TnSAM State Chapter Meeting

Saturday October 1st  9am to 1pm.
Embassy Suites, Murfreesboro Tennessee
Please join us for our state chapter meeting this Fall.
Agenda Soon to Follow
We will be discussing current policies, membership drives, educational initiatives, and any other topics of interest.
Light refreshments and/or breakfast will be served.
Please let us know who will be attending and more importantly if you will be staying overnight the night prior so we may apply for a discounted group rate.
Please contact Dr. Zotos via email or phone.

 

Message from Our President

Greetings from TnSAM,
I hope everyone is enjoying their summer and taking some time off for family, friends, and personal endeavors.
It is an exciting time for addiction medicine.  More and more light is being shed on the opioid epidemic currently facing our communities.  The tides are turning on the liberal use of opiates for “chronic pain”.  Just recently the President of the AMA, Steven Stack, M.D. addressed the issue regarding the overprescribing of opiates and steps we should all follow to help curb the crisis.  In March of 2016, the CDC released new recommendations for the prescribing of opiates for chronic pain.  Furthermore, discussions have taken place in congress questioning the current practice of the CMS for coupling reimbursements to patient satisfaction scores in regards to pain control.    As this all comes to light, prescribing practices will change and help reduce the excessive use of opiates for pain control, inadvertently leading some down the vicious cycle of addiction.
However, this in itself does not directly impact our current crisis of opiate dependent patients.  Recently, the HHS announced an increase of 275 patients that can be prescribed buprenorphine, for certain qualified physicians, mainly boarded physicians and certified treatment facilities.  This is definitely a step in the right direction yet there are people on both sides of the fences in regards to whom should be qualified to do this.  There are many non boarded physicians whom do an outstanding job that could definitely see more than a 100 patients.  On the other hand, there are some boarded physicians whom do not practice quality addiction medicine and simply write for buprenorphine. They do not spend time with their patients or provide counseling or therapy for them.  Time and time again patients will tell us how another provider did not even take the time to listen to them or show interest.  Poor providers beware, your patients tell on you!!!
Over time, I have changed my view as to the necessity of some regulation and oversight.  If it serves to improve the care of the patient then so be it.  Simply writing medication and taking payment for it without providing insight and solutions to the disease of addiction is simply wrong.  My belief is that over time the “bad apples” will go away and the law of economics will bring about the highest quality care at a reasonable cost for the patient.
Furthermore, TnSAM must support to fight for reimbursement from insurance companies and increase access to care.  It is my hope that one day we all can simply bill insurance and be reimbursed at a “fair and reasonable” level just like any other specialty.  We can not say we want to be regarded as a specialty and not practice billing the way they do.  On this, we have a long way to go…….
Most of us in the field keep up with the regulations and standards in regards to medication assisted therapy.    However, some do not.  Thus I wanted to summarize to anyone who may not be aware of current policies and regulations that will go into effect soon in Tennessee.  Tennessee will be placing all practices under one of two regulatory agencies.  If you are a solo practitioner and see up to 150 patients then you will fall under the Department of Health, Division of Health Related Boards. i.e. the medical board.  If you are seeing 150 or more patients, whether a solo, group practice, or clinic, you will fall under the Department of Mental Health and will be a licensed facility and have to meet certain guidelines.   This will include regulatory fees, meeting certain criteria, and monitoring to ensure the highest quality standards are met.  These regulations are being adopted due to the concerns of many groups including state legislators, law enforcement agencies, health care providers, and certain concerned citizens in Tennessee.  This came out of necessity invariably due to a few providers whom practice out of the standard of care, and may not have their patient’s best interest at hand.
Please continue to do what you do best and that is to provide your patients with the best quality care possible.  I do not know of many other fields where patients thank you on a daily basis for saving their lives.  Addiction medicine is truly a rewarding specialty.
Sincerely,
Alexander Zotos, M.D.
President, Tennessee Society of Addiction Medicine

 

ABMS RECOGNIZES ABAM AS NEWEST MEDICAL SUBSPECIALTY!!!!!

Drs. Sokol and O’Connor said it eloquently in their letter of this announcement to all ABAM diplomates:

As we all celebrate this occasion, we hope that you will take a moment and reflect with pride on your own contributions to our newly recognized field. As ABAM diplomates you have been at the forefront in the care of patients with substance use disorders. Your work has been driven by the will to care for patients and families, and to improve their lives and the health of your community. You have stood up to stigma, ignorance and to outdated policies and practices that accompanied this most challenging of all diseases. You have had many successes with patients and colleagues along the way and have set the stage for medicine’s response to addiction. You have pioneered this new era in American medicine and healthcare. Thank you, and savor the moment.

ABMS RECOGNIZES ABAM AS THE NEWEST MEDICAL SUBSPECIALTY!!!!!

Drs. Sokol and O’Connor said it eloquently in their letter of this announcement to all ABAM diplomates:

As we all celebrate this occasion, we hope that you will take a moment and reflect with pride on your own contributions to our newly recognized field. As ABAM diplomates you have been at the forefront in the care of patients with substance use disorders. Your work has been driven by the will to care for patients and families, and to improve their lives and the health of your community. You have stood up to stigma, ignorance and to outdated policies and practices that accompanied this most challenging of all diseases. You have had many successes with patients and colleagues along the way and have set the stage for medicine’s response to addiction. You have pioneered this new era in American medicine and healthcare. Thank you, and savor the moment.

Dr. John Standridge Passes the Presidency Baton to Dr. Alex Zotos

Happy 2015, Everyone. I want to thank you for entrusting me with the presidency of TNSAM for my 2-year term which just ended. I want to wish Dr. Alex Zotos all the best as he assumes the leadership of this strong and commendable organization. I also wish to welcome our newest members to TNSAM: Kenneth Trzil, Jonesborough, Tennessee; Joseph Radawi, Jonesborough; Tony Yost, Greeneville;  Brandon Coffey, Oneida;   Stephen Averett, Linden; Richard Bowie, Johnson City; and Rikki Halavonich, Knoxville, Tennessee. I hope to see each of you at our annual meeting in April in Austin, Texas.

Allow me to review just a few of our 2013-2014 accomplishments. First we formulated the PEACE agenda:

  1. Parity – equality in access, benefits, coverage, respect, and treatment
  2. Education – of public, legislators, physicians in training and those in practice
  3. Advocacy – advancing the stature and recognition of the specialty
  4. Communication – facilitating the spread of ideas among members and the public
  5. Evidence-based practice – improve the quality of addiction treatment through research and education

Towards accomplishing these goals, I and others have made many trips to Nashville. We have witnessed remarkable acceptance, respect and inclusion in the legislative processes that affect us. We have worked with the TMA and others to promote legislative proposals that include the Addiction Treatment Act of 2015. This bill seeks to provide Good Samaritan protections for an individual who is having a drug overdose or in good faith seeks medical assistance for a person experiencing or believed to be experiencing a drug overdose. Second, the bill codifies the prescribing of buprenorphine/naloxone to physicians with a DEA “X” number and only in doses and diagnoses which the FDA has approved for the use of the drug. The final piece of the bill repeals a section of the code that allows an insurer to refuse payment to a provider if the patient seeks treatment and it is determined that the patient is under the influence of alcohol or illegal drugs. The Tennessee Society of Addiction Medicine has worked closely with the TMA to promote patient safety and patient access to the best available addiction treatment. This legislation is an important step in the right direction. Treatment decisions on the use of FDA-approved medications for addiction should be made only by skilled physicians, as is true in any of the specialties.

We have witnessed Federal advances in patient care access with the Affordable Care Act and with parity from implementation of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act.

We have held very successful CME activities, including our third TNSAM Addiction Medicine Conference and the ASAM-sponsored CO*RE/ASAM ER/LA Opioid REMS: Achieving Safe Use While Improving Patient Care course. We have held chapter meetings at ASAM’s Med-Sci Annual Conferences. We have created and maintained our website at http://www.tnsam.org. We have revived our charter with the state, and rewritten and approved our by-laws and constitution. We have successfully fought and defeated legislative efforts that would have harmed our efforts to provide proper care to those with substance use disorders. There’s more, but enough is enough.

Mostly I want to share my thanks and appreciation to each of you for all that you do every day for the addiction community. I am your past-president now, but I plan to continue to assist Dr. Zotos where I can, and continue to fight the good fight for addiction medicine and the patients we serve.

God Bless,

John Standridge, MD, FAAFP, FASAM

Past-president. Tennessee Society of Addiction Medicine

ASAM Supports Markey Bill

ASAM declared its support for The Recovery Enhancement for Addiction Treatment (TREAT) Act. This bill would lift the buprenorphine prescribing limit for addiction physician specialists and non-specialist providers. As it stands, the prescribing limit inhibits treatment for many people suffering from the chronic disease of addiction.

Read the ASAM letter of support from Dr. Gitlow.

Liquid Soap

Soper Says:

Addiction-categories: Process-Appetite  or  Substance/Behavioral
 
 

In 2012 the American Society of Addiction Medicine smartly set forth a definition of addiction that encompasses both substance abuse and certain compulsive behaviors. Using ASAM’s definition a clinician can assess process and appetite addictions. Some discussion of this classification is topic today.

In most ways, substance and behavioral addictions are incredibly similar. Essentially, substance addicts are people who’ve lost control over their use of nicotine, alcohol, prescription drugs, and/or illicit substances such as methamphetamine, heroin, and cocaine.   Behavioral addictions (also called “process addictions”) involve the same basic loss of control. The only real difference is that with behavioral addictions the loss of control involves not substances but potentially pleasurable activities such as gambling, working, eating, spending, sex, others.

Sadly, numerous people, professional and lay public, mistakenly view behavioral addictions as “moral flaws” that are “less serious” than “real” addictions. However, those of us who treat these concerns on a regular basis continually witness the consequences of out-of-control impulsive, compulsive behaviors.  Addictive behaviors wreak as much havoc on families, careers, and lives as substance addictions nicotine, alcohol, prescription medications, and others. Furthermore, we see the ways in which behavioral addictions often pair with substance abuse. For instance, many who suffer from compulsive sexual disorder or impulse control disorder, also struggle with stimulant abuse or addiction, to such substances as cocaine or methamphetamine. Usually, if such a person/patient is to find lasting sobriety he or she needs to  be treated for both addictions simultaneously. Otherwise, whichever addiction it is that hasn’t been treated can easily lead to active recurrence with the other.

The Process of Process Addictions

Part of the confusion around behavioral addictions stems from the fact most addictive behaviors are – for most people, most of the time – healthy, perhaps even essential activities. Things like eating and being sexual, for instance, contribute to survival of the individual and the species. Without these activities the human race would quickly die out. Because of this, our brains are programmed to encourage these behaviors. And for people who become addicts, this is where the problem starts. Simply put, eating and being sexual trigger, among other things, the release of dopamine in the rewards center of the brain, resulting in feelings of pleasure. (Addictive drugs trigger a similar neural response.) Not surprisingly, this biochemical pleasure process is a key element in the development and maintenance of addictions. Essentially, the brain remembers that eating or being sexual or gambling,  causes feelings of pleasure. The dopamine surge in  the brain overrides homeostatic responses, the easy way to feel better is to engage in the pleasurable (and  potentially addictive) activity.  
 

To further understand the similarities between substance addictions and behavioral addictions, it may help to consider the individual who, cash in hand, has found a source for the addictive substance he so desperately wants. He leaves work early without informing his boss, hops in the car, and speeds to the source of purchase. The brain dopamine release is occurring prior to the purchase,in anticipation of  substance use. The brain adapts, (neuroplastic changes occur) to the surge of the dopamine from the expectation of substance use. After all, his thinking is impaired (he’s making bad decisions), his pulse racing, and he desires/feels compelled to purchase and use the substance, no matter the consequences. The closer he gets to using, the higher the pusle, respiration, body temperature, and the more tunnel-visioned and impulsive his thinking becomes. Yes, indeed, he is becoming mind altered in anticipation. Yet at this point there has been no current use of substance !

Behavioral addictions operate on the same “anticipatory high” principle. For instance,  sex addicts find as much (if not more) pleasure and relief (from stress and emotional pain) in the fantasy and pursuit of sex as in the sex act itself. They sometimes refer to this elevated, fantasy-driven state of neurochemical excitement as “the bubble” or “the trance.” They simply lose touch with reality for hours or even days at a time – high on the idea of sex – with little or no actual physical contact. Very similar changes are described by gambling addicts. Thus we see that for both substance addiction and behavioral addiction, the fantasies and actions that lead up to actually using/acting out (the ritualized process of the addiction) are every bit as compelling and desirable as the actual drug or behavior.

Identifying Behavioral Addictions

Behavioral addictions are often initially identified during substance abuse treatment or soon thereafter. Usually they pop up as either a cross-addiction or a co-occurring addiction. (Cross-addictions are when the addict uses one addiction to replace another; co-occurring addictions are when two disorders are present at the same time.)

 

  • Cross-Addiction: While in residential treatment for alcohol addiction, Sydney gains 20 pounds, replacing her drinking with compulsive eating. Later, when she eventually decides to go on a diet, she suddenly finds herself drinking again.
  • Co-Occurring Addiction: Jack leaves treatment for cocaine abuse, thinking he is cured. Once home, he calls up a sexual partner, thinking he’ll “treat” himself because he’s been sober for 30-plus days. Within minutes of partner arrival, he’s doing lines of cocaine, little realizing that his cocaine use and his sexual behaviors are directly linked.

As is the case with substance abuse recovery, the journey toward sobriety from behavioral addictions is a long-term process that typically requires professional counseling with a clinician or team of clinicians experienced in addressing the specific addiction, along with any cross- or co-occurring disorders that may be present. Happily, such treatment is now available at facilities, which we can refer to.

 One significant treatment difference between substance and behavioral addictions lies in the definition of sobriety. Whereas complete abstinence from the addictive substance, is typically expected in drug and alcohol treatment, those addicted to things like food and sex must  learn to carefully identify the behaviors that do and don’t compromise the values and relationships they hold most dear. Then they contract to not engage in the problematic activities and to limit their engagement in the non-problematic activities to moderate and appropriate levels. Otherwise, the treatment and recovery process is incredibly similar for both substance and behavioral addictions…

Progress not perfection.
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Legislating Limited Treatment Will Worsen Outcomes

Recovery , stable sustained abstinence,  does not alleviate the accountabilities of addiction treatment by the healthcare professionals. Each year, more than 13,000 specialized addiction treatment programs in the United States serve between 1.8 and 2.3 million individuals, many of whom are seeking help under external duress.  Those who are the source of such pressure are, as they see it, giving the individual a chance — with potentially grave consequences hanging in the balance.   Now with recent intended legislation, we again see non medical professionals attempt to limit the chances one is given to obtain “remission” from their disorder.  Imagine telling the diabetic or asthmatic —  one 6 month period of treatment, that’s it. 

Accepting the mantra that “Treatment Works”, families, varied treatment referral sources and the treatment industry itself, as well as legislators, believe that responsibility for any resumption of alcohol and other drug use following service completion rests on the shoulders of the individual, even with mandated limitations of care.  This is unique in the annals of medicine.  With other medical disorders, continuation or worsening of symptoms is viewed as an indication that the initial treatment is not effective for this particular patient and that changes in the treatment protocol are needed.  In contrast, when symptoms continue or worsen following addiction treatment, it is the patient who is blamed and often punished.  The stance is, “You had your change and you blew it!  You must now suffer the consequences of your actions.”  And those consequences are often quite dire, including divorce, loss of children, loss of housing or educational opportunities, termination of employment, discharge from the military under less than honorable conditions, loss of professional licenses, loss of driving privileges, and incarceration, to name just a few.  Such punishments are often meted out with an air of righteous indignation in the belief that the person for whom we have done so much has failed this chance we have given them.  The question I am raising in this blog is:  Was it really a chance?  Does this pending legislation  appropriately address or provide adequate care, or raise the quality of healthcare for our citizens?

Put simply, we are routinely placing individuals with high problem severity, complexity and chronicity in treatment modalities  whose low intensity and short duration of service (possibly mandated by law) offer little realistic hope for successful post-treatment recovery maintenance. By using terms like “completion of “, ” limited clinical treatment”, and ending the service relationship following such brief clinical interventions, we convey to patients, to families and to all other interested parties at “discharge” from treatment that recovery is now self-sustainable without continued professional support.  And this is true just often enough (but often attributable to factors unrelated to the treatment) that this expectation is maintained for all those treated.  For those with the most severe problems and the least recovery capital, I believe this expectation is not a chance, but a set-up for failure with potentially greater consequences than might have naturally accrued.   This proposal will not provide evidence-based improved outcome to our patients.  I would posit, quite likely as many of us have seen before, we will see recurrence in the disorder (recurrent illicit drug use and all its consequences).

What we know from primary medicine is that ineffective treatments (via placebo effects) or an inadequate dose of a potentially effective treatment (e.g., as in antibiotic treatment of bacterial infections) may temporarily suppress symptoms.  Such treatments create the illusion of resumed health, but these brief symptom respites are often followed by the return of illness — often in a more severe and intractable form.  This same principle operates within addiction treatment and recovery support services.  Flawed service designs, or mandated statutory laws, may temporarily suppress symptoms while leaving the primary disorder intact and primed for reactivation.  But now the treated individual has three added burdens that further erode recovery capital.  First, there is the self-perceived experience of failure and the increased passivity, hopelessness, helplessness, and dependency that flow from it.  Second, there are the perceived failure and disgust from others and its accompanying loss of recovery support — losses often accompanied by greater enmeshment in cultures of addiction.  Finally, possibly mandated by law, time/dose limits of care. There are the very real other consequences of “failed treatment,” such as incarceration or job loss that inhibit future recovery initiation, community re-integration and quality of life. That will be the outcome of this proposed legislation.

The personal and social costs of ineffective treatment are immense.  If we as a society and as a profession, and dare I say, legislators, commissioners, law enforcers, clergy, educators and others, want to truly give people with severe and complex addictions “a chance”, then we have a responsibility to provide systems of care and continued support that speed and facilitate recovery initiation, buttress ongoing recovery maintenance, enhance quality of personal and family life in long-term recovery, and provide the community space (physical, psychological, social and spiritual) where recovery and sustained health can flourish.  Anything less is a set-up for failure.  We are closing the door to medical care and recovery to attempt to legislate limits on scientifically based, proven effective medical treatment such as office based opioid  treatment using buprenorphine and other medications. 

As addiction professionals, we should always be mindful of the power we wield and its potential effects on people’s lives.  That power comes from our professional decisions and actions, but it also flows from the treatment designs within which we operate.  If we are going to participate in giving people a chance, then we need to make sure it is a real chance and not a set-up for what is ultimately more a system failure than a personal failure.  As Dr. Standridge has requested,  it is time for leaders of addiction treatment to contact our legislators and law makers.  Perhaps addiction treatment as a system of care is itself in need of becoming active in patient advocacy  and active in the  legislative process.  Our  voice, that  of our specialty, Addiction Medicine, has for too long been silent.  Let’s advocate for our patients, NOW.

A proposed amendment to TCA Title 53 Chapter 10 limits buprenorphine prescribing

For consideration in January, 2014, there is a proposed amendment to TCA Title 53 Chapter 10.  The proposed legislation is problematic on several levels. The first of which has to be recognized as a state-sponsored restraint of trade that prohibits qualified specialists in the field of addiction from using an effective medication appropriately.  The question of how long a patient “should” be on buprenorphine for addiction management is not an appropriate legislative issue.  A banner on the www.TnSAM.org website reads, “Treatment decisions on the use of FDA-approved medications for addiction should be made only by skilled physicians.”  A proposed top dose and forced taper is inappropriate. The issue of requiring the naloxone combination is flawed. These issues are fundamental to the proposed bill and therefore there is no acceptable amendment. Continue reading