Prescription Drug Abuse and Impaired Drivers

Attached you find an article published in the New York Times (July 25th,2010) highlighting the exponentially growing problem of prescription drug abuse as it relates to driving under influence.

The article emphasizes that :

"There is no reliable data on how many drivers are impaired by prescription drugs, but law enforcement officials say the problem is growing so quickly that states are putting hundreds of police officers through special training to spot signs of drug impairment and clamoring for better technology to detect it."

"Even the prevalence of drug-impaired driving is unknown, since many states combine the arrest data with that for drunken driving."

".. persuading a jury to convict someone of impaired driving due to prescription drugs remains difficult except for the most egregious cases ...because most people on the jury will also likely be taking prescription drugs for some ailment."

I recommend reading the article. As addiction treatment professionals we should get involved in guiding law enforcement officials and legal experts to address this growing public health issue.
Looking forward to your comments.
Yours
Bernd

Drivers on Prescription Drugs Are Hard to Convict

By ABBY GOODNOUGH and KATIE ZEZIMA

The accident that killed Kathryn Underdown had all the markings of a drunken-driving case. The car that hit her as she rode her bicycle one May evening in Miller Place, N.Y., did not stop, the police said, until it crashed into another vehicle farther down the road.

The driver could not keep her eyes open during an interview with investigators, according to the complaint against her, and her speech was slow and slurred. But the driver told the police that she had not been drinking; instead, the complaint said, she had taken several prescription medications, including a sedative and a muscle relaxant.

She was charged with vehicular manslaughter and driving under the influence of drugs — an increasingly common offense, law enforcement officials say, at a time when drunken-driving deaths are dropping and when prescriptions for narcotic painkillers, anti-anxiety medications, sleep aids and other powerful drugs are rampant.

The issue is vexing police officials because, unlike with alcohol, there is no agreement on what level of drugs in the blood impairs driving.

The behavioral effects of prescription medication vary widely, depending not just on the drug but on the person taking it. Some, like anti-anxiety drugs, can dull alertness and slow reaction time; others, like stimulants, can encourage risk-taking and hurt the ability to judge distances. Mixing prescriptions, or taking them with alcohol or illicit drugs, can exacerbate impairment and sharply increase the risk of crashing, researchers say.

“In the past it was cocaine, it was PCP, it was marijuana,” said Chuck Hayes of the International Association of Chiefs of Police. “Now we’re into this prescription drug era that is giving us a whole new challenge.”

The police also struggle with the challenge of prosecuting someone who was taking valid prescriptions.

“How do we balance between people who legitimately need their prescriptions and protecting the public?” said Mark Neil, senior lawyer at the National Traffic Law Center, which works with prosecutors. “It becomes a very delicate balance.”

Some states have made it illegal to drive with any detectable level of prohibited drugs in the blood. But setting any kind of limit for prescription medications is far more complicated, partly because the complex chemistry of drugs makes their effects more difficult to predict than alcohol’s. And determining whether a driver took drugs soon before getting on the road can be tricky, since some linger in the body for days or weeks.

Many states are confronting the problem as part of a broader effort to keep so-called drugged drivers, including those under the influence of marijuana and other illegal drugs, off the road.

“We have a pretty clear message in this country that you don’t drink and drive,” said R. Gil Kerlikowske, President Obama’s top drug policy adviser, who wants to reduce drugged-driving accidents by 10 percent over the next five years. “We need very much to have a similar message when it comes to drugs.”

There is no reliable data on how many drivers are impaired by prescription drugs, but law enforcement officials say the problem is growing so quickly that states are putting hundreds of police officers through special training to spot signs of drug impairment and clamoring for better technology to detect it.

Even the prevalence of drug-impaired driving is unknown, since many states combine the arrest data with that for drunken driving. Mr. Kerlikowske points to a 2007 survey by theNational Highway Traffic Safety Administration, which screened 5,900 nighttime drivers around the country and found that 16.3 percent tested positive for legal or illegal drugs.

The tests could not determine which drivers were impaired by drugs, but Mr. Kerlikowske said the results suggested a problem that had “flown below the radar” for too long.

“You don’t want to scare people,” he said, “but you certainly want to make them aware of the dangerousness. You can be as deadly behind the wheel with prescription drugs as you can with over-the-limit alcohol, and you are responsible for your own actions.”

In interviews, law enforcement officials around the country said anyone who drives while taking prescription drugs is at risk of arrest, not only those who drive recklessly. In one recent case near Bangor, Me., a pickup truck on a rural road was not swerving, speeding or otherwise hinting that its driver was impaired. A police officer stopped the truck because of its noisy muffler, then saw that the driver’s eyes were bloodshot and his speech slurred.

A Breathalyzer test found that the driver, Chester Annance, had not been drinking. Yet he was arrested based on the officer’s suspicion that he was on drugs, and a blood test later found opiate painkillers in his system.

Mr. Annance was convicted this month of driving under the influence of drugs. He received seven days in jail, a three-year license suspension and a fine. He is appealing the conviction.

“You don’t need to wait for a crash to happen before you charge someone,” said R. Christopher Almy, the district attorney in Bangor.

Defense lawyers say that in their zeal to make a statement about drug-impaired driving, the police are casting too wide a net and unfairly punishing people who are taking prescriptions as directed.

Tara Jenswold-Schipper, an assistant attorney general in Wisconsin, said she usually stuck to cases where drivers had mixed drugs, exceeded the proper dose or taken controlled medications without a prescription.

In one such case in that state, a former physician slammed his S.U.V. into a Honda Accord in April 2008, killing the pregnant driver and her 10-year-old daughter. Prosecutors said the physician, Mark Benson, had high levels of the sleep aid Ambien in his system, as well as Xanax, an anti-anxiety drug, and oxycodone, an opiate painkiller. Mr. Benson was sentenced to 30 years in prison.

Defendants can try to prove that they did not realize their medication would affect their driving, prosecutors said, but that argument may not hold up if the bottle had a warning label.

“Would you go home and start a chain saw and cut down a tree?” said Lt. Col. Thomas C. Hejl, the assistant sheriff in Calvert County, Md. “Why should you get behind the wheel of a vehicle when the same medication has the same side effects?”

Unable to prove impairment with blood tests, prosecutors in drugged-driving cases rely heavily on the testimony of “drug recognition experts,” law enforcement officers trained to spot signs of impairment in drivers. But there are only about 7,000 such officers nationwide, Mr. Hayes said, not nearly enough to respond to every traffic stop that may involve drugs.

“When they are involved,” he said of the experts, “our chances of convicting people are much higher.”

But persuading a jury to convict someone of impaired driving due to prescription drugs remains difficult except for the most egregious cases, said Douglas F. Gansler, the attorney general in Maryland.

“Because most people on the jury will also likely be taking prescription drugs for some ailment,” Mr. Gansler said, “whether it’s Lipitor or allergy pills or whatever it might be, they might think, ‘I don’t want that to become criminal.’ ”

Use of Synthetic Marijuana on the Rise:

Attached you find an article from today's New York Times highlighting the increasing use of synthetic marijuana (K-2) and the efforts to curb the metastatic spread of these substances. A food store next to my office sells it as incense to teenagers and I have tried convincing the shop-owner to stop its sale. Her argument " if I stop selling it the kids go to the other guy around the corner and I loose customers."
I urge you to read this article and to consider what actions FSAM can take to suggest state regulation. I would NOT wait for the FMA to step in because government regulation is not part of their political agenda. This is an urgent public health issue and we need to act fast.
Looking forward to your comments.
Yours
Bernd

Factsheet:

+ Often marketed as incense, K2 — which is also known as Spice, Demon or Genie — is sold openly in gas stations, head shops and, of course, online. It can sell for as much as $40 per gram. The substance is banned in many European countries, but by marketing it as incense and clearly stating that it is not for human consumption, domestic sellers have managed to evade federal regulation.
+ K2’s active ingredients are synthetic cannabinoids — research-grade chemicals that were created for therapeutic purposes but can also mimic the narcotic effects of tetrahydrocannabinol, or THC, the active ingredient in marijuana.
+ K2 does not show up on drug tests, and users say that while they would like to know what is in it, they would take their chances if it means a clean urine test.




New York Times, Sunday, July 11, 2010:

Synthetic Marijuana Spurs State Bans
By MALCOLM GAY

ST. LOUIS — Seated at a hookah lounge in the Tower Grove district, Albert Kuo trained his lighter above a marbleized glass pipe stuffed with synthetic marijuana Inhaling deeply, Mr. Kuo, an art student at an area college, singed the pipe’s leafy contents, emitting a musky cloud of smoke into the afternoon light.

Mr. Kuo, 25, had gathered here with a small cohort of friends for what could be the last time they legally get high in Missouri on a substance known popularly as K2, a blend of herbs treated with synthetic marijuana.

“I know it’s not going to kill me,” said Mr. Kuo, who likened the drug’s effects to clove cigarettes. “It’s a waste of time, effort and money to ban something like this.”

On Tuesday, Gov. Jay Nixon, a Democrat, signed a bill prohibiting possession of K2. Missouri is the nation’s eighth state this year to ban the substance, which has sent users to emergency rooms across the country complaining of everything from elevated heart rates and paranoia tovomiting and hallucinations.

Investigators blame the drug in at least one death, and this month, Gov. Mike Beebe of Arkansas, a Democrat, signed an emergency order banning the substance. Similar prohibitions are pending in at least six other states, including Illinois, Louisiana, Michigan, New Jersey, New York and Ohio, according to the National Conference of State Legislatures.

“It’s like a tidal wave,” said Ward Franz, the state representative who sponsored Missouri’s legislation. “It’s almost an epidemic. We’re seeing middle-school kids walking into stores and buying it.”

Often marketed as incense, K2 — which is also known as Spice, Demon or Genie — is sold openly in gas stations, head shops and, of course, online. It can sell for as much as $40 per gram. The substance is banned in many European countries, but by marketing it as incense and clearly stating that it is not for human consumption, domestic sellers have managed to evade federal regulation.

“Everybody knows it’s not incense,” said Barbara Carreno, a spokeswoman for the federal Drug Enforcement Administration. “That’s done with a wink and a nod.”

First developed in the lab of a Clemson University chemist, John W. Huffman, K2’s active ingredients are synthetic cannabinoids — research-grade chemicals that were created for therapeutic purposes but can also mimic the narcotic effects of tetrahydrocannabinol, or THC, the active ingredient in marijuana.

In a statement, Mr. Huffman said the chemicals were not intended for human use. He added that his lab had developed them for research purposes only, and that “their effects in humans have not been studied and they could very well have toxic effects.”

Nevertheless, pure forms of the chemical are available online, and investigators believe that many sellers are buying bulk quantities, mixing them with a potpourrilike blend of herbs and labeling the substance K2.

“It’s not like there’s one K2 distributor — everybody is making their own stuff, calling it K2 and selling it, which is the most unnerving aspect,” said Dr. Christopher Rosenbaum, an assistant professor of toxicology at the University of Massachusetts who is studying the effects of K2 in emergency room patients.

The American Association of Poison Control Centers reports that so far this year there have been 567 K2-related calls, up from 13 in 2009. But investigators add that no one is really certain what is in K2, and people are arriving at emergency rooms with symptoms that would not normally be associated with marijuana or a synthetic form of the drug.

“I don’t know how many people are going for a box of doughnuts after smoking K2, but they’re sure getting some other symptoms,” said Dr. Anthony Scalzo, a professor of emergency medicine at the St. Louis University who first reported a rise in K2-related cases and is collaborating with Dr. Rosenbaum in researching K2’s effects. “These are very anxious, agitated people that are requiring several doses ofsedatives.”

Dr. Scalzo, who is also the medical director for the Missouri Poison Control Center, added that although tests had found cannabinoids in K2, it was unclear “whether the reaction we’re seeing is just because of dose effect, or if there’s something in there we haven’t found yet.”

That question remains at the center of an investigation into the death of David Rozga, an Iowa teenager who last month committed suicideshortly after smoking K2. Mr. Rozga, 18, had graduated from high school one week earlier and was planning to attend college in the fall.

According to the police report, Mr. Rozga smoked the substance with friends and then began “freaking out,” saying he was “going to hell.” He then returned to his parents’ house, grabbed a rifle from the family’s gun room and shot himself in the head.

“There was nothing in the investigation to show he was depressed or sad or anything,” said Detective Sgt. Brian Sher of the Indianola Police Department, who led the investigation. “I’ve seen it all. I don’t know what else to attribute it to. It has to be K2.”

But many users say they are undaunted by reports of negative reactions to the drug. K2 does not show up on drug tests, and users say that while they would like to know what is in it, they would take their chances if it means a clean urine test.

The Missouri ban, which goes into effect Aug. 28, prohibits several cannabinoids that investigators have found in K2 and related products. Nevertheless, investigators and researchers say that bans like the one in Missouri are little more than “Band-Aids” that street chemists can sidestep with a slight alteration to a chemical’s molecular structure.

“Once it goes illegal, I already have something to replace it with,” said Micah Riggs, who sells the product at his coffee shop in Kansas City. “There are hundreds of these synthetics, and we just go about it a couple of them at a time.”

Investigators say that a more effective ban might arise once the Drug Enforcement Administration completes its review of cannabinoids, placing them under the Controlled Substances Act. Currently, however, only one such substance is controlled under the act, though the agency has listed four others as “chemicals of concern.”

“It’s hard to keep up with everything,” said Ms. Carreno of the D.E.A., adding, “The process of scheduling something is thorough and time consuming, and there are a lot of gifted chemists out there.”

Meanwhile, states are largely on their own when it comes to controlling this new breed of synthetic cannabis, which often comes down to a game of cat-and-mouse where law enforcement agents, politicians, users and their families must formulate new responses as each iteration of a drug comes to market.

“Where does a parent go to get answers?” asked Mike Rozga, who said he learned of K2 only after his son’s death. “We talk to our kids about sex. We talk to our kids about drugs, and we talk to our kids about drinking and being responsible. But how can you talk to your kids about something you don’t even know about?”

Raves, Ecstatsy and Overdose Deaths

Attached two interesting articles of concern:

1. Wall Street Journal, 07/03/2010: Out in the Open: Raves and Ecstasy http://online.wsj.com/article/SB10001424052748704699604575343133677383828.html#

"Twenty years after their heyday as an underground phenomenon, the drug-fueled dance parties known as raves are making a comeback as massive, commercial events. But a recent wave of ecstasy-related deaths and hospitalizations tied to such events have left some officials skeptical about their makeover.Unlike the original raves in the late 1980s and early '90s, which were often staged without permits in hard-to-find patches of desert or abandoned industrial warehouses, today's version has gone aboveground. The drug of choice for many attendees is still ecstasy, an illegal stimulant/hallucinogen also known as MDMA that is often cut with other substances. Taken as a pill or powder, the drug, whose full chemical name is 3,4-methylenedioxymethamphetamine, can induce euphoria and doesn't typically cause the kind of traumatic overdose symptoms associated with drugs such as heroin. But ecstasy can cause dehydration—potentially a serious health problem for people dancing all night in hot, cramped conditions. Doctors say many ecstasy-users end up in emergency rooms because they try to combat dehydration by drinking too much water, causing water intoxication—which can lead to seizure and coma.
This represents another challenge for physicians to diagnose and treat. Hopeffully, we can reduce the adverse publich health effect by educating adolescents in schools and at home.

2. Miami Herald, 07/01/2010, Experts fear new wave of addiction, http://www.miamiherald.com/2010/07/01/1709624/experts-fear-new-wave-of-addiction.html

While drug-related deaths across Florida rose an alarming 20 percent last year over 2008, South Florida saw a notable decrease in two key areas of substance abuse: cocaine and heroin.
Still, addiction experts say, there is an indication that the nation's sixth-largest metro area could be on the verge of a new wave of addiction unseen since the cocaine craze of the early 1980s. Two separate reports released this week by James C. Hall, director of Nova Southeastern University's Center for the Study and Prevention of Substance Abuse, and the Florida Medical Examiners Commission, show more than 8,600 deaths in Florida in 2009 in which victims had at least one prescription drug in their system that contributed to their passing. That's up from about 6,200 drug-induced deaths in 2008.
What's more, both reports say almost all the increase in drug deaths -- especially in Broward and Miami-Dade counties -- is due to a disturbing and relatively new trend of drug abusers mixing opiates and narcotics like heroin and cocaine with opioids -- prescription drugs like oxycodone -- or simply switching indiscriminately from one to the other.
Fort Lauderdale and St. Petersburg far outpaced every other city in Florida in terms of prescription drug deaths.
In Broward County last year, 225 people died with large amounts of oxycodone in their bodies; 57 had morphine in their systems, 60 were high on methadone, 46 on hydrocodone, and 27 on propoxyphone, for a total of 415 opioid-related deaths in Broward, compared to 342 such deaths in 2008.
Among the 2009 Broward County totals, 62 percent took lethal doses of opioids before their deaths, and 91 percent had at least two drugs in their systems at the time of death -- typically a combination of opioids and cocaine.

We must continue to push for a moratorium on narcotic dispensing in doctors offices and support revocation of licensure for ANY physician who prescribes or dispenses scheduled drugs in LARGE quantities WITHOUT treatment rationale. For example: its almost routine for certain "doctors" - or better drug dealers in a white coat- to prescribe 180-500 Oxycontin Tablets for one patient on one prescription for one month!!!
How is that possible? Because everyone involved in this process makes big $$$$.
This has to stop but obviously nobody has the will to stand up and call it what it is: drug dealing!!

Yours
Bernd

Arizona Law For Florida and Medical Practice

Attached an important and troubling article from today's Miami Herald pointing out that "Florida Republican leaders have begun crafting anti-illegal-immigrant legislation modeled after an Arizona law that has incited widespread protests and fueled national and international debate over U.S. immigration policies.
Under the proposed bill, police would have broad power under state law to ask suspects for proof of legal residency."
I am strongly opposing such legislation and urge my specialty society to raise concerns regarding this bill as it pertains to the way family physicians practice medicine.
I often (even today) encounter patients, mostly uninsured, who are reluctant to go to the hospital because of their residency status fearing a backlash, or possible investigation by the immigration authorities.
Today I referred a Haitian patient to Publix to benefit from a FREE Metformin program. She asked me if she would have to provide a form of identification because she has no papers. I reassured her that she should not worry.
What will happen IF we have such a discriminatory law on the books? More undocumented immigrants will avoid doctors but will be taken by ambulance to emergency rooms for preventable illnesses instead. Who will pay? The taxpayer!
Just the debate of such a law in the legislature will trigger additional pressure on our State which already has to deal with a massive and continuous oil spill, high unemployment and a jittery tourism industry. Do we need anything else to shut down!!
Looking forward to your comments.
Yours
Bernd




Posted on Sat, Jun. 26, 2010
Florida GOP risks Hispanic anger with Arizona-like crackdown

Cristina Silva
Miami Herald/St. Pete Times

TALLAHASSEE — Florida Republican leaders have begun crafting anti-illegal-immigrant legislation modeled after an Arizona law that has incited widespread protests and fueled national and international debate over U.S. immigration policies.
Under the proposed bill, police would have broad power under state law to ask suspects for proof of legal residency, said Rep. William Snyder, a Republican from Stuart who plans to introduce the legislation in November.

"We have significant components from the Arizona bill that I plan to incorporate,'' he said. "We have the beginnings of it.''

The effort, which would be filed for consideration during the March legislative session, is already drawing broad support within the GOP.

Majority leaders in the Florida Senate and House said a new approach is needed to address the federal government's failure to temper illegal immigration.

It has the backing of both leading Republican gubernatorial candidates -- businessman Rick Scott and Attorney General Bill McCollum, whose office is helping to draft the bill.

Snyder, a former police officer, said the proposed legislation is needed to protect undocumented immigrants, who are vulnerable to abusive employers and violent criminals.

"This is a human right issue,'' he said. "They don't enjoy the same rights and privileges that you and I do. The solution is to enforce the laws that currently exist and to discourage people from coming here to `find a better life' when in fact they just come here and are victimized.''

Immigrant advocates and Hispanic lawmakers alike called the measure an unconstitutional assault on minority communities.

"The reaction is, 'What? This is ridiculous,' '' said Neelofer Syed, a Tampa immigration lawyer from Pakistan. "It is supposed to be that you are legal until you are proven guilty. This law is like, `We think you are guilty unless you establish that you are innocent.' ''

Rep. J.C. Planas, a Republican from Miami, called it an election-year stunt.

"I don't understand how anyone can think the Arizona law is good for Florida,'' said Planas, chairman of the Florida Hispanic Legislative Caucus. "It is a huge waste of police resources to start doing these things.''

Senate and House leaders said immigration reform is ripe for passage.

"What we want to do is encourage legal immigration and discourage illegal immigration,'' said incoming Senate President Mike Haridopolos, who cautioned that any changes will be shaped by how the Arizona law is put into practice after it takes effect next month.

Republican leaders in Pennsylvania, Rhode Island, Minnesota, South Carolina and Michigan have made similar vows to mirror Arizona's immigration law, amid growing criticism that the federal government has not adequately protected the nation's borders.

Civil rights groups such as the American Civil Liberties Union have filed legal challenges to the legislation, and President Barack Obama's administration is expected to follow suit.

Critics questioned why Florida lawmakers would consider replicating Arizona's untested immigration strategy while legal challenges are still pending.

"Rep. Snyder's proposal solves nothing, exploits public concern over immigration and just creates new problems,'' said Howard Simon, executive director of ACLU Florida.

The tension has become a rallying point for candidates on both sides of the political spectrum.

Democratic gubernatorial candidate Alex Sink has highlighted her Republican opponents' support of the law in stump speeches.

"She was opposed to the law in Arizona,'' said campaign spokeswoman Kyra Jennings. "She believes it unfairly discriminated against American citizens. She would veto that type of legislation.''

Championing tougher immigration laws is a risky election strategy, said George Gonzalez, a University of Miami political science professor.

"It is a way to channel people's anger and frustration about the labor market onto a group and to take advantage of it, too,'' he said.

But it could also anger Hispanic voters, an important constituency in Florida's increasingly diverse political landscape, Gonzalez said.

Florida's estimated illegal immigrant population ranks third in the nation. Arizona places seventh. But while Florida's undocumented population has dropped by 10 percent during the past decade, Arizona's climbed by 42 percent.

"None of this is foolproof,'' Gonzalez said. "It could blow up in the Republicans' faces either way.''

Snyder said he doesn't want his law to stir up the same accusations of racism that hounded Arizona's decision.

His law would be refined, he said, because it would only allow law enforcement officials to inquire about immigration status during a potential arrest or traffic violation. In Arizona, officers are required to request legal documentation during any lawful stop if ``reasonable suspicion'' exists.

Coming up with the precise language will be difficult, conceded Snyder, who recently defended his views on Fox News. ``Reasonable suspicion makes people nervous,'' he said.

But he vowed his final draft would apply equally to all illegal immigrants, regardless of skin color or ethnicity.

"I've never in my 32 years been accused of using the `N' word or being racially motivated,'' he said. "No one who knows me would say I have a racist bone in my body.''

Shorter Work Days For Doctors

Attached a link to an important NEJM article http://content.nejm.org/cgi/content/full/NEJMsb1005800 entitled "The New Recommendations on Duty Hours from the ACGME Task Force."The goal of the ACGME's new approach to duty hours is to foster a humanistic environment for graduate medical education that supports learning and the provision of excellent and safe patient care.
At the heart of the ACGME's proposed changes is the recognition that the least-experienced residents need to be treated differently than more experienced ones. The plan recommends that first-year residents be limited to 16-hour shifts, and those in the second year and above work continuously for no more than 24 hours. They can stay an additional four hours to facilitate patient handoffs to another doctor. Currently residents are allowed to work up to 30-hour shifts.
The guidelines also include detailed expectations about direct supervision of younger residents by more experienced ones, in the hopes that a supervising doctor would catch any error before it affects a patient, according to Dr. Nasca.In addition, the ACGME will step up its monitoring and enforcement of the requirements, conducting on-site visits of each institution annually beginning in July 2011. The site visits are likely to cost each institution about $12,000 to $15,000, according to Dr. Nasca.
Those programs that don't comply with the rules could ultimately lose accreditation and be forced to disband.
I strongly support the proposed changes and call upon my colleagues to do the same.
Our patients deserve the same assurance about the quality of service as millions of airline passenger do already: strictly enforced duty hours for pilots, checklists before take-off and landing, elimination of human errors and the relentless pursuit of excellence.
We must change the way we do business! Our patients deserve it!!
Yours
Bernd

Opioid Dependence

Attached a very interesting article supporting the fact that office based treatment of opioid dependence can decrease illegal activity and incarceration.
Yours
Bernd

Family Practice News

Volume 40, Issue 10, Page 31 (1 June 2010)


Opioid-Dependent Patients Respond to Therapy

DIANA MAHONEY

Article Outline


Major Finding: Office-based buprenorphine/naloxone treatment was associated with a statistically significant decrease in participants reporting illegal activity, from 19% to 2%, and in interacting with the legal system, from 16% to 1%.

Data Source: A secondary analysis of data from a randomized clinical trial of 166 opioid-addicted individuals treated with buprenorphine/naloxone in a primary care clinic.

Disclosures: Dr. Fiellin reported no relevant financial conflicts of interest.

MINNEAPOLIS — Opioid-dependent patients with a history of incarceration do well with office-based buprenorphine/naloxone therapy and have fewer interactions over time with the legal and criminal justice systems, according to a data analysis of a previous randomized, controlled trial.

“Our findings should offer some reassurance for community health care providers about initiating buprenorphine/naloxone treatment in the office setting,” Dr. David Fiellin reported. Office-based buprenorphine/naloxone treatment also can be an avenue for addressing other negative health consequences of chronic addiction, including referral for hepatitis C treatment, when indicated, as well as vocational and mental health programs.

Dr. Fiellin, along with lead investigator Dr. Emily Wang and colleagues at Yale University, New Haven, Conn., performed a secondary data analysis of a previous trial of three levels of psychosocial counseling and medication dispensing in conjunction with buprenorphine/naloxone maintenance treatment in a primary care clinic (N. Engl. J. Med. 2006;355:365-74).

The investigators compared demographics, clinical characteristics, and treatment outcomes for 166 adults receiving primary care–based buprenorphine/naloxone treatment, stratifying by history of incarceration as determined by the legal domain of the Addiction Severity Index.

Of the 166 patients, 52 had previously been incarcerated, Dr. Fiellin reported. Former inmates were more likely than other patients to be older, male, an ethnic minority, and unemployed. Also, they were more likely to have long histories of opioid dependence, have received methadone treatment, and have hepatitis C infection. The mean dose of buprenorphine/naloxone (Suboxone) was 17.9 mg and 18.0 mg for the previously incarcerated and never incarcerated patients, respectively, he said.

Among the previously incarcerated patients, the mean consecutive weeks of opioid abstinence was 6.2 based on opioid-negative urine samples. For other patients, it was 5.9 weeks. Mean treatment duration was 17.9 weeks and 17.6 weeks. The percentage of previously incarcerated patients completing treatment was 38%; for other patients, it was 46%.

Among patients who remained in treatment, a subsequent longitudinal analysis of self-reported illegal activity and interactions with the legal and criminal justice systems, conducted at 4-week intervals, showed “office-based buprenorphine/naloxone treatment was associated with a statistically significant decrease in participants reporting illegal activity, from 19% to 2%, and in interactions with the legal system, from 16% to 1%,” Dr. Fiellin said.

About “25% of all of those dependent on heroin pass through the criminal justice system each year,” Dr. Fiellin said. Correctional facilities provide an obvious opportunity to engage opioid-dependent individuals with treatment. “Unfortunately, less than 0.5% of all opioid-dependent individuals receive treatment while incarcerated, and as such they are more likely to connect with services in office-based programs upon release,” he said.

From the Annual Meeting of the Society of General Internal Medicine

Should We Stop Healthcare Reform Now?

Should We Stop Healthcare Reform Now?

After the election in Massachusetts many predict the collapse of the health care reform efforts. President Obama seems to seek a scaled back version, which is acceptable for Republicans who are blocking ANY reform efforts. But why do we need health care reform NOW? Lets look at the facts: If nothing will happen healthcare spending will continue to outpace the growth in the rest of the domestic product by at least 2.5% annually. Despite the overall slowdown in national health spending growth in 2008, increases in this spending continue to outpace the growth in the resources needed to pay for it! At that rate health spending will absorb 40% of GDP by 2050! The suggested reform proposal will provide 30 Million uninsured Americans adequate coverage requiring about $800 Billion to $1 Trillion in federal subsidies over the next decade. This represents only 3% of the $35 Trillion projected by actuaries to be spent on U.S. health care in the coming decade in the ABSENCE of reform. The relatively small $ 1 Trillion investment in preventing the surge of neglected chronic disease will save Trillions of healthcare dollars normally spent for the emergency room care needed to serve the growing numbers of uninsured! We need to invest money in order to save money!!!
Furthermore, health care insurance companies know very well that the initial rise in health care stocks, on expectations that the Massachusetts’s vote might derail health care reform, may symbolize a pyrrhic victory only! Even though, the reform package included mandated coverage for everyone, regardless of health status, it also offered to heavily subsidize the health care for 30 million Americans who are currently uninsured. This potential financial windfall may not materialize. Insurance companies are very well aware that selling insurance package to employers has slowed because of rising premiums, which reflect rising health care expenditures. The insurance companies must have an interest to bend the cost curve and to expand insurance coverage to offer competitive products. Insurers may gamble with their financial future by supporting the Naysayer because without an overhaul of the insurance industry and the health care market they may face an even bleaker future, which will force draconian government intervention to cut costs.
Therefore, we must support rational reform efforts and President Obama should stop pandering to the opponents of any meaningful reform efforts. We have to act now to avoid a future financial crisis!


Bernd Wollschlaeger,MD,FAAFP,FASAM