Monday, April 14, 2014

Managing Benzodiazepines with MAT: The Philadelphia Story




Maureen Fitzgerald
Editor, ATTC Network Coordinating Office and NIATx


With this month’s Third Thursday iTraining (2:00pm EST, April 17) coming up, “Management of Benzodiazepines in Medication-Assisted Treatment,” I took a few minutes to chat with Roland Lamb, Director of the Office of Addiction Services at Philadelphia’s Department of Behavioral Health and Intellectual disAbility Services (DBHIDS).

Lamb and colleagues at DBHIDS got the ball rolling to create a set of practice guidelines for benzodiazepines back in 2011, in response to what they saw as a very confusing environment for Philadelphia providers and their constituents. 

“We were seeing a lot of different approaches to benzodiazepines and MAT for opioid dependence,” says Lamb. “Some providers were medicating patients with benzodiazepines and others refused to treat anyone who was using them. There were also providers who just didn’t know what to do with patients who continually tested positive for benzodiazepines while receiving MAT. And then there were patients who were getting prescriptions for benzodiazepines but not testing positive—so they must have been dealing. It was a very confusing environment for providers and for patients, but our main concern at DBHIDS was that we did not want to see people discharged from treatment for the very reason they needed treatment.”

A suggestion from Dr. Trusandra Taylor led Lamb to consider creating a resource similar to the ATTC buprenorphine treatment blending product. He then reached out to Dr. Arthur Evans, Commissioner of DBHIDs, Dr. Matthew Hurford, Chief Medical Officer at DBHIDS, Dr. James Schuster, Chief Medical Officer at Community Care Behavioral Health Organization, and Mike Flaherty, then director of IRETA, to get the project going.  Drs. Hurford and Schuster, along with Dr. Dawn Lindsay of IRETA, will present the April 17 iTraining.

“We saw this as not just a Philadelphia problem, but a statewide and national problem,” says Lamb. “The end result we hoped would be a set of guidelines that would focus on treating the person rather than managing the medications.”

The resulting guidelines, developed by IRETA, join the of Practice Guidelines for Recovery Oriented Treatment that DBHIDS has created as part of its Tools for Transformation initiative. Jessica Williams provides a great overview of the guidelines in her article in this month’s ATTC Messenger. For more about the Transformation Initiative, see Jon Korczykowski’s recent story in Behavioral Healthcare, "Transformation in Philadelphia". 

“Philadelphia providers have welcomed the benzodiazepine guidelines, but at the same time they’ve given some providers reasons to question use of benzodiazepines. We still need to figure out how to fit this all together in terms of risk management,” says Lamb. “We’re hoping that providers will begin to tell us which guidelines are useful, and we also want to hear from those they’re treating.”

Overall, says Lamb, creating the guidelines demonstrates how payers like DHBIDS can enhance quality of care. “Partnering with providers serves our constituents better, and creating guidelines like these allows us to extend the partnership with greater continuity.” 

Tuesday, April 8, 2014

New Medication Shows Promise for Effective Treatment of Alcoholism and Depression



Meg Brunner, MLIS
Librarian
Alcohol & Drug Abuse Institute, University of Washington
CTN Dissemination Library

Alcoholism is often accompanied by co-occurring mental health disorders such as depression. While evidence-based medications for alcoholism treatment are effective in reducing cravings and preventing relapse, a single medication to treat alcoholism and co-occurring depression has not been available.   

A long-term study partially funded by NIDA’s National Drug Abuse Treatment Clinical Trials Network (CTN) found promising results for the treatment of alcoholism with co-occurring depression using the antidepressant mirtazapine (trade name Remeron).

Mirtazapine is unique among antidepressants, unrelated to tricyclics or selective serotonin reuptake inhibitors (SSRIs).  Instead, it is classified as a second-generation “tetracyclic” antidepressant and is commonly used both for treatment of depression and also as an appetite stimulant and antiemetic.

Recently, it has also demonstrated effectiveness as a medication used to treat substance abuse disorders.

Though this particular study was very small, conducted with only 12 adult outpatient subjects suffering from both alcoholism and major depressive disorder, the results were impressive, with self-reported depressive symptoms decreasing by 74% and drinking decreasing by 60.8% at the end of the study’s 8-week acute phase.  

Additionally, while none of the subjects in the study were employed full-time at baseline, by the 2-month mark, 75% of them were back to full-time work, suggesting an increase in level of functioning thanks to decreases in both depressive symptoms and alcohol use.

All of these clinical improvements occurred relatively quickly after starting mirtazapine, as well, which is consistent with the rapid onset of response in previous research about this medication.

Two years after entry into the acute phase of this study, 10 of the 12 original patients were evaluated for long-term effects.  The large magnitude improvements in depressive symptoms, drinking, and sleep disturbances persisted.  Only 2 of the patients demonstrated symptoms of major depressive disorder at the 2-year follow-up, while all 10 had at baseline.  Six of the 10 had continued to use antidepressants during the follow-up period.

These preliminary findings suggest exciting possibilities for the use of mirtazapine as a treatment for co-occurring depression and alcoholism in both acute and long-term treatment phases. It is hoped that this study will encourage further research on this medication’s efficacy, as double-blind studies are needed to confirm these results. 

Citations:
Cornelius JR, Douaihy AB, Clark DB, et al. Mirtazapine in comorbid major depression and alcohol dependence: an open-label trial. J Dual Diagnosis 2012;8(3):200-204.

Cornelius JR, Douaihy AB, Clark DB, et al. Mirtazapine in comorbid major depression and alcohol use disorder: a long-term follow-up study. J Addict Behav 2013;2:4.



Meg Brunner, MLIS, has been a research librarian and web development specialist at the University of Washington’s Alcohol & Drug Abuse Institute in Seattle since 1996. Along with Nancy Sutherland, MLS, she runs the National Drug Abuse Treatment Clinical Trials Network (CTN) Dissemination Library, an online library of materials by and about the NIDA CTN.  Meg Brunner is also very active in the international organization Substance Abuse Librarians & Information Specialists (SALIS), where she has served as Chair of the Executive Board and is currently the editor of their quarterly newsletter, SALIS News.  She is also a new member of the Addiction Technology Transfer Center (ATTC) Network’s Advisory Board.  In her personal time, she writes for her humorous web site and book/movie review blog at http://megwood.com, featured in Elle Canada, Mademoiselle, USA Today, and Yahoo! Magazine, and serves on the Board of Directors at Purrfect Pals, a regional cat shelter and sanctuary.

Wednesday, April 2, 2014

Alcohol Awareness Month and Technology



Dave Gustafson, Ph.D.


This April marks the National Council on Alcoholism and Drug Dependence’s 28th Alcohol Awareness Month, “Help for Today. Hope for Tomorrow.” NCADD devotes this month every year to reducing stigma and increasing awareness about alcohol addiction. NCADD’s message is that alcoholism is a serious illness and not a choice. This year’s theme on preventing underage drinking is a reminder about starting early in educating our children on the dangers of alcohol abuse.

What’s interesting to me is that probably a lot more people are hearing about Alcohol Awareness Month today than back in 1987, when NCADD started the campaign. In 1987, radio, TV, and print media were the main ways to build awareness.

Today, the Internet and social media are spreading NCADD’s message faster and farther. Through Facebook, Twitter, and email, more people in more places can participate easily in alcohol awareness discussions and activities. My guess is that this translates into an exponential increase in awareness and activities and that more schools, parents, churches and communities will be getting the word out.

The Internet is an incredible tool for sharing information, and with technology changing at breakneck speed we may be at just the start of huge technological innovations. I’ve heard that we are in the first minute of the first day of the digital revolution. It’s hard to even imagine what might be in store for us just a year from today.

Public information campaigns like Alcohol Awareness Month use the Internet to increase awareness. But increasing awareness doesn’t solve the problem. We need to equip people with effective tools to manage their chronic conditions. How do we do something about the problem once we’ve raised awareness?

And here again, Internet technology offers an answer. 

Back in 2003 when we started to look at ways to improve the treatment system—with the Robert Wood Johnson Foundation grant that created NIATx—I talked to a lot of researchers and policy makers who said that the problem was “not enough people.” There also seemed to be a general feeling that having more counselors would give more people access to treatment. 

But as an engineer (stay with me now), my first thought was that addiction treatment is incredibly labor-intensive, and that almost any industry that builds things (I was thinking of treatment as a product) doesn’t ask, “How can we get more people?” They ask instead—“How can we do more with what we already have?”
 
I never thought that “more people” was the answer to improving the addiction treatment system. I thought we needed to ask different questions: “How can we supplement the work that people are already doing? How can we reduce repetitive tasks? How can we use other existing resources to meet our goals?”

Don’t get me wrong—people are great. (I’m even married to one and she’s pretty wonderful.) But they have limited memory and have to deal with competing demands like eating and sleeping and even taking a vacation now and then. And in the treatment field (as in other fields) counselor skill and the quality of care they provide varies.

Enter the Internet. While some have raised concerns about new mobile health systems reducing or eliminating the human factor, the Internet actually supplements the human factor.  People suffering from alcoholism and other SUDs need emotional and social support to recover. A counselor can provide some of that support once a week or so—but an Internet-based social support group makes it available 24/7. Now it’s possible for a teen in small Iowa farming community to connect at any time of day or night with someone in his support network of people of different ages and backgrounds from across the country, all united in their goal to embrace a life in recovery.

That’s just one example of how technology is really a facilitator, an extension of the human support that a counselor and groups such as AA provide. With unlimited time and energy, technology is an addition, not a replacement.

NCADD’s Alcohol Awareness Month reminds us that alcoholism is a chronic disease; like other chronic conditions it requires using various resources to make a difference. Technology-based tools increase the resources available to help people manage their conditions. These rapidly evolving innovations offer great potential to combat the devastating consequences of alcohol and other drugs on individuals, families, and communities.   


David H. Gustafson, Ph.D., is Research Professor of Industrial and Systems Engineering at the University of Wisconsin-Madison and director of the Center for Health Enhancement Systems Studies, which includes NIATx. His interests in decision, change, and information theory come together in the design of systems and tools to help individuals and organizations make effective changes. Dr. Gustafson leads a research team that has developed A-CHESS, a smartphone-based health system for recovery support and relapse prevention. 

Wednesday, March 26, 2014

eHealth requires a new research model



Kim Johson, MBA, MSEd

Deputy Director, NIATx

Co-Director, ATTC Network Coordinating Office


What apps do you use?  If you are like most people with smart phones, I bet you have at least one health app. Maybe, like me, you use myfitness pal or My Tracks or one of many other exercise apps that are available. Maybe you have a Fitbit that tracks your movement. I even have a SleepBot “smart alarm” that measures the quality of my sleep (and makes a recording of my snoring!). Maybe you have a chronic disease and you’re using an app that monitors your heart rate or other vital signs.

Unless they have an attachment that is considered a medical device, none of these apps have been demonstrated to be effective in a clinical trial. Do you care?  Is it important for your apps to have demonstrated efficacy?
As discussed in the recent article “How Can Research Keep Up With eHealth? Ten Strategies for Increasing the Timeliness and Usefulness of eHealth Research” (Baker, Gustafson, Shah, Journal of Medical Internet Research, February 2014), the timeline for federally funded research can be seven years or more. If we look back to 2007, I bet most of you were psyched if you had a BlackBerry. The first iPhone was released in June of 2007. Almost all of the published research on healthcare apps covers only pilot tests and conceptual designs. Why? Because if it takes seven years from concept to outcome, then we will just start seeing RCT results on health apps developed in 2007 this year.
In the five-year time frame of our clinical trial for A-CHESS (a smart phone app to support addiction recovery) we had to completely rewrite the code because the operating system we started with was obsolete within a year of the study launch. The application that the last study participants recruited received was quite different from the application that the first participants receivedby necessity, not by design. And the results have just been published online in JAMA Psychiatry.

So perhaps it’s time we design a different kind of a study. When technology moves as fast as it does now, we need a different research model to keep up with it. As the article mentioned above suggests, there are ways of designing studies that can provide adequate evidence with small samples and shorter time frames. Changing the way we design studies would have a very big impact on the research world. Researchers live in five-year cycles of funding. If our studies only last a couple years, we are going to spend even more time chasing money, unless the funding process also changes. Hard to imagine that a shift that large could come to academia, but technology has driven so much transformation in so many industries and is on the verge of significantly changing the way healthcare is delivered. So why shouldn’t it upset the apple cart for researchers as well?

Kim Johnson, MBA, MSEd
Kimberly Johnson served for seven years as the director of the Office of Substance Abuse in Maine. She has also served as an executive director for a treatment agency, managed intervention and prevention programs, and has worked as a child and family therapist. She joined NIATx in 2007 to lead the ACTION Campaign, a national initiative to increase access to and retention in treatment. She is currently involved in projects with the ATTC Network and NIATx that focus on increasing implementation of evidence-based practices, testing mobile health applications, and developing distance learning programs for behavioral health.

Wednesday, March 19, 2014

10 Reasons Why You Should Attend the National Hispanic and Latino ATTC Conference 2014


Registration is now open for the National Hispanic and Latino ATTC Conference 2014!
October 8-9, Learning Commons Center, University of Texas at Austin

http://www.hispaniclatinoattcconference.com/

The Hispanic and Latino population in the United States has grown by 40% in the past decade. Today, Hispanics and Latinos make up 17% of the U.S. population; by 2060 it is estimated to grow to 30 percent. The group is disproportionately affected by substance use disorders, depression, diabetes, and other physical and behavioral health conditions, intensifying the need for a culturally competent workforce.

http://www.attcnetwork.org/regcenters/index_nfa_hispaniclatino.asp
Our conference, “Integrating Research, Education, and Services to Reduce Behavioral Health Disparities in Hispanic and Latino Populations,” will bring professionals from across the country together to address health disparities faced by the Hispanic and Latino population in the United States. The conference will  promote  an understanding of these disparities in services to Hispanic populations in need of quality substance abuse treatment.

Why should you attend? For any one of these top 10 reasons:



1. Expand your knowledge: The conference promotes an understanding of behavioral health disparities among Hispanics and Latinos in the United States.

2. Connect:
Network with your fellow providers, researchers, and educators.

3. Hear from the experts: top researchers will present the latest findings on substance use disorders and the Hispanic and Latino population.

4. Address disparities: through research, education, and service models combined with science-based knowledge.

5. Gain easy access to The National Hispanic and Latino National Focus Area ATTC suite of services: an array of resources for behavioral health professionals and paraprofessionals.

6. Increase your understanding of the social, economic, political factors contributing to behavioral health disparities in Hispanic and Latino populations.

7. Tackle barriers to access and care for Hispanic and Latino populations in a forum where providers, researchers, and educators share ideas and resources.

8. Learn about novel, promising, and culturally appropriate approaches to address behavioral health disparities in Hispanic and Latino populations.

9. Build the skills you need to apply evidence-based practices in real-world settings.

10. Earn CEUs for attending one or both days.

For more information, please visit the conference website or contact us by email at hispaniclatinoattc@uccaribe.edu

The team at the National Hispanic and Latino ATTC is looking forward to seeing you in Austin.  Don’t miss this unique opportunity—register today!




Miguel Cruz
BS, MS, PhD.c
National Hispanic and Latino ATTC
Associate Director

Tuesday, March 11, 2014

Minimizing March Madness

Keith Whyte
Executive Director
National Council on Problem Gambling 


Everyone knows that “March Madness” refers to the NCAA Basketball Tournament. While there are over nine quintillion possible brackets, serious bettors and casual fans alike bet on the games. The tournament has become one of the biggest betting events of the year. We believe it is time to make sure that the behavioral health workforce and the general public understands some who bet will develop problems and that these problems are serious but treatable.

NCPG invites professionals in the addictions treatment and recovery services field to participate in National Problem Gambling Awareness Month (NPGAM). NPGAM is a grassroots public awareness and outreach campaign to educate the general public and health care professionals about the warning signs of problem gambling and raise awareness about the help that is available both locally and nationally. For campaign materials and more information, please visit www.npgam.org 

When problem gambling became re-classified as a behavioral addiction in the American Psychiatric Association’s Diagnostic Manual, Fifth Edition (DSM-5) last year, it was important to reach concerned citizens and healthcare professionals to educate them about the newly classified addiction and available resources, including brief screens.

Why participate in the campaign?  Why should you screen your clients for gambling addiction? Consider the following:  Adult problem gamblers are five times more likely to have co-occurring alcohol dependence, four times more likely to abuse drugs, three times more likely to be depressed, eight times more likely to have bipolar disorder, three times more likely to experience an anxiety disorder and have significantly elevated rates of tachycardia, angina, cirrhosis. High-risk groups include veterans and individuals with disabilities.

Through the use of brief screens and early interventions to address the myriad of emotional, physical and financial problems created by gambling addictions, significant reductions in service demand and costs associated with intensive treatment interventions will be realized. By providing therapeutic approaches that are appropriate for problem gamblers and their families, it is hypothesized that recovery rates will increase for a wide variety of health, substance abuse and mental health disorders given the significant rate of co-occurring disorders.

We therefore encourage all healthcare providers to screen all their clients for gambling addiction in March (and throughout the year). Screening for gambling-related history and symptoms is justified because of the prevalence and potential severity of gambling addiction, the potential to improve client outcomes, the possibility of preventing relapse or transference, and the low costs/high benefits of detecting a co-occurring gambling addiction. Screening and brief intervention has been proven to be an effective intervention in a number of areas and may help you minimize the impact of this hidden addiction on your clients and communities.

Learn more about problem gambling through the ATTC Network's Problem Gambling Webinar Series

 Keith S. Whyte became the Executive Director of the National Council on Problem Gambling (NCPG) in October 1998.  NCPG is the national advocate for programs and services to assist problem gamblers and their families. 

Previously, Mr. Whyte served as Director of Research for the American Gaming Association where he was responsible for research and public policy issues, including problem gambling.  Mr. Whyte has written numerous articles, studies and book chapters on gaming issues.  In addition, he has testified four times before the United States Congress on gambling-related legislation.  He regularly discusses gaming issues in national and international print, radio and broadcast media.

Wednesday, March 5, 2014

Problem Gambling: Let's Bring the Problem out of Hiding



Bill LaBine

Executive Director and Clinical Supervisor

Jackie Nitschke Center

Green Bay, WI



My name is Bill LaBine. I am the executive director and clinical supervisor at the Jackie Nitschke Center in Green Bay, WI. Green Bay has three casinos, all located within three miles of my home; I pass one daily on my way to and from work. I am saddened when I drive by the casino early in the morning. I see many cars that have been parked there through the night.
I know the casinos collect data on each individual’s behavior patterns and market to those behaviors. I know casinos pump in oxygen to keep gamblers awake, along with music and sounds that make people believe others are winning jackpots. The slot machines vary in stature so the flashing lights stimulate people of all heights. The carpeting is ugly on purpose: to keep your eyes on the machines, not the floor. There are no windows or clocks to help you keep track of time. And it's easy to get lost in the labyrinth and stop at another machine on your way to cash out your "winnings."
I know the tired, depressed, shameful walk from the casino door to my car. I know the feeling of having to work all week to pay off the credit card withdrawal from the casino ATM—and blaming the credit card company for charging high withdrawal fees. I know the feelings of isolation and shame of this secret world. I also know the frustration of telling myself I would never gamble again, only to have the obsessive thoughts and cravings overtake me by week’s end.
The Jackie Nitschke Center is located in downtown Green Bay. All taverns, many restaurants, and some gas stations have video slot machines hidden in a corner. I have worked with clients that gambled through local bookies. Many businesses and taverns have a variety of baseball and football pools. When I go for a lunch walk, the neighborhood is littered with empty vodka bottles, beer cans, empty drug baggies, and state of Wisconsin scratch-off lottery tickets. It’s alarming to see the amount of this litter that accumulates over the winter when the snow begins to melt in spring.
This blog post has been incredibly difficult to write. I am again trying to identify new sources of revenue to keep our treatment center open, and writing this blog post has reminded me of the depth and mostly hidden destruction of gambling addiction. I have had to come to terms with the fact that even though I am not gambling as I did prior to entering recovery from alcohol, drugs, and (I thought) gambling 21 years ago, I have continued to gamble, just in different ways. Betting a few bucks on the dirt track races, family football pools on Thanksgiving, non-profit fundraising raffle tickets, video games, Ebay auctions, rummage sales. Or even just being the fastest car through a triple roundabout near my home.
It all comes down to trying to gain something (could be an emotional response) for less than my investment, which is the definition of gambling. It's easy to rationalize: I was only gambling a few bucks vs. several hundred. And I would give in, just to fit in. The truth is that gambling is gambling: the adrenaline rush, the excitement, and the competitiveness are the same no matter what the stakes. I really believe it to be a spiritual illness, and my daily choices are directly related to the quality of my relationship with my higher power. When spiritually fit, I am focused on giving and helping, not on demanding or wanting.
As a treatment professional, I have participated in several trainings on treating pathological gambling. We have not been able to offer treatment for problem gambling at The Jackie Nitschke Center, as we are licensed to treat only chemical addictions. I am pleased to see the DSM-V reclassifying pathological gambling as an addiction rather than an impulse control disorder (a mental health diagnosis), due to growing scientific literature that shows that problem gambling has the common elements of a substance use disorder. This should bring more attention to potential gambling problems in people with—or at risk of having—a substance use disorder. With the new classification, substance abuse counselors will be able to openly discuss gambling issues with their clients. 

I challenge all addiction treatment professionals to talk about National Problem Gambling Awareness Month with your clients and explore just how devastating their gambling activities might be. Let’s bring the problem out of hiding.

 Bill LaBine (r) with keynote speaker Herman Boone at the NIATx Summit 2012, New Orleans.

Bill LaBine, MSW, is Executive Director and Clinical Supervisor of the Jackie Nitschke Center, Inc. a non-profit substance abuse treatment facility in Green Bay, WI, providing a full continuum of care to adult clients and their family members. LaBine has been employed at the Jackie Nitschke Center since 1995, working as a residential assistant, cook, counselor, maintenance person, assistant director, and since 2005, executive director and clinical supervisor.  Since 2003, LaBine has led a variety quality improvement and leadership development projects with NIATx/Paths to Recovery.  He has also assisted the State of Wisconsin since 2005 with the Wisconsin STAR-SI Program - as a member of the state management team, presenter, coach, peer mentor, and agency grant recipient.