Drug Facts: High School and Youth Trends

Attached a link to an article posted onthe NIDA web site titled "DrugFacts: High School and Youth Trends" It contains a mixed bag of good and bad news including: Illicit drug use among teenagers has continued at high rates, largely due to the popularity of marijuana. Marijuana use by adolescents declined from the late 1990s until the mid-to-late 2000s, but has been on the increase since then. In 2012, 6.5 percent of 8th graders, 17.0 percent of 10th graders, and 22.9 percent of 12th graders used marijuana in the past month—an increase among 10th and 12th graders from 14.2 percent, and 18.8 percent in 2007. Daily use has also increased; 6.5 percent of 12th graders now use marijuana every day, compared to 5.1 percent in the 2007. Comment: The marijuana legalization efforts will further contribute to the acceptance of this drug as a "harmless" mood altering substance with "no" addictive potential. Synthetic marijuana is a new and major concern. Also known as Spice or K2, synthetic marijuana refers to herbal mixtures laced with synthetic cannabinoids, chemicals that act in the brain similarly to THC, the main active ingredient in marijuana. These mixtures could be obtained legally until recently and are still wrongly perceived as a safe alternative to marijuana. Synthetic marijuana was added to the MTF survey in 2011. In that year, 11.4 percent of 12th graders—one in nine—reported using it in the past year. This year 4.4 percent of 8th graders, 8.8 percent of 10th graders, and 11.3 percent of 12th graders reported past-year use. Nonmedical use of prescription and over-the-counter medicines remains a significant part of the teen drug problem. In 2012, 14.8 percent of high-school seniors used a prescription drug nonmedically in the past year. Data for specific drugs show that the most commonly abused prescription drugs by teens are the stimulant Adderall and the pain reliever Vicodin. Positive trends in the past several years include reduced use of inhalants and less use of cocaine. Inhalant use is at its lowest levels in the history of the survey. Past-year inhalant use by younger teens dropped significantly between 2007 and 2012, from 8.3 percent of 8th graders and 6.6 percent of 10th graders to 6.2 percent and 4.1 percent, respectively. Past-year use of cocaine by 12th graders dropped from 5.2 percent to 2.7 percent from 2007 to 2012. Other drugs, such as heroin, methamphetamine, and hallucinogens, are holding fairly steady. Ecstasy (MDMA) is seeing a significant drop among teens. Past-year use of ecstasy by 12th graders decreased from 5.3 percent in 2011 to 3.8 percent in 2012. Among 10th and 8th graders it dropped from 4.5 to 3.0 percent and from 1.7 to 1.1 percent, respectively. Yours Bernd

Opioid Treatment in the News

The content of the WSJ article titled "Painkiller Advocate Thinks Twice" neither shocks nor surprises me. Its a fact that in the US opioids are being prescribed by medical practitioners with little or no training in their clinical indication, application, dosing and length of treatment. As an international medical graduate from Germany and Israel I can attest to the fact that the use of prescription narcotics is far more restricted and controlled in other countries than in the US. It appears that in the US doctors are practicing on another planet, where the laws and rules of medicine do not apply: no tolerance to drugs, no drug induced hyperalgesia , no addiction. In South Florida ( another planet by itself) I routinely see patients for opiod dependence treatment who are being prescribed ungodly amounts of Oxycontin,Percocet or Lorcet for unspecified chronic pain syndromes related to "old" injuries, migraine or back pain with no, or little, documentation. Most of them I safely took off opioids and they are doing much better. The article clearly points out that the proponents of long-term opioid treatment provided little evidence for their efficacy or safety. Furthermore, the article also highlights how pharmaceutical companies such as Purdue Pharma, influenced and manipulated key decision makers and regulators including the Federation of State Medical Boards. Regarding Dr. Portenoy: after years of opioid treatment "education" and hundreds of thousands of dollars worth of paychecks by the pharmaceutical industry he still seems to struggle with the reality that opioid dependence can be induced by prescription narcotics and can be treated successfully. This article serves as an attempt by Dr. Portenoy to emulate Pilate in Matthew 27:24 in which he washes his hands in public to proclaim his own innocence. I definitely do not believe him and neither should any of the readers of this article. Happy Holidays. Yours

A Common Sense Approach

Attached a link to an article titled "UM offers community service program for students facing minor pot charges" describing a University Law Enforcement Assisted Diversion Program (U-LEAD), a first in Florida, which offers young first-time offenders facing misdemeanor marijuana possession charges an opportunity to avoid criminal charges. Personally, I fully support the decriminalization of marijuana possession which differs from legalization of marijuana as a drug. Its about time that we start focusing on addiction treatment and stop warehousing non-violent offenders in already overcrowded jails. Yours Bernd

Success in Florida

Miami, October 25th, 2012: Attached an article published in yesterday's Sun Sentinel highlighting the significant decrease in prescription narcotics overdose deaths as a result of the crackdown on pain clinics and the availability of the Prescription Drug Monitoring Program. Deaths related to oxycodone, the widely abused prescription painkiller, dropped by 17.7 percent in 2011. Overall, prescription drug overdoses fell by slightly more than 6 percent. But despite the decline in deaths due to painkillers, overall drug-related deaths increased by 134 last year, to 9,135.The increase was largely due to more fatalities linked to cocaine, alcohol and benzodiazepines, normally prescribed for anxiety or insomnia. Florida Attorney General Bondi said that she was "shocked" at how quickly the reforms had reduced oxycodone deaths. The new laws were in effect for only about six months last year. And the state prescription drug monitoring database was operational for only about three months. Finally, we are making progress and I thank all of you who work so hard to make our great State of Florida a safer place to live for us and our children. Yours Bernd =============================================================================================== Prescription drug overdoses fall in Florida October 24, 2012|By Kathleen Haughney, Tallahassee Bureau TALLAHASSEE -- Deaths related to oxycodone, the widely abused prescription painkiller, dropped by 17.7 percent in 2011, state officials announced today. The drop, they say, is a direct result of the state's battle to root out pain clinics and crack down on pill pushers. Overall, prescription drug overdoses fell by slightly more than 6 percent. "This is a milestone," said Attorney General Pam Bondi. "We know we have a long way to go. We have so far to go in this fight against drugs, but these numbers to us in such a short time are truly remarkable." Still, Wednesday's report by the Florida Department of Law Enforcement was a jarring reminder of the severity of Florida's overdose problem. It showed that, despite the decline in deaths due to painkillers, overall drug-related deaths increased by 134 last year, to 9,135. The increase was largely due to more fatalities linked to cocaine, alcohol and benzodiazepines, normally prescribed for anxiety or insomnia. FDLE Commissioner Guy Bailey acknowledged that the state's effort to target oxycodone and other painkillers sold through "pill mills" may have had the effect of diverting addicts to other drugs. "I will tell you there is speculation that it is a supply and demand issue, that some of the addicts, if you will, that we've blocked from the oxycodone have turned to these other drugs in the place, but we don't know that," he said. "At this point, it's speculation." In March 2011, Bondi and Gov. Rick Scott created strike force teams, partly funded by a federal grant, to target prescription-drug dealers in "pill mills," amid reports that Florida doctors prescribed more oxycodone than any other state. That spring, lawmakers also passed a comprehensive measure to crack down on pain clinics and the following fall, pharmacists began logging prescriptions for most controlled substances in a state database. Bondi said that she was "shocked" at how quickly the reforms had reduced oxycodone deaths. The new laws were in effect for only about six months last year. And the state prescription drug monitoring database was operational for only about three months. However, the oft-repeated statistic that seven people per day are dying of prescription-drug overdoses still holds true, Bailey said. Though there has been a decrease, it hasn't been quite enough to get the number down by even one person. "There was a very slight downtick," he said. "It's a little less than seven." Added Dr. Jan Garavaglia, the medical examiner for Orange and Osceola Counties: "To me, [the report] just shows there's still a lot of deaths from prescription drugs." The report showed that benzodiazapenes, like Xanax, were found to have at least contributed to the death of 1,879 people, and were the principal cause of death of 39 of them. Easier to obtain than oxycodone, the medications are increasingly showing up mixed in a cocktail with other drugs. Bailey said the state hasn't been "flag flying" on benzodiazapenes the way agents have been highlighting oxycodone abuse. Bondi said that she is hopeful that next year, when the laws have been in place longer, the numbers will go down even further. She said that her office, combined with law enforcement, is also working on more prevention programs.

Governor Scott May Reconsider PDMP Funding

Attached a link to an article titled " Scott, lawmakers may consider state dollars for drug database" reporting that Florida Governor Scott may agree to fund the important Prescription Drug Monitoring Program after all. As of September, 52 million records had been uploaded into the database, and more than 2.2 million patient reports had been generated for review by officials. With the launch of the database last fall and implementation of other reforms, law enforcement has seen a major reduction in street sales of oxycodone, one of the most widely abused prescription drugs. Last January, the Drug Enforcement Administration said oxycodone sales in Florida dropped 20 percent from 2010 to 2011. Lets keep up the pressure on Governor Scott to guarantee the financial sustainability of this important program which protects public health and saves lives. Yours Bernd ============================================================================================== Attached a link http://articles.sun-sentinel.com/2012-10-03/news/fl-editorialdrugs-td1003-20121003_1_prescription-drug-abuse-drug-database-oxycodone to an article titled " Drug Database Must Be Funded" published in the Sun Sentinel and my response in the form of a letter to the editor. I encourage you to act now by writing to your legislator and the Governors office supporting sustainable PDMP funding. Yours Bernd Letter to the Editor RE: Drug Database must be funded, Sun Sentinel, October 3rd 2012 I am a family physician and addiction specialist and use the Prescription Drug Monitoring Program (PDMP) as an essential tool in my daily medical practice. Having access to the history of prescribed controlled substances increases transparency and accountability and helps me to protect patients from inadvertent drug interactions which can often lead to accidental overdose and death. Yes, the program is imperfect and requires improvement. Real time drug dispensing reporting is still lacking and pharmacies have up to 7 days to enter dispensing data into the database. Physicians are not mandated to use the program when prescribing controlled substances and less than 900 physicians in Dade and Broward county are registered user. Therefore, we should double our efforts to increase PDMP access and use which requires funding and legislative support. Unfortunately, government officials are more interested in scoring political correctness points than providing the resources to protect public health by preventing accidental overdose deaths. There is no time for complacency. We need to act now to protect the PDMP. Bernd Wollschlaeger,MD,FAAFP,FASAM Former member of the Prescription Drug Monitoring Program Implementation and Oversight Taskforce

Drug database Must Be Funded

Attached a link to an article titled " Drug Database Must Be Funded" published in the Sun Sentinel and my response in the form of a letter to the editor. I encourage you to act now by writing to your legislator and the Governors office supporting sustainable PDMP funding. Yours Bernd Letter to the Editor RE: Drug Database must be funded, Sun Sentinel, October 3rd 2012 I am a family physician and addiction specialist and use the Prescription Drug Monitoring Program (PDMP) as an essential tool in my daily medical practice. Having access to the history of prescribed controlled substances increases transparency and accountability and helps me to protect patients from inadvertent drug interactions which can often lead to accidental overdose and death. Yes, the program is imperfect and requires improvement. Real time drug dispensing reporting is still lacking and pharmacies have up to 7 days to enter dispensing data into the database. Physicians are not mandated to use the program when prescribing controlled substances and less than 900 physicians in Dade and Broward county are registered user. Therefore, we should double our efforts to increase PDMP access and use which requires funding and legislative support. Unfortunately, government officials are more interested in scoring political correctness points than providing the resources to protect public health by preventing accidental overdose deaths. There is no time for complacency. We need to act now to protect the PDMP. Bernd Wollschlaeger,MD,FAAFP,FASAM Former member of the Prescription Drug Monitoring Program Implementation and Oversight Taskforce

DEA Blocks The Distribution of Controlled Substances

Attached a link to an interesting article titled "DEA blocks controlled-substance distribution at Florida Walgreens facility" reporting that " U.S. Drug Enforcement Administration on Friday banned a Walgreens distribution center in Jupiter from dispensing controlled substances to its pharmacies in Florida and the East Coast, saying the business constituted an "imminent danger" to the public. The DEA said that since 2009, the Jupiter distribution center has been the single-largest distributor of oxycodone products in Florida. An immediate suspension order alleges the distribution center did not have effective controls against the illegal use of controlled substances, DEA reports." The Jupiter facility is one of 12 Walgreens distribution centers, the DEA reports. The DEA served an administrative inspection warrant at the facility in April, as well as its top six retail pharmacies in Florida. One of those was at the Walgreens on Lockwood Boulevard in Oviedo. DEA said the Oviedo pharmacy ordered about 80,900 oxycodone units from the Jupiter distribution center in 2009. By 2011, that spiked to nearly 1.7 million units. In 2010, three Walgreens pharmacies were in the top 100 purchasers of oxycodone in Florida, DEA reports. Last year, 38 Walgreens pharmacies made the top 100, and six of those were in the top 10. A Walgreen spokesman responded that Walgreens has taken steps since mid-2011 to enhance monitoring and reporting criteria and that these actions have resulted in a 35 percent drop in the number of tablets dispensed by our pharmacies in Florida for the most commonly abused pain management drug between June 2011 and March 2012. In my opinion the DEA is correct in taking this drastic measures in order to curb the flood of Oxycodone prescriptions on the open market. Nevertheless, we also should ascertain the continuous supply of Oxycodone containing products for those patients with legitimate medical. This could be achieved by enrolling those patients in a chronic pain management program monitored by the prescribing physician to assure appropriate dosing, and the prevention of abuse and diversion. This would include the mandatory use of the Florida Prescription Drug Monitoring Program. This epidemic can be contained and the quality and safety of medical care must be assured. Yours Bernd Happy and Sweet New Year Shana Tova ve Metukah

Methadone Prescribing and Overdose Deaths

Methadone was involved in more than 30% of opioid-related deaths in the United States in 2009, second only to the painkiller oxycodone, according to new data from the Centers for Disease Control and Prevention. The high rate of overdose deaths from methadone occurred even though the drug accounted for less than 2% of opioid prescriptions in 2009. Part of problem is that methadone is more likely than other opioids to cause an overdose, according to the CDC. The findings, which were published on July 3 in Morbidity and Mortality Weekly Report, show that as the use of methadone for pain relief has risen, so has the number of overdose deaths associated with the drug (MMWR 2012;61:1-5). Health officials urged physicians not to prescribe the drug unless they had experience with it, and to limit its use to areas where the benefits outweigh the risks, such as in the treatment of cancer pain or for palliative care. In the MMWR article, the CDC researchers said that the current uses of the drug in pain treatment might be inappropriate. They pointed to a study from the FDA showing that musculoskeletal problems such as back pain and arthritis were the most common diagnoses associated with methadone use for pain in 2009. The researchers specifically urged physicians not to prescribe methadone for low back pain because studies have not shown benefits to using opioids for this condition. Methadone also should not be prescribed for acute pain or to opioid-naive patients, and should be avoided in patients taking benzodiazepines because of the risk for severe respiratory depression, according to the researchers. In a separate CDC web article the following recommendations were published: Health care providers can: Follow guidelines for prescribing methadone and other prescription painkillers correctly, including Screening and monitoring for substance abuse and mental health problems. Prescribing only the quantity needed based on the expected length of pain. Using prescription drug monitoring programs to identify patients who are misusing or abusing methadone or other prescription painkillers. Monitoring patients on high doses of methadone for heart rhythm problems. Educating patients on how to safely use, store, and dispose of methadone and how to prevent and recognize overdoses. Health insurers can: Evaluate methadone’s place on preferred drug lists. Consider strategies to ensure that pain treatment with any dose higher than 30 mg of methadone a day (the recommended daily starting dose) is appropriate. I hope that we can all be part of the solutions because lately I see a proliferation of methadone prescribing among my colleagues, many of whom I do NOT recognize as experts in pain management or pharmacology. Appreciate your comments and suggestions. Yours Bernd

Medicaid Expansion in Florida

Attached a link to an editorial published in today's Miami Herald titled "Not so fast, Gov. Scott" focusing on Governor's Scott refusal to expand Medicaid. The editorial emphasizes that " for Floridians desperate to get basic healthcare the consequences could be dire. Train wreck, perfect storm, falling off the cliff — all of these phrases have been used to describe the impact of Mr. Scott’s decision unless the Legislature takes a more thoughtful approach. ....If Florida continues to ignore the “working poor” who can’t afford health insurance, these patients will have no recourse except to continue relying on public hospitals for unreimbursed care. But they will do so without the increased funding that the new law guarantees as compensation for the states, placing the burden on local taxpayers." The costs of uncompensated care will be passed down as a "hidden tax" to business that provide insurance for their employees, or to individual insurance policy holders. In 2008 this added an extra $1,017 to annual family health insurance premiums, and an additional $368 in individual premiums. The National Association of Public Hospitals estimates that about 4 million people who would have been eligible for Medicaid could go uninsured in states that have decided against expansion. In Florida, the move would expand coverage to an estimated one million more adults and children. Rejecting expansion will worsen the problem of uncompensated care in Florida, which already has the third highest percentage of uninsured patients in the country. But wait, it gets worse! Officials at the Jackson Health System are wary. They get $350 million in a special Medicaid appropriation from the Low Income Pool, far more than any other hospital in the state. They worry that if those funds are redistributed by Congress to cover Medicaid expansion nationwide, they could lose more than they gain in federal funds for new Medicaid patients. Without those funds Jackson Memorial Hospital and other hospitals in South Florida will be in dire financial straits. Lets remind ourselves why that is happening: Because the political leadership in this state is dominated by ideological "thinkers" who are refusing to acknowledge reality. Therefore, its of crucial importance that we act now using all available social networking tools at our disposal to educate and mobilize Floridians. Yours Bernd

Practical Pain Management

In case you missed reading this: Dr. Ilene Robeck wrote an excellent article titled " Chronic Pain in the Elderly: Special Challenges" published in the March 2012 edition of Practical Pain Management. Very thorough, easy to read and contains many practical tips for the daily practice. Kudos to Ilene!!! Yours Bernd

Pills, Guns and Missile Launchers

According to an article published in today's Sun Sentinel officers of the Broward Sheriff's Office raided the office and home of the Pompano Beach pain clinic owners Frank and Bernice Turturo and discovered, among other items, $250,000 in cash, gold coins and nuggets, two short-barreled assault rifles, a portable rocket launcher case and a tiny .22-caliber pistol that would fit in a brassiere. During a news conference at BSO's Fort Lauderdale headquarters today , Sheriff Al Lamberti called the firearms array "scary" and "sophisticated" and "not the day-to-day, target practice weapons you'd normally see." It does not surprise me that pain clinics in South Florida are operating in the criminal underworld of racketeering and drug trafficking . Guns are the necessary accessories required to intimidate anyone probing these shady businesses. Our law enforcement officers need more resources to crack down on drug traffickers and drug dealers in white coats. Yours Bernd

Getting High For Higher Scores

Attached a link to an article titled " Risky Rise of the Good-Grade Pill" reporting the abuse of ADHD drugs by high-school students to improve their grades. Its is troubling that the number of prescriptions for A.D.H.D. medications dispensed for young people ages 10 to 19 has risen 26 percent since 2007, to almost 21 million yearly, according to IMS Health, a health care information company — a number that experts estimate corresponds to more than two million individuals. But there is no reliable research on how many high school students take stimulants as a study aid. Doctors and teenagers from more than 15 schools across the nation with high academic standards estimated that the portion of students who do so ranges from 15 percent to 40 percent. I share the observation that physicians are being asked for prescriptions for Adderall solely for better grades. I recently " lost" a patient because I refused a mothers request to prescribe Adderall for her daughter to prepare for an " important exam." Despite the observation of increased ADHD prescription abuse a respected annual survey financed by the National Institute on Drug Abuse, “Monitoring the Future,” reports that abuse of prescription amphetamines by 10th and 12th graders nationally has actually dipped from the 1990s and is remaining relatively steady at about 10 percent. However, some experts note that the survey does not focus on the demographic where they believe such abuse is rising steadily — students at high-pressure high schools — and also that many teenagers barely know that what they often call “study drugs” are in fact illegal amphetamines. Most of these drugs are now being snorted to achieve the desired effect. A number of teenagers interviewed laughed at the ease with which they got some doctors to write prescriptions for A.D.H.D. Many youngsters with prescriptions said their doctors merely listened to their stories and took out their prescription pads. The prescription abuse is increasing because users were becoming more common, they said, and some students who would rather not take the drugs would be compelled to join them because of the competition over class rank and colleges’ interest. Whats the solution? Physicians should abide by the treatment guidelines. The disorder’s definition requires inattentiveness, hyperactivity or impulse control to present “clinically significant impairment” in at least two settings (school and home, for example), according to the Centers for Disease Control and Prevention. Crucially, some of this impairment must have been in evidence by age 7; a proper diagnosis for a teenager claiming to have A.D.H.D., several doctors said, requires interviewing parents, teachers and others to confirm that the problems existed long before. As physicians we have the ability to control this problem by carefully monitoring our own prescribing habits. I am interested in your response(s) Yours Bernd

Adverse Economic Impact of Opioid Abuse

Attached a link to an article titled "Pain Pills Add Cost and Delays to Job Injuries" highlighting the adverse economic impact of narcotic pain prescriptions. According to the article workmans compensation insurance carriers spend an estimated $1.4 billion annually on narcotic painkillers, or opioids. But they are also finding that the medications, if used too early in treatment, too frequently or for too long, can drive up associated disability payouts and medical expenses by delaying an employee’s return to work. Workers who received high doses of opioid painkillers to treat injuries like back strain stayed out of work three times longer than those with similar injuries who took lower doses, a 2008 study of claims by the California Workers Compensation Institute found. When medical care and disability payments are combined, the cost of a workplace injury is nine times higher when a strong narcotic like OxyContin is used than when a narcotic is not used, according to a 2010 analysis by Accident Fund Holdings, an insurer that operates in 18 states.Between 2001 and 2008, narcotics prescriptions as a share of all drugs used to treat workplace injuries jumped 63 percent, according to insurance industry data. Costs have also soared. In California, for example, workplace insurers spent $252 million on opioids in 2010, a figure that represented about 30 percent of all prescription costs; in 2002, opioids accounted for 15 percent of drug expenditures. Nationwide, data suggests that a vast majority of narcotic drugs used to treat occupational injuries are prescribed by a tiny percentage of doctors who treat injured workers; in California, for example, that figure is just 3 percent. Also, the bulk of such prescriptions go to a relatively small percentage of injured workers, including those who might be addicted to the drugs or those who sell them, experts said. Whats the solution? We must adopt new pain treatment guidelines for doctors which include the emphasis on NON-narcotic pain treatment modalities. In New York, one proposal would require a doctor to refer a patient who is not improving to a pain specialist when an opioid dose exceeds a certain level,Washington State has already adopted such a policy. Furthermore, we need to financially incentivize doctors to apply alternative approaches like specialized psychotherapy or referring addicted workers to treatment facilities. I am interested in your responses. Yours Bernd

Face-Off and Bath Salts

Attached a link to an article published in today's Sun Sentinel titled " Face-eating attack spurs crackdown on synthetic drugs" highlighting the widespread and growing use of synthetic drugs camouflaged as "bath salts" and "incense." These dangerous drugs that are being sold across store counters and several of those I personally found displayed in our neighborhood foodstore. Regulators have struggled to control these drugs as manufacturers stay one step ahead of them by changing ingredients to escape legal action. Frustration reached a fever pitch this week with speculation that the Miami "Cannibal" may have been high on bath salts when he chewed off most of a man's face in Miami on Saturday before he was gunned down by police. Many so-called "bath salts" are sold in small packets under names including Ivory Wave, Bliss and Vanilla Sky. Most come with labels that say they are not for human consumption and are intended as real bath salts to sooth customers. Others claim to serve as deodorizers and pool and spa cleaners. In reality, they have contained chemicals such as mephedrone and MDPV that produce a high similar to illegal narcotics such as cocaine and methamphetamines. They come in tiny jars, resemble crystals, and are packaged in quantities small enough to be snorted or swallowed. Florida banned those chemicals last year, then had to add 92 chemicals to its list of banned ingredients this year to keep up with the manufacturers. (For more information about "bath salts" see the NIDA web site) In my opinion we should launch a public awareness campaign to educate parents, schools, colleges and employer groups about this growing threat to public health and safety. We must recognize our individual responsibility to reach out to those we love and care for. Its not too late. Yours Bernd

US Military and Mental Health

Attached a link "Branding a Soldier With ‘Personality Disorder" to an article in which the author reports that military commanders pressure clinicians to issue unwarranted psychiatric diagnoses to get rid of troops. In the case described a 50-year old female behavioral health professional was diagnosed suffering from a a personality disorder, a diagnosis that the military has used to discharge thousands of troops. Subsequently, she was sent home.She disputed the diagnosis, but it was not until months later that she found what seemed powerful ammunition buried in her medical file, portions of which she provided to The New York Times. “Her command specifically asks for a diagnosis of a personality disorder,” a document signed by the psychiatrist said. By comparison, a diagnosis of post-traumatic stress disorder is usually linked to military service and leads to a medical discharge accompanied by certain benefits. In recent weeks, questions about whether the Army manipulates psychiatric diagnoses to save money have been raised at Joint Base Lewis-McChord near Tacoma, Wash., where soldiers undergoing medical evaluations before discharge complained that psychiatrists rescinded PTSD diagnoses, leaving the soldiers with diagnoses like personality disorder that did not qualify them for medical discharges. If these ALLEGATIONS are correct then several questions and issues must be addressed: Did military psychiatrist, or those contracted by the military, violate the code of medical ethics? Should the U.S. military order their credentialed medical staff to follow evidence-based diagnostic guidelines before reaching a mental health diagnosis? Shouldn't soldiers have the right for a second-opinion BEFORE facing a potentially dishonorable discharge? Those brave man and women in uniform deserve better treatment. Yours Bernd

Deep Cuts for Mental Health and Substance Abuse Treatment Programs

Attached a link State Senate proposes $87 million cut in mental health, substance-abuse programs to an article titled " State Senate proposes $87 million cut in mental health, substance-abuse programs" reporting that a Florida Senate proposal would make deep cuts in funding for adult mental health and substance-abuse programs, and entirely eliminate support for some of them.The proposal would slash overall state spending on adult mental health and substance-abuse treatment by about 40 percent, or $87 million.The cuts would include eliminating state support for some programs — including, potentially, the Miami Behavioral Health Center and the Northside Mental Health Center in Tampa. Sen. Joe Negron, the Stuart Republican in charge of the Senate’s healthcare budget, stated that “When it comes to funding, an 85-year-old woman in a nursing home matters more to me than a 45-year-old guy with a substance-abuse problem,” he said. “It’s all about priorities.” Unfortunately, his statement reveals that most politicians have yet to understand that mental health and substance abuse treatment represents cost-effective care! The benefits of treatment far outweigh the costs. Even beyond the enormous physical and psychological costs, treatment can save money by diminishing the huge financial consequences imposed on employers and taxpayers. Comparing the direct cost of treatment to monetary benefits to society determined that on average, costs were $1,583 compared to a benefit of $11,487 (a benefit-cost ratio of 7:1)! In comparing cost offsets in Washington State of people in treatment to non-treated, the authors noted lower medical costs ($311/month); lower state hospital expenses ($48/month); lower community psychiatric hospital costs ($16/month); reduced likelihood of arrest by 16%; and reduced likelihood of felony convictions by 34%! It is a penny wise and pound foolish approach to CUT finding for mental health and substance abuse treatment because in the long run we as tax payers have to pay the higher price for short term political decisions. For more information see Cost Offset Substance Abuse. I urge you to e-mail, call or write Senator Negron! Yours Bernd

Ban on Bath Salts

Attached a link http://www.miamiherald.com/2012/02/14/2641748/lawmakers-seek-to-expand-bath.html to an interesting article titled "Lawmakers seek to expand bath-salt ban" reporting that Florida lawmakers want to make it a third-degree felony to manufacture or sell new synthetic drugs which have returned to convenience-store shelves.The drugs – which are marketed as herbal smokes, incense, bath salts, plant food and cleaning products – have been problematic throughout the state. Last year, the Florida Legislature banned several forms of synthetic cathinones, or bath salts, that had become popular among teenagers. Lawmakers also banned synthetic cannabinoids, known informally as K2. The drugs have been known to cause violent hallucinations, paranoia, muscle damage and kidney failure.In Charlotte County, three high-school students were recently hospitalized after overdosing – and a fourth had to be restrained after chasing his father around the house with a machete while hallucinating, Sheriff Bill Cameron said. I wholeheartedly support the measure but we certainly have to play catchup during the next legislative session to respond to new synthetic drugs which are going to be developed by clever chemists. We should brainstorm to develop ideas on how to respond to the synthetic drug challenge. Please feel free to share your suggestions on our blog at http://fsamnews.blogspot.com Yours Bernd

We Are Making Progress

Attached a link http://www.sun-sentinel.com/news/opinion/editorials/os-pain-pills-editorial-0209-20120209,0,3698549.story to an interesting article published in the Sun Sentinel titled "Pill mill law sends 'pillbillies' packing." Indeed, we are making great progress: "In a state that had garnered the humiliating national reputation as the go-to state for Oxycontin, the number of oxycodone pills purchased last year by Florida doctors plunged an astonishing 97 percent. Overall oxycodone sales dropped 20 percent, according to figures from the Drug Enforcement Administration. Didn't hurt that the roster of the top 100 oxycodone-buying doctors shed its overwhelmingly Florida vibe. Two years ago, 90 of the top 100 doctors hailed from Florida; last year, only 13 made the list." But more work needs to be done!! We need to create awareness among our fellow colleagues to sign up for and to use the PDMP in their daily practice of medicine; we need to close loopholes that exempt doctors from using the PDMP which includes ALL physicians employed by the Veteran Administration resulting in a sharp increase of opioid use by VA patients. I also suspect that those patients represent a source for illegal prescription opioid street sales. Furthermore, we must identify those doctors in the community which still prescribe prescription opioids in large amounts contributing to overdose deaths of patients. Even though I believe in educating them about safe prescription practices I also advocate for swift revocation of their licenses to protect the public from their actions. Looking forward to your comments. Yours Bernd

Addiction and Brain Changes

Attached a link Abnormal Brain Structure Implicated in Stimulant Drug Addiction to an interesting article published in a recent edition of Science. The authors report that they discovered abnormalities in fronto-striatal brain systems implicated in self-control in both stimulant-dependent individuals and their biological siblings who have no history of chronic drug abuse; these findings support the idea of an underlying neurocognitive endophenotype for stimulant drug addiction.
Drug dependence is increasingly recognized as a “relapsing brain disorder”and, in support of this view, marked structural changes in striatal and prefrontal brain regions have been reported in people dependent on stimulant drugs . These reports, however, raise the question of whether these brain abnormalities may have predated drug-taking, rendering individuals vulnerable for the development of dependence.
Individuals at risk for drug dependence typically have deficits in self-control, which may reflect a diminished ability to recruit prefrontal networks for regulating behavior. Stimulant drugs are highly reinforcing, because they directly affect brain systems implicated in motivated behavior, such as the basal ganglia and the limbic system, and they modulate control systems in the prefrontal cortex. Malfunction of these circuitries may increase the susceptibility for stimulant-induced neuroadaptive changes and facilitate the development of drug dependence.
In the study they compared brain structure and the ability to regulate behavior in 50 biological sibling pairs; within each pair, one sibling satisfied the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for dependence on stimulant drugs and the other had no history of chronic drug or alcohol abuse. The sib-pairs were also compared with 50 unrelated healthy volunteers matched for age and intelligence quotient.
The findings indicate that gray matter changes in the dorsal striatum, together with abnormal inferior prefrontal cortical connectivity, underlie an increased risk for developing stimulant drug dependence. However, the almost equivalent impairments in SSRT (Stop-Signal Reaction Time) in both the stimulant-dependent individuals and their unaffected siblings need careful interpretation, as they do not reflect the classic pattern for endophenotypes, i.e., that the first-degree relatives have trait values intermediate between the patients and the unrelated healthy volunteers. Presumably, the siblings must have some other resilience factors that counteract the familial vulnerability to drug dependence. The identification of these brain and behavioral biomarkers for familial risk of drug dependence demonstrates that an individual’s predisposition to become addicted to stimulant drugs may be mediated by brain abnormalities linked to impaired self-control.

Stratify Patients for Opioid Misuse and Abuse Risk : Internal Medicine News

Attached a link Stratify Patients for Opioid Misuse and Abuse Risk : Internal Medicine News to an interesting article titled " Stratify Patients for Opioid Misuse and Abuse Risk" to assess which of your patients is likely to misuse or abuse opioid medications.
The risk stratification tool utilized in the article is based on quantitative opioid misuse assessment such as the Opioid Risk Tool (ORT) http://www.opioidrisk.com/node/887
Looking forward to your comments.
Yours
Bernd

Binge Drinking

Post According to a recent study by the Centers for Disease Control and Prevention about one out of six adults in the United States is a binge drinker. Results http://www.cdc.gov/media/releases/2012/t0110_binge_drinking.html from a 2010 telephone survey show that more than 38 million U.S. adults are binge drinkers, defined as consuming five or more alcoholic drinks in a short period of time for men and four of more for women. The average frequency of binge drinking was four times a month, the study found. Key findings include: Overall, about 1 in 6 U.S. adults surveyed said they had binged on alcohol at least once in the previous month, though it was more than 1 in 4 for those ages 18 to 34. Excessive alcohol consumption, including binge drinking, accounts for an average of 80,000 deaths and 2.3 million years of life lost in the united states each year and costs the U.S. an estimated $223 billion dollars in 2006 or about $1.90 per drink. Binge drinking is responsible for over half of deaths, two-thirds of the years of potential life lost and three-quarters of the economic costs that are due to excessive drinking. Binge drinking was most common among those in the 18 to 34 age group but the frequency was higher among those over age 65. It was most common in the Midwest, New England, Washington, D.C., Alaska and Hawaii, the survey found said. Men were twice as likely as women to binge drink, according to the study Binge drinking is more common among Americans with household incomes of $75,000 or more per year. The study also found that Americans with household incomes of less than $25,000 per year consume more drinks when they binge drink, averaging eight or nine drinks per binge. Yours Bernd

Marijuana Legislation

Attached a link http://blogs.miaminewtimes.com/riptide/2012/01/medical_marijuana_bills_introd.php to an article titled "Medical Marijuana Bills Introduced In Florida Senate and House" reporting that State Sen. Larcenia Bullard (D-Miami) has " fired up a big ol' blunt of legislative reform..", , as her proposal to give Florida voters a chance to legalize medical marijuana was introduced in the Senate. Bullard's bill joins a similar proposal by Rep. Jeff Clemens (D-Lake Worth) in the House -- the first time in decades that both Florida chambers have had marijuana reform bills at the same time. Both the House and the Senate resolution would put the legalization of medical pot into the hands of voters, adding a statewide referendum later this year that would need 60 percent approval to pass. Sixteen other states around the country have already legalized some uses of marijuana; Miami Beach advocates recently collected enough signatures to force a vote on whether to decriminalize small amounts of weed, although the city attorney is still contesting that referendum. Sen. Larcenia Bullard, D-Miami, who is sponsoring the bill in the Senate, said that what started as a courtesy filing has become a cause for her, after she started looking into it. Her belief that it should pass stems from 1) wanting to de-glamorize it for young people who are looking to do something illegal, and 2) the medical relief it offers to those who need it. And it’s good for the state budget, too, she said. “The state spends $288 million of effort due to the prohibition of marijuana,” she said, adding that it could also be a source of tax revenue. For more information and the original text of both resolutions see HJR 353 at http://www.myfloridahouse.gov/Sections/Documents/loaddoc.aspx?FileName=_h0353__.docx&DocumentType=Bill&BillNumber=0353&Session=2012 and SJR 1028 at http://www.myfloridahouse.gov/Sections/Documents/loaddoc.aspx?FileName=_s1028__.DOCX&DocumentType=Bill&BillNumber=1028&Session=2012. I strongly urge all of you to OPPOSE such initiatives to legalize and promote the medical use of marijuana!!! There is currently no conclusive evidence that marijuana, in the smoked form, has accepted medical use for treatment. Furthermore, marijuana has a high potential for abuse and lacks the safety of medical supervision. The science, though still evolving, is clear: marijuana use is harmful. Marijuana smoke contains more than 400 chemicals, including most of the harmful substances found in tobacco smoke. While marijuana may provide relief from pain, it is also associated with dependence, respiratory and mental illness, poor motor performance, and cognitive impairment, among other negative effects. According to recent surveys marijuana use among youth is on the rise. Nearly two thirds (63 percent in 2009) of the first time users of marijuana are below the age of 18. Research shows that people who used marijuana before age 15 are six times more likely to develop a substance use disorder later in life than those who did not start using until they were 18 or older. Making marijuana more available through legalization efforts will lead to greater use and increased dependence. We already know that about 10 percent of marijuana users develop marijuana dependence which costs our communities monetarily and socially. Prolonged marijuana use is associated with lower test scores and lower educational attainment. This drug affects the user’s ability to learn and process information, thus influencing attention, concentration, and short-term memory. I ask for the active support of the Florida Society of Addiction Medicine to lobby against these two House and Senate resolutions. I look forward to your comments. Yours Bernd

Florida PDMP Update

Attached you find the link https://docs.google.com/viewer?url=http%3A%2F%2Fwww.eforcse.com%2Fdocs%2FPDMP_Annual_Report_2011_FINAL.pdf to the 2010-2011 Prescription Drug Monitoring Program Annual Report.The information collected in the database is available to registered health care practitioners to help guide their decisions in prescribing and dispensing certain highly abused prescription drugs. It may also assist health care practitioners in identifying patients who are “doctor shopping” or trying to obtain multiple prescriptions for the same controlled substance from multiple health care practitioners, which is a felony in the State of Florida. The PDMP became operational on September 1, 2011, when it began receiving controlled substance dispensing data from pharmacies and dispensing practitioners. Health care practitioners began accessing the data reported to the PDMP on October 17, 2011, and Law Enforcement Agencies began requesting PDMP reports during the course of active investigations on November 14, 2011 Here are some highlights: As of November 15, 2011.Number of Pharmacies/Dispensers who have reported to the PDMP 5,502. Number of prescription records reported to the PDMP 21,248,872 For this reporting period, 873,814 INDIVIDUALS filled prescriptions for Schedule II drugs and 2,567,209 for Schedule II and III drugs. The report also identified that 2,710 of the individuals died with at least one prescription drug in their system that was identified as the cause of death. Among the licensed professionals, pharmacists have the highest registration rate, with over 9.7% registering. Roughly 3.7% of all medical doctors and osteopathic physicians and 2% dentists have registered as of November 15, 2011. BUT 56,218 licensed PRESCRIBERS in Florida issued one or more controlled substance prescriptions and most probably do NOT check the PDMP. Number of PDMP Queries by Registered Users: October 2011 34,486 November 2011 71,928 TOTAL 106,414 Number of Data Request by Law Enforcement 36 !! This demonstrates that we have a wealth of data available on which we can base our prescription decisions BUT only 3.7% of all medical doctors in Florida choose to use the system!! Furthermore, the available data indicates that law enforcement is far less "trigger happy" to access the data than previously claimed. What problem(s) remain? More physicians should be encouraged to use the PDMP. Otherwise, we have to consider mandating its use prior to the issuance of a controlled substance prescription. I personally use the program each time I issue a Schedule II,III or IV prescription and have discovered quite a few surprises!! In 2009, 223,700 controlled substance prescriptions were dispensed by out-of state pharmacists in Alabama, Louisiana, North Carolina, Arizona, and Vermont for prescriptions written by Florida prescribers. Currently health care practitioners licensed outside the state of Florida are not allowed access to Florida’s PDMP prior to dispensing. Therefore, we need to allow for exchange of Florida PDMP data with other state PDMP programs which will enable health care practitioners and law enforcement officers to determine if their patient/subject has received controlled substance prescription drugs in the State of Florida. Yours Bernd

US Healthcare Costs

According to the latest edition of "Health at a Glance" http://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2011_health_glance-2011-en published by the Organization for Economic Co-operation and Development (OECD) The United States stands out as performing very well in the area of cancer care, achieving higher rates of screening and survival from different types of cancer than most other developed countries. The United States does not do well in preventing costly hospital admissions for chronic conditions, such as asthma or chronic obstructive pulmonary disease, which should normally be managed through proper primary care. Avoidable hospital admissions for asthma complications and chronic obstructive pulmonary disease (COPD) are much greater in the United States than the OECD average. For asthma admissions, the rate in the United States was 121 per 100 000 adults in 2009, more than two times greater than the OECD average of 52. For COPD, hospital admission in the United States was 230 per 100 000 adults, compared with an OECD average of 198. Regarding healthcare expenditures the United States spent 17.4% of GDP on health in 2009, much more than the OECD average of 9.6%. Spending per person is two-and-a-half times higher than the OECD average. Following the United States were the Netherlands, France and Germany, which allocated respectively 12.0%, 11.8% and 11.6% of their GDP to health. Is US health spending higher due to higher prices or higher service provision? (or both?) Facts: 1) US prices for a set of hospital services is over 60% higher than the average of 12 OECD countries, 2) US prices for certain procedures (including appendectomy,coronary angioplasty, coronary artery bypass graft, hip & knee replacement) are much higher than in other OECD countries, 3) Almost DOUBLE the spending on Insurance administration expressed in terms of purchasing power parity. Its also of interest to note that in most countries, health spending is largely financed out of taxes or social security contributions, with private insurance or ‘out-of-pocket’ payments playing a significant but secondary role. This is not the case in the United States which, together with Mexico and Chile, is the only OECD country where the government plays the smallest role in financing health spending. The public share of health expenditure in the United States was 47.7% in 2009, much lower than the OECD average of 71.7%. However, the level of health spending in the United States is so high that public (i.e. government) spending on health per capita is greater than in all other OECD countries, except Norway and the Netherlands. For this amount of public expenditure in the United States, government provided in 2009 insurance coverage only for the elderly and disabled people (through Medicare) and some of the poor (through Medicaid and the State Children’s Health Insurance Program, SCHIP), whereas in most other OECD countries this was enough for government to provide universal health insurance. Public spending on health in the United States has been growing more rapidly than private spending since 1990, largely due to expansions in coverage. Private insurance accounted for 33% of total health spending in the United States in 2009, by far the largest share among OECD countries. Beside the United States, Canada and France are the only two other OECD countries where private insurance represents more than 10% of total health spending. Conclusions: we are spending more for healthcare per person than in any other country in the world utilizing an inefficient private insurance model. But also public (i.e. government) spending on health per capita is greater than in all other OECD countries but fails to provide universal coverage. We must achieve a broad based consensus on how to efficiently allocate our healthcare resource to achieve high quality healthcare for all Americans. Tinkering on the edge will not provide us with a meaningful and sustainable solution. If we do not engage in such a dialogue now we will face rationing and further economic slowdown. Yours Bernd

Pharmacies and Pill Mills

Attached a link http://www.miamiherald.com/2011/12/24/2560690/painkiller-peddlers-pharmacies.html to an important article you might have missed titled "Painkiller peddlers: Pharmacies targeted in pill-mill crackdown" published in the Miami herald on December 24th, 2011. The article reports that according to a federal indictment an ordinary mom-and-pop pharmacy, conveniently located on the first floor of the Stephen P. Clark Government Center, the 28-story heart of Miami-Dade County government, steps from a heavily used Metromover stop, was actually operating as a pill mill illegally trafficking in painkillers, part of a wave of rogue pharmacies that have become the new front line in the continuing war on prescription drug abuse in Florida. In the emergency order suspending the owner's pharmacy permit based on the U.S. Drug Enforcement Administration investigation, the Florida Department of Health said he posed a serious danger to the public health and showed reckless disregard for pharmacy laws and rules by dispensing excessive or inappropriate dosages of oxycodone and oxymorphone. The four Robert’s Drug stores purchased a total of 1,692,700 tablets of oxycodone between Jan. 1 and June 1 this year, according to the DEA. A state expert said in state documents that an 80-mg. daily dose of oxycodone “is potentially lethal” for some people but that Aryan’s customers routinely received far more. But there aslo good news to report: After a three-year investigation, federal authorities dismantled four of the nation’s largest pain clinics in August along with two pharmacies and one pharmaceutical supplier. Thirty-two people from across South Florida were indicted. Over the years, the enterprise doled out 20 million pills and profited $40 million from illegal sales of controlled substances. In July, federal authorities arrested a family of five charged as part of a drug and money laundering enterprise based at a Plantation pharmacy. From April, 2009 to May, 2010, the pharmacy ordered 1,038,560 tablets of oxycodone, more than 28 times the national average for dispensing pharmacies, according to federal documents. The profits: nearly $2 million.Last month, CVS — with more than 700 stores in the state — notified a small number of Florida physicians that it will no longer fill their prescriptions written for Schedule II narcotics, including oxycodone, a measure to “prevent drug abuse and keep controlled substances out of the wrong hands,’’ according to a statement. Looking forward to your comments. Happy New Year Yours Bernd

Oxycontin in the News

Attached a link http://www.pressdisplay.com/pressdisplay/viewer.aspx to an interesting article titled "Stronger form of Oxycodone means more pain for the US" published in the Sun Sentinel on December 29th, 2011. In this commentary the author points out that "several drug companies are completing FDA trials to introduce a new, much stronger form of Oxycodone to the $10 billion opiate prescription drug market in 2013. Unlike the more than 400 opiate pain killers already on the market that blend the powerful narcotic with other medications, the new drug is solely composed of pure Oxycodone. It will be very potent, delivering up to 10 times more pain relief than present prescriptions." Whereas all of us are struggling to contain the prescription drug epidemic, pharmaceutical companies, driven by the profit motive, seem to have found a business opportunity to sell more powerful narcotics to the ever growing number of opioid dependent addicts. Therefore, I agree with the authors conclusion: "If tobacco companies are forced to contribute a portion of each sale of a cigarette pack to pay for the effort to curb tobacco use and the financial and medical consequences cause by American smoking cigarettes, why not the manufacturers of the most abused addictive prescriptive drug in the United States? It is time to make politically powerful drug companies responsible and accountable for their destructive products. They, not U.S. taxpayers, should have to bear the brunt of the financial and social burdens from rampant illegal misuse of Oxycodone." Looking forward to your comments. Happy New Year Yours Bernd