message we should be delivering unequivocally is that alcohol is bad for health."


NZFP Volume 34 Number 2, April 2007 122-126. 2007 The Royal New Zealand College of General Practitioners
Drink to your health is alcohol really cardioprotective? Graham Gulbransen and Ross McCormick. Correspondence to Graham Gulbransen gg@woosh.co.nz

FSAM RESOLUTIONS FOR FMA MEETING

Dear Friends and Colleagues:
I seek your comments, critique and suggestions regarding both resolutions:


FLORIDA MEDICAL ASSOCIATION HOUSE OF DELEGATES


Resolution:

Introduced by: Florida Society of Addiction Medicine

Subject: Repeal of Certain Provisions of the Uniform Individual Accident and
Sickness Policy Provision Law (UPPL)


Referred to:



Whereas, in 1947, the National Association of Insurance commissioners (NAIC) adopted the UPPL (Uniform Accident and Sickness Policy Provision) as a model law. The law states that health insurers would not have to reimburse patients for costs incurred when an accident is a result of "the insured's being intoxicated or under the influence of any narcotic” unless administered on the “ advice of a physician,” thus allowing insurers to deny payment for treatment of alcohol-related injuries; and

Whereas, forty to fifty percent of injured patients treated in ERs are under the influence of alcohol or other intoxicant; and

Whereas, data from the Centers for Disease Control and Prevention indicate that emergency room physicians are significantly less likely to screen injured patients for an alcohol problem in UPPL states due to reluctance to potentially burden patients, even those drinking in a legal manner, with large medical bills caused by denial of coverage under UPPL; and

Whereas, there are over 40 studies evaluating the use of brief alcohol interventions in health care settings, including ERs and trauma centers, that document effectiveness in reducing subsequent alcohol intake, DUI's, alcohol-related traffic infractions, alcohol-related arrests, and injury-related hospital readmission;and

Whereas, denial of coverage under UPPL also has a potentially large financial impact on emergency rooms; and

Whereas, our American Medical Association support state and specialty medical societies and the public heath associations in their efforts to secure repeal of laws and state insurance codes which allow for the denial of insurance payments for the treatment of injuries sustained as a consequence of the insured person being intoxicated due to alcohol or under the influence of narcotics; therefore be it

RESOLVED, that our Florida Medical Association supports and endorses legislation intended to repeal the Uniform Individual Accident and Sickness Policy Provision Law, thereby allowing for insurance payments for the treatment of injuries sustained when the insured person is intoxicated or under the influence of narcotics.

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FLORIDA MEDICAL ASSOCIATION HOUSE OF DELEGATES


Resolution:

Introduced by: Florida Society of Addiction Medicine

Subject: Parity for Mental Health and/or Substance Use Disorders


Referred to:



Whereas, substance abuse and/or dependence , also commonly referred to as “addictions,” are components of a “brain disease,” not unlike any other brain disease such as Parkinson Disease or Depression; and

Whereas, such a brain disease can be successfully treated involving pharmacological, behavioral and psychosocial approaches; and

Whereas, most health plans do not provide equal access and coverage for mental health and addiction treatment modalities compared to other medical and surgical benefits; and

Whereas, the Florida legislature has not enacted comprehensive parity legislation which eliminates discriminatory co-payments, deductibles, and annual and lifetime caps; and

Whereas, the Florida legislature has not enacted comprehensive parity legislation that include coverage for substance use and addictive disorders; and

Whereas, our AMA reaffirmed its support for parity in treatment coverage for mental illness and substance use disorders at the 2006 Interim meeting of the AMA House of Delegates in Las Vegas; therefore be it

RESOLVED, that our Florida Medical Association supports and endorses legislation mandating that a health plan provide both equal treatment limits and financial requirements for all conditions listed in the DSM-IV, as compared to medical and surgical benefits under that plan; and be it further

RESOLVED, that any such legislation require any health plan to provide the same level of out-of-network coverage for mental health and addiction treatment as for out-of-network benefits for medical and surgical treatment.

===========================================================================

FLORIDA MEDICAL ASSOCIATION HOUSE OF DELEGATES


Resolution:

Introduced by: Florida Society of Addiction Medicine

Subject: Support of Screening and Brief Intervention Measures


Referred to:



Whereas, today there are over 20 million Americans who meet the medical definition of abuse or addiction to drugs and alcohol and over 94% of those Americans are unaware that they need help and have not sought treatment or intervention from health care professionals; and

Whereas, by encouraging health care professionals to identify at-risk populations and by early intervention programs, we can significantly reduce the abuse of alcohol and addiction to drugs among Americans; and

Whereas, substance abuse screening and intervention (SBI) programs are cost-effective and successful strategies in regard to reducing substance abuse and other health problems associated with drug use; and

Whereas, The Federal Government has established in seventeen states (including Florida) a demonstration program entitled “ Screening, Brief Intervention, Referral and Treatment”(SBIRT); and

Whereas, As of January 2007,more than 460,000 patients have been screened as part of the SBIRT demonstration program and a six month follow-up review of patients showed significant declines in substance abuse after the brief interventions; and

Whereas, since January 2007 doctors can bill Medicaid for drug and alcohol abuse screening using "CMS codes” approved by the Centers for Medicare and Medicaid Services; therefore be it

RESOLVED, that our Florida Medical Association supports the development and promotion of CME programs instructing physicians on how to conduct screening and brief intervention modalities ; and be it further

RESOLVED, that our Florida Medical Association supports any legislative efforts to mandate health plans to reimburse doctors for screening and brief intervention modalities.

Marijuana in the News

Monday, June 4, 2007


Letter To The Editor

RE: Double standards persists on marijuana 06/04/07


The article “Double standards persists on marijuana” reveals the widespread use of marijuana and suggest that this drug is less dangerous even harmless compared to other “real” drugs. This is an urban myth far from the truth! Cannabinoids, the active ingredients in Marijuana, trigger the pleasure and reward system in the brain, resulting in the repetitive use of the drug to avoid withdrawal symptoms that include irritability, anger and depressed mood. Chronic use of marijuana can lead to anxiety and panic disorder, worsened short-term memory, reduced sex drive and deceased motivation.
In animal studies chronic exposure to marijuana changed the structure and function of parts of the brain (hippocampus) in ways similar to the effects of the aging process. College students who use marijuana report significantly higher rates of motor vehicle crashes, smoking, use of alcohol and tranquilizers, use of sex as a coping mechanism, violent dreams, sleeplessness and psychiatric problems than do nonusers. Furthermore, marijuana smoke does have a significantly higher tar content than cigarettes, contains many carcinogens and, unlike most cigarettes, is smoked unfiltered. This can cause chronic lung disease, including chronic bronchitis, and lung cancer.
We should not debate marijuana’s safety anymore. Decades of research have provided overwhelming evidence to the contrary. We should ask ourselves instead, why the United States, with only 4 percent of the world's population, consumes two-thirds of the world's illegal drugs? Can we only manage our reality with an unhealthy dose of mood-altering substances? If true, how can we change that?

Bernd Wollschlaeger,MD,FAAFP, President, Florida Society of Addiction Medicine
Phone: (305) 940-8717, E-mail: info@miamihealth.com


Posted on Mon, Jun. 04, 2007
Double standard persists on marijuana
BY LYDIA MARTIN AND FRED TASKER
At a recent backyard barbecue in Miami's Upper Eastside, a group of middle-age, middle-class folks tamely sipped berry cocktails and beers. Among them: a couple of lawyers, a couple of city administrators and an arts administrator. Somewhere between the skirt steak and the apple pie, somebody lit a joint and passed it around.
Nobody blinked. Even in mainstream, white-collar settings, smoking marijuana can be commonplace and unremarkable, like having a little wine with dinner.
Once a stamp of the arty, the marginal and the counterculture, today marijuana's popularity cuts across social boundaries. Yet several high-profile marijuana arrests have recently made headlines, highlighting the hazy double standard that exists around an illegal, potentially harmful drug that continues to encroach into the mainstream:
• In March, Lawrence Korda, 59, a Broward Circuit Court judge, was charged with openly smoking marijuana in a park in Hollywood. Korda completed a drug and alcohol program to erase the misdemeanor charge, and must take monthly random drug tests for six months and perform 25 hours of community service.
• Last month, Utpal Dighe, 31, a prosecutor in the Miami-Dade state attorney's office, was fired after police charged him with buying marijuana from a street dealer in Coconut Grove.
• Also last month, Ricky Williams, 30, erstwhile superstar running back for the Dolphins, probably ended his Miami career by testing positive for marijuana for the fifth time.
For good or ill, people from all walks smoke weed. In fact, 40.1 percent of all Americans 12 years old and up admit having tried marijuana at least once -- and 6 percent acknowledge having used it in the past month, federal drug surveys show. The FBI says 786,500 people were arrested for it in 2005, the latest figures available.
One group at least modestly turning away from marijuana is middle- and high-schoolers, ages 12 to 17. The percentage who have used pot at least once dropped from more than 20 percent in 2000 to about 17 percent in 2005, federal researchers say.
''I don't know if more people are smoking or more people are admitting it,'' said Betsy Wise, a Miami stand-up comic. Wise recently started to freelance for a New York ad agency. She confided in a co-worker that a friend was delivering pot brownies to the office -- and told him to help himself.
''When I got to the agency, all but a few of the brownies were gone,'' Wise said. ``Pretty much everyone partook, right in the office. They all greeted me with smiles. I thought that was remarkable. I would have expected maybe one or two people would have been simpatico.''
More and more, weed is cropping up in the popular culture. It isn't just the domain of hip-hop records with parental-guidance labels. On cable-TV shows like Six Feet Under,The Sopranos,Entourage and The L Word, characters have sparked up casually, the way they might sip merlot, without their marijuana use being part of any plot development or morality tale.
And it isn't just cable. On ABC's Brothers & Sisters, Sally Field's character gets high. The kids on That '70s Show often emerged from clouds of funny smoke.
GOING UPSCALE
''I think there is more of a laissez-faire attitude these days about smoking pot,'' said Jenji Kohan, creator of Showtime's Weeds, about a mother who sells marijuana to make ends meet after her husband dies unexpectedly. 'One of the things that I find interesting is that there are boutique farms that are really into their strains. It reminds me of when wine started to become really popular and people started talking about this vine and that grape. Marijuana has become more upscale. In L.A., dealers have full menus of `unique teas.' ''
Not that marijuana use is a function of wealth.
For $20 on the street, a buyer can score one-eighth ounce of low-grade marijuana from Mexico, Belize or Jamaica -- enough for four or five cigarettes. For $800, the connoisseur can acquire an ounce of exotic, extra-potent marijuana grown from modern hybrids in hydroponic labs or special soil indoors in ''grow-houses'' from Pompano Beach to Coral Gables, said James Hall, director of the Center for the Study and Prevention of Substance Abuse at Nova Southeastern University.
''It's like wine; you can buy an expensive one or you can buy the jug stuff,'' Hall said.
The truth is, for all of the marijuana possession arrests, police often look the other way, or let smokers go with friendly warnings.
At a Snoop Dogg concert at a Fort Lauderdale club a while back, a uniformed officer stood by unflinchingly as Snoop, and dozens in the audience, sent up telltale clouds.
''It's selective enforcement,'' said Miami musician Todd Thompson, who doesn't have a problem admitting that he gets high. ``At Langerado [a Broward outdoor music festival], there was smoking going on everywhere. I wouldn't do it in front of a cop, just in case. But cops don't always do something about a little marijuana smoke.''
Marijuana laws are a mishmash among the 50 states. It isn't entirely legal anywhere, but 12 states have at least partly decriminalized it, to the point that in Alaska there is no penalty for possessing an ounce or less at home.
In Florida, possession of 20 grams or less -- 28 grams would be an ounce -- is a misdemeanor punishable by a year in jail and/or a $1,000 fine; having more than 20 grams is a felony worth five years and/or a $5,000 fine.
Over the decades, debate about whether marijuana should be legalized has remained lively.
Said Howard Finkelstein, Broward County public defender and legal guru of the ''Help Me Howard'' segment on WSVN-Fox 7: 'We're making war on our own people. We take good fathers and lawyers and doctors and wives and make them outlaws. We're playing a stupid and harmful game of `gotcha.' ''
Some support for legalization comes from the belief that it's not dangerous to health, says Dr. J. Bryan Page, professor of anthropology and psychiatry and an expert on substance abuse in the University of Miami Department of Psychiatry.
''A student I knew claimed to be part of a group who all had grade-point averages over 3.6 who were very regular users,'' he said. 'She wanted me to study them to counter all the `Just say no' stuff.''
White House drug czar John Walters, not surprisingly, sees it differently. In April, his office released an analysis from the University of Mississippi's Potency Monitoring Project that said the level of THC -- the psychoactive ingredient in marijuana -- has more than doubled since 1983, from 4 percent to 8.5 percent.
`WAKE-UP CALL'
''This new report serves as a wake-up call for parents who may still hold outdated notions about the harms of marijuana,'' his announcement said.
The increased potency is from the exotic new hybrids and sophisticated indoor growing techniques, says Nova Southeastern's Hall.
Marijuana-related emergency-room visits increased from 45,000 in 1995 to 119,000 in 2002, the most recent comparison available, federal drug officials say.
Added Dr. Nora Volkow, director of the National Institute on Drug Abuse: ``Science has shown that marijuana can produce adverse physical, mental, emotional and behavioral changes, and -- contrary to popular belief -- it can be addictive.''
Norman Kent, a Fort Lauderdale lawyer and board member of NORML, the National Organization for the Reform of Marijuana Laws, scoffed: ``More people died last year from eating spinach than smoking pot.''