9 May 2012

Postcard from New York. Tuesday, 8 May 2012.

Dear Colleagues,

I have been in New York City for three weeks and will try to summarize some of my activities relating to dependency issues (opera blog below for those interested).  I will give more detailed accounts of some of these meetings in the future but wanted readers to know what issues were being looked at currently in the dependency field at the four or more centers of learning here in New York. 

It has been a terrible time for public funding of research in our field and some of the most well endowed and well known organisations have been threatened with closure over a lack of continuing funding from NIDA under current austerity measures as well as increasingly strict guidelines and requirements for such funding.  I noted a lack of enthusiasm across the board in the development and research areas but continued optimism in those involved in the clinical side of dependency medicine and what Americans often refer to as ‘recovery’, a word seldom used by Australian patients and clinicians in my experience.  It may be partly due to the lack of public funds that drug company sponsorship is also eagerly sought, despite it ensuring that research is almost always slanted towards the use of big-profit drugs and avoidance of ‘bread and butter’ medications (see many references for this and work of Marcia Angell, previous NEJM editor). 

My trip began with a 3 hour seminar/dinner at Columbia University in which Dr Deborah Hasin told us that the essential change to DSM-V is that the new classification will lose the distinction between abuse and dependency so that there will only be one diagnosis based on 11 criteria.  Substance Use Disorder (SUD) will be ‘moderate’ if 2 or 3 are present and severe SUD if there are 4 or more.  Patients with just one of the criteria will have no DSM diagnosis and will not be considered to have SUD.  The old criterion of involvement in frequent legal issues has been removed while 'cravings' has been added this time.  The time frame for such reports needs to be within 12 months apart in general.  The concept of 'dependence' now only refers to the physiological states of tolerance and withdrawal.  I cannot help thinking that the new definition will have no benefits and may cause confusion in the 'dependency' field for years to come.  It is slated for introduction in May 2013. 

Grand rounds at Bellevue Hospital were chaired by Dr Marc Galanter: three addiction medicine registrars discussed literature reviews on three topics: ADHD in SUD (and vice versa); Acupuncture in dependency treatments; Ketamine in the treatment of severe depression.  These were each comprehensive and equally fascinating - more anon. 

Fort Hamilton, Brooklyn, is where the Guantanamo Bay trials were televised for New York journalists, family members and others.  I was asked to give Grand Rounds on methadone maintenance treatments in Australia there and was paired with one of their experienced doctors, Lucas Dreamer who spoke about buprenorphine.  It was intriguing that most American doctors who routinely prescribe buprenorphine in their practices (on in this case the Veterans Administration) have never prescribed methadone for addiction cases (and vice versa for many doctors in methadone clinics).  There was a lively discussion about maintenance, detox, psychosocial service, induction and transfer from one agonist to the other. 

I also gave a talk at Beth Israel Medical Center only a stone’s throw from the institution where methadone was first used in addiction treatment.  The department ‘Leaders’ seemed pleased to hear about treatment down-under.  There were discussions about hepatitis C, diazepam ‘maintenance’, needle provision and injecting centres. 

I had a brief discussion with a colleague from NDRI who is investigating drug courts in America.  These vary in the way they operate in different states with methadone and buprenorphine available as a treatment option in only a minority of cases (30-40%).  Reasons for a lack of maintenance treatments included court bans, financial factors, lack of prescriber and sometimes that the person was already detoxified by the time of reaching the court. 

The Drug Policy Alliance gave me their usual 'open arms' welcome at their new offices in 33rd Street.  Boss Ethan Nadelmann and his capable staff are working on a series of initiatives from ‘medical marijuana’ (cannabis to Australians), chronic pain medications, buprenorphine and much, much more. 

Today would have been the 99th birthday of Dr Vincent P. Dole who died in 2006.  Dr Dole, who was a great friend, colleague and mentor to me and lots of others, changed the lives of many people during his long career.  In fact he pioneered blood ion measurement (sodium/potassium, etc) and cholesterol aggregation research years before they became commonplace, prior to his ground-breaking work on drug addiction treatments at Rockefeller University in 1964. 

I was interviewed by a senior anthropologist who is doing an in-depth study on the history and implementation of buprenorphine treatment.  Her group is only too aware of the commercial factors involved in each aspect, some very positive and in the interests of dependency patients while other moves by the manufacturer or distributor may have in fact denied substantial numbers of dependent patients receiving any opioid maintenance treatment at all, both in America and elsewhere.  It is by no means unique for drug companies to endeavour to 'evergreen' their profitable products using numerous well known means.  However, in this case it may be unique that a drug developed over 30 years ago remains in the high-profit bracket. 

Dr Tom Haines brought me up to date with the situation in Portugal as well as the history of how their government brought in decriminalisation of all personal drug use 12 years ago … stemming amazingly from the persistent use of derogatory humour by a popular radio personality and whose views were then supported by the Law Faculty at Lisbon University and both political parties numerous early public forums on the subject.  While it has not eliminated drug use, the Portuguese ‘experiment’ has been a success in every other way according to reports which have been published in reputable places.  In a way, the implementation of interdiction of drugs from the 1950s was in fact a world-wide, uncontrolled experiment, only to compare with the American experiment with alcohol in the 1920s.  We never learn from history!

My last evening in the city is back to where I started with a panel discussion including Dr Jerome Carroll, Herman Joseph, Charles Winick and George De Leon on the past, present and future of dependency interventions starting from the 1950s.  This is the final meeting for Dr Carroll who has run these meetings for over ten years. 

I hope these brief notes are of interest to readers. 

Andrew Byrne .. (back to Australia next weekend). 

Clinic web page: http://methadone-research.blogspot.com/  

Opera blog: http://andrewsopera.blogspot.com/

DSM - V drops 'dependency' forever!

Drugs and Society meeting at Columbia University. 7.30pm Tuesday 17th April 2012.

I have just had the privilege of attending a presentation of the newly proposed DSM-V criteria for substance use disorders (SUD) which is due for implementation in May 2013. The talk was to have been given by Charles 'Chuck' O'Brien who was apparently entwined in 'grants' and was replaced by Deborah Hasin who is also on the committee devising the new DSM standards.

Dr Hasin is an epidemiologist who has done work with adolescent drug use, HIV, alcohol, household surveys, natural history, etc. She was at home at Columbia University where the meeting was held at their Faculty House in Amsterdam Avenue near 110th Street in Manhattan (West Harlem). Deborah is one of about fifteen members of the DSM-V committee looking as substance use disorders, chaired by Dr O'Brien from U Penn. There is also international representation from Australia (John Saunders), Holland (Wim van der Brink) and elsewhere. We were told some details of the process being followed with consensus and unanimity being attempted rather than confrontation and disagreement. In fact, we were told that there was agreement on most of the issues, often after extensive reviews of the research and discussion.

The DSM-IV was implemented in 1994, replacing the DSM-III and “IIIR”. There was also a 'text review' to DSM IV in 2000. Dr Hasin told us that this very meeting was one of many in the review process and she assured us that our views would be reported back to her committee members.

Dr Hasin gave us a splendid talk about the process being undertaken by the DSM review committee and the brief they were given to redefine the diagnostic categories for drug use disorders.

The committee had discussed changing 'abuse' to 'misuse' but opted to remove any 'loaded' terminology, remaining completely scientific with 'substance use disorder' (SUD). Likewise, 'pathological' gambling was rejected since any diagnosis in the manual was obviously 'pathological' so it became a redundancy and will be called something like ‘gambling disorder’.

The essential change, now virtually concluded, is that the new classification will lose the distinction between abuse and dependency so that there will only be one diagnosis based on 11 criteria. The diagnosis will be moderate SUD if 2 or 3 are present and severe SUD if there are 4 or more. The old criterion of involvement in frequent legal issues has been removed while 'cravings' has been added this time. The time frame for such reports needs to be within 12 months apart from cravings which can last for many years after drug use has ceased, causing an immediate anomaly.

The concept of 'dependence' now only refers to the physiological states of tolerance and withdrawal, something which I predict will cause confusion in the 'dependency' literature for years to come. I worry that the entire process may end up like accreditation, forming an unproductive bureaucracy, language and series of steps to nowhere.

Shopping, sex, eating and internet/gaming disorders have been put into the too hard basket while gambling itself has been taken on board with the same criteria but with minor differences as above.

The criteria for inclusion for 'Substance use disorder' ('SUD') are (simplified):

1. Repeated use with negative consequences

2. Repeated use in hazardous situations

3. Repeated use despite interpersonal issues

4. Tolerance

5. Withdrawals

6. Repeated use for longer or in larger quantities than intended

7. Unsuccessful desire and/or attempts to cut down drug use

8. Long periods taken to obtain drugs or recover from the effects

9. Repeated use causes neglect of other important activities

10. Repeated use despite known continuing adverse consequences on health

11. Cravings

1 criterion = no DSM diagnosis

2-3 criteria positive = Moderate diagnosis of SUD

4 or more criteria positive = Severe diagnosis SUD

Under the existing DSM-IV the first three (plus repeated legal problems) were used to define substance "abuse" (one or more) while 'dependency' required three or more of the remaining criteria (excluding cravings which were not included until DSM-V).

In the ‘case’ to justify the changes Dr Hasin quoted numerous published papers which examined the ‘discrimination’ of individual criteria against an overall diagnostic measure. Various rather complex graphs were shown, each with a flattened ‘S’ curve purportedly showing the effect of up to 15 chosen criteria upon the "latent trait" for problem severity measured in some non-linear manner. Each tracing was coded with its criterion below and each formed a flattened 'S' curve starting from a flat take-off on the X axis, ending similarly on a possible maximum parallel above. I noted that Dr Hasin herself was co-author of some of these papers. She has done extensive public health research in Israel where we were told that American surveys had been translated into Russian and Hebrew (but apparently not Arabic).

We were told that the close approximation of these curves showed the degree of contribution concordance each had with the overall occurrence of problematic drug use in the various (population) samples (none were clinic or patient samples). While the overall impression was that each of the criteria had a similar contribution, the value of the process in population studies was questioned by some delegates so we were then shown some curves of clinic / dependency populations (oops, should not use the term ‘dependency’ any more!).

Dr Hasin's point seemed to be that the inclusion of 'legal issues' added little to the statistical 'mix' for diagnosis. Yet several people in the room pointed out that it was legal issues alone which originally brought some of their most needy patients into treatment. Furthermore, with 10 or more criteria, removing any one would likewise have had little effect on the diagnosis. In practice, the great majority of our patients by the time they get to treatment have not 2 or 3 of these criteria but most of them.

I was a little surprised that there was no patient representative on the committee. Perhaps I should not have been surprised that a majority of delegates contribution to a psychiatry manual were not MD’s or psychiatrists. This is not to question the superb qualifications and need for non-medical input … in fact one member even had two PhD degrees in her credentials (I had thought it was a ‘typo’!).

The new DSM-V definitions remind me of accreditation in a way. The supposed improvements will be of very limited value to my view. The definitions have hazy time-lines with most being 'in the past 12 months have you had …'. As an exception, ‘cravings’, a new criterion, can last for decades after any drugs have been consumed! There is a somewhat closer parallel with smoking, drinking and other medical diagnoses ... but to what end I am not sure. There is absolutely nothing about the quantities of drug used, we were told due to the illicit nature of most of the drugs (now no longer the case with so much prescription drug abuse). However this does not stop every clinician in the field taking such a history, albeit with the inherent difficulties. Hence under the new system $10 per day smoked heroin use on two days per week could be the same under DSM-V as $500 per day if the consequences and reported symptoms were the same. 'Remission' is another problem issue they have decided to avoid altogether. "A lack of symptoms" one delegate said of remission. But for how long? And what of ‘recovery’? Don't ask!

Gambling is ‘in’ the new DSM classification, partly, we were told, because about 20% of substance users have gambling problems and a substantial proportion of gamblers have alcohol/drug troubles too.

But shopperholics and sex addicts and internet habitues don't use enough substances to be included apparently, at least in the SUD section ‘and related disorders’ department. We were told that eating problems and sexual problems had lobby groups of their own and thus were left well alone by this committee. Internet/gaming victims likewise.

Denise Kandel had some most interesting stuff to tell about her mouse experiments ... I am getting the references ... also about adolescent drug use definitions.

Gross and Edwards’ definition of alcoholism in 1960s and is still the basis for all of these modern definitions.

Dr Hasin was thanked for her input and she promised to get feedback working in both directions. True to her word an email mooting a survey appeared only a week after the meeting calling for volunteers to become involved in the process.

Written by Andrew Byrne ..