ASAM Releases New Guidelines on Treating Opioid Addiction

New guidelines from the American Society of Addiction Medicine (ASAM) on the use of medications in the treatment of opioid addiction should increase the number of patients who receive medication-assisted treatment, says the chair of the guidelines committee. Broad implementation of the guidelines can save lives, according to Kyle Kampman, M.D.

“Less than 30 percent of treatment programs offer medications to treat addiction, and less than half of those eligible patients in those programs receive medications,” said Dr. Kampman, who is Professor in the Department of Psychiatry at the Perelman School of Medicine at the University of Pennsylvania Treatment Research Center.

The consequence of untreated addiction – overdose from prescribed opioids and heroin – kills 68 people a day in the United States. The number of deaths from prescription opioids has more than tripled since the 1990s. From 2002 to 2013, the rate of heroin overdose deaths nearly quadrupled.

Dr. Kampman noted that while there are existing guidelines for treating opioid addiction, they tend to focus on single medications—such as guidelines for using buprenorphine or methadone. Until now there have been no comprehensive guidelines that included all medications approved by the Food and Drug Administration (FDA) to treat opioid addiction, he noted. The National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use, released on September 24, will help doctors treating patients addicted to opioids match the best treatment to each individual patient.

“Doctors treating patients with opioid addiction have many questions about which patients are appropriate for which medications,” Dr. Kampman said. “They want to know which drug to use, at what dose, and for how long. They also want to know about how to treat special populations, such as pregnant women, adolescents, and patients in pain. All of these are addressed in the guidelines. The answers are all in a single place, which makes this unique.”

The guidelines also include a section on how to use the opioid overdose antidote naloxone. “This is an area that is very important, but not very well known among doctors,” Dr. Kampman observed.

The guidelines are designed for any doctor who treats patients with opioid addiction, including internists and family practitioners, Dr. Kampman said. “Our hope is that doctors who have been reluctant to treat opioid addiction, or were unaware there were so many effective treatments available, will start to use these treatments now that they have guidelines from ASAM, which is a trusted source.”

Two areas generated a lot of discussion among the experts who devised the guidelines, Dr. Kampman said. First, although buprenorphine treatment is generally started in a doctor’s office, the experts ultimately decided that treating patients at home is appropriate if both the doctor and patient are familiar with the treatment.

Second, although the hypertension drug clonidine is not approved by the FDA for opioid addiction, many doctors prescribe it for this purpose. The experts decided that since it is so widely used for opioid addiction, they would include it in the guidelines.

AAP Clinical Report on Binge Drinking in Adolescents

National Recovery Month

Pediatricians should talk to kids about the dangers of drinking alcohol starting when the children are as young as 9 years old, a new clinical report from the American Academy of Pediatrics recommends.

Initiating this discussion at such an early age is “absolutely” a “very reasonable” approach, says addictive behavior expert Harris Stratyner, PhD, regional vice president, Caron Treatment Centers, New York City, who trains pediatric residents and fellows in this area.

“That’s the age when kids are becoming aware of what alcohol is,” said Dr Stratyner, who had no role in preparing the new report. “And that’s when the brain starts to formulate and understand that something can be enjoyable, but it can still be deleterious to your health.”

But if the child comes from a family of heavy alcohol users, the conversation should start even earlier. “If the child is exposed at age 7, then that’s a good time to sit them down and talk to them about addiction,” said Dr Stratyner.

If adults do not broach the subject at that early stage, in today’s world, where children see advertisements for alcohol just about everywhere they turn, “you’re going to see kids around the age of 12 start to drink and smoke pot as gateway drugs.”

The new clinical report on binge drinking was published online August 31 and appears in the September issue of Pediatrics.

In-Office Screening

According to the surveys cited in the report, 21% of young people have had more than a sip of alcohol before the age of 13, and 79% have done so by the 12th grade. The proportion who drink heavily is higher among youth who drink than among adult drinkers.

The report also advises pediatricians to screen every adolescent for alcohol use. “Just using one’s clinical impression can underestimate substance use and therefore structured screening instruments are recommended,” write the authors, co-led by Lorena Siqueira, MD, Miami Children’s Hospital.”When time does not permit, alcohol-only screening tools may be a reasonable approach.”

A screening tool developed by the National Institute on Alcohol Abuse and Alcoholism in collaboration with the American Academy of Pediatrics can quickly identify youth at risk for alcohol- related problems, say the authors. It includes only two questions ― one on alcohol use among friends, and the other on use among the patients themselves. The questions are changed slightly depending on the age of the child.

Pediatricians should not only ask whether youngsters ever drink alcohol but also tell these kids why that question is important, said Dr. Statyner. “They need to say that alcohol affects your liver and the liver is an organ in your body that cleans your blood before it goes through your brain.”

This, he said, “raises consciousness” so that kids will think about the consequences of excess drinking. “At 9 years old, you have to raise consciousness so that at 16 years or 17 years, you don’t have binge drinkers” on college campuses.

The report defines binge drinking as the pattern of drinking that brings a person’s blood alcohol concentration (BAC) to 0.08% or greater. In adults, binge drinking refers to the consumption of five or more alcoholic drinks in a row by men, and four or more by women, during a 2-hour period.

Because youth typically weigh less than adults, they are likely to reach a BAC much higher than 0.08% with five drinks in a 2-hour period.

Binge drinking is a common problem. In a 2013 report, 22.9% of Americans aged 12 years and older reported binge drinking in the 30 days before the survey. It revealed that 0.8% of 12- to 13- year-olds and 4.5% of 14- to 15-year-olds reported binge drinking.

Dr Stratyner sees a growing rate of such drinking in his practice. “I’m seeing a lot more binge drinking on weekends among college students,” he said. “I think youngsters are under more pressure, and pressure to self-medicate. They see alcohol as being legal and safe.”

Certain personality characteristics might increase the risk for underage drinking, including sensation seeking, low inhibitory control, and impulsivity, according to the report. Hormonal changes during puberty may affect sensitivity to alcohol, making adolescents less sensitive to the effects of intoxication.

Underage drinkers (those younger than 21 years, which is the legal drinking age in all states) typically obtain alcohol from adults, including from parents, siblings, and other relatives. They drink most often at home or at the home of others.

Costly Habit

Binge drinking among kids is costly. According to a 2006 study, underage drinking was responsible for a median of $361.4 million in economic costs, including healthcare expenditures, lost productivity, court costs, property damage from vehicle crashes and fires, and special education for those with fetal alcohol spectrum.

Adolescents who binge drink are more likely to exhibit poor judgment, such as driving while drunk. Alcohol use is involved in each of the major causes of mortality in adolescents ― accidents, suicides, and homicides ― says the report. In the United States, 50% of all head injuries in adolescents are associated with alcohol consumption.

The developing adolescent brain is more vulnerable to alcohol-induced brain damage and cognitive impairment than the adult brain, says the report.

Binge drinking may result in a “blackout” or losing memory of events that occurred while drinking. During a blackout, drinkers are disinhibited and may engage in risky behaviors, such as having unprotected sex, which increases risk for pregnancy.

Research shows that binge drinking is more harmful to the fetus than more continuous drinking patterns, even if the overall amount of alcohol consumed is less.

Traditional Views on Alcoholism Challenged by New Study

National Recovery Month

Recent findings from the National Epidemiologic Study on Alcohol and Related Conditions (NESARC) are challenging traditional views of alcoholism and point to the need for a paradigm shift in prevention and treatment strategies, a leading expert says.

Among other findings, recent data from NESARC, a prospective, population-based study that surveyed 43,000 US adults in 2001–2002 and again in 2004–2005, show that more than half of alcohol-dependent individuals are healthy, functional, young adults — a far cry from the stereotypical middle-aged, white-male, skid-row alcoholic, said Mark L. Willenbring, MD, director of the division of treatment and recovery research at the National Institute on Alcohol Abuse and Alcoholism (NIAAA).

“Much of what we thought we knew about alcoholism was based on middle-aged people, primarily white men in treatment programs and Alcoholics Anonymous, but the NESARC data are turning what we thought we knew about alcoholism completely on its head,” Dr. Willenbring told reporters attending a press conference here at the American Psychiatric Association 162nd Annual Meeting.

NESARC data also show that young adult alcohol-dependent individuals tend not to seek treatment and have the lowest rates of recovery and full remission.

Tip of the Iceberg

Furthermore, he said, the NESARC results show 72% of individuals who have alcohol dependence in their lifetime have 1 episode that lasts an average of 3 to 4 years and then remits and does not come back.

“This isn’t how I have traditionally viewed alcoholism, because I have worked in treatment programs where we see the most severely affected patients — those with chronic and severe dependence who frequently have psychiatric, medical, and social comorbidities,” Dr. Willenbring told Medscape Psychiatry in a follow-up interview.

“The fact is that most people who develop heavy drinking or alcohol dependence do not fit that stereotype. There are many who are not falling apart — their marriage is intact, they parent, they go to work, and in many cases nobody even knows they are coming home and drinking a pint or more of whisky, and these people are not getting any attention at all,” he said.

The NIAAA guidelines recommend that women should drink no more than 3 drinks in any day and 7 drinks in any week. Men should drink no more than 4 drinks in any day and 14 drinks in any week. One standard drink equals 14 g of ethanol, the amount in 12 oz of beer, 5 oz of table wine, or 1.5 oz of 80-proof spirits.

Dr. Willenbring added that only 1 in 8 individuals who develop alcohol dependence ever receives any treatment for the disorder and only 1 in 4 gets any kind of support such as going to an Alcoholics Anonymous meeting or talking to a counselor.

“We are really missing the boat here, and we need to shift our focus and start paying attention to this large group of people who are heavy drinkers and focus on risk reduction, early identification, and treatment.”

To help clinicians screen and treat their at-risk patients, NIAAA has developed 2 resources. The first, Helping Patients Who Drink Too Much: A Clinician’s Guide, is available in booklet form and on the Internet ( It provides training to help clinicians identify and counsel at-risk drinkers as well as treat individuals with mild to moderate alcohol dependence.

The second resource, Rethinking Drinking, is a patient guide that is also available online or in booklet form that is geared toward individuals who are heavy drinkers or who are concerned about their drinking (

Waiting for the Prozac Moment

One particularly promising area is the recent development of medications to treat alcoholism. While behavioral therapy can be effective, 1 of the major challenges with this mode of treatment is that it is not widely available, said Dr. Willenbring.

However, he said, the development of medications to help treat alcohol-dependence provides an opportunity to reach a greater number of individuals with drinking problems.

“I think treatment for alcohol dependence is going to mirror what happened with depression treatment — that is, 35 or 40 years ago very few people got treatment for depression and only psychiatrists treated it. Then along came Prozac and all of the other medications that revolutionized the treatment of depression.”

Primary-care physicians treat most patients with depression today, while psychiatrists treat the most severe and chronic cases.

“I think that’s where we’re heading with treatment for alcohol dependence. The bulk of people with mild to moderate dependence, who are the majority, can be effectively treated with medication and brief behavioral support in primary care and general psychiatry,” said Dr. Willenbring

Drug Overdose Now Leading Cause of Injury-Related Deaths

Drug overdose deaths continue to increase in the United States and are now the leading cause of deaths from injury in the United States, a new report shows.

Every year, nearly 44,000 people die from drug overdoses. Deaths due to drug overdose have more than doubled in the past 14 years, and half of them are related to prescription drugs (22,000 per year), the report shows.

During the past 4 years, the number of overdose deaths rose significantly in 26 states and Washington, DC, and decreased in only six states. In 36 states and Washington, DC, overdose deaths now exceed motor vehicle–related deaths.

The findings from The Facts Hurt: A State-By-State Injury Prevention Policy Report were released today by the Trust for America’s Health (TFAH) and the Robert Wood Johnson Foundation. The report was developed in partnership with leading injury prevention experts from the Safe States Alliance and the Society for the Advancement of Violence and Injury Prevention (SAVIR).

Prescription drug abuse is a “national epidemic,” Jeffrey Levi, PhD, TFAH executive director, said during a media briefing, but it affects some states much more than others. West Virginia has the highest number of drug overdose deaths (33.5 per 100,000), and North Dakota, the lowest (2.6 per 100,000).

“More than two million Americans misuse prescription drugs. The prescription drug epidemic is also contributing to an increase in heroin use,” noted Corrine Peek-Asa, PhD, MPH, professor and associate dean for research, College of Public Health, University of Iowa, in Iowa City.

She noted that 34 states and Washington, DC, now have “rescue drug” laws in place to expand access to and use of naloxone (multiple brands) ― twice the number of states with these laws in 2013. Although every state except Missouri has some form of prescription drug monitoring program in place to help reduce doctor shopping and misprescribing, only 25 states require mandatory use by health providers in at least some circumstances.

During the past 4 years, injury death rates have increased significantly in 17 states, have remained stable in 24 states, and have decreased in nine states. The national rate is 58.4 per 100,000 people.

West Virginia has the highest number of injury-related deaths of any state (97.9 per 100,000), a rate more than twice that of the state with the lowest rate, New York (40.3 per 100,000).

Motor vehicle death rates have declined 25% in the past decade (to 33,000 per year); 21 states have drunk driving laws that require ignition interlocks for all offenders; most states have graduated drivers licenses that restrict times when teens can drive; 10 states restrict nighttime driving for teens starting at 10 pm; and 35 states and Washington, DC, require car safety or booster seats for children up to the age of 8 years.

Homicide rates have fallen 42% in the past 20 years (to 16,000 per year). For black male youth (aged 10 to 24 years), the rate of death by homicide is 10 times higher than it is for the overall population; 1 in 3 female homicide victims are killed by an intimate partner; 31 states have homicide rates at or below the national goal of 5.5 per 100,000 people.

Suicide rates have remained stable but have been persistently high for the past 20 years (41,000 per year); more than 1 million adults attempt suicide, and 17% of teens seriously consider suicide each year; 70% of suicides deaths are among white males.

One in 3 Americans older than 64 years suffers a serious fall each year; falls are the most common nonfatal injuries, and the number of fall injuries and deaths are expected to increase as the baby boomer cohort ages; 13 states have unintentional fall-related death rates that are lower than the national goal of 7.2 per 100,000 people.

Traumatic brain injury from sports/recreation among children has risen by 60% in the past decade.

Predictable, Preventable

“One person dies from an injury every 3 minutes in the United States,” Dr Levi said. “Injuries are the leading cause of death for all Americans between the ages of 1 and 44. They are responsible for nearly 193,000 deaths each year, and more than 27 million Americans seek medical treatment for injuries each year.”

“Injuries are not just acts of fate. Research shows that they are pretty predictable, and they are actually very preventable,” he noted. Preventing injuries “is not rocket science, but it requires common sense and an investment in good public health practice,” he added.

“Injuries are persistent public health problems,” added Dr Peek-Asa. “New troubling trends, like the prescription drug overdose epidemic, increasing rates of fall-related deaths, and traumatic brain injuries, are serious and require immediate response. But we cannot afford to neglect or divert funds from ongoing concerns like motor vehicle crashes, drownings, assaults, and suicides. We spend less than the cost of a box of bandages, at just $.028 per person per year, on core injury prevention programs in this country.”

The report also includes a report card of 10 key indicators of leading evidence-based strategies that help reduce injuries and violence. Twenty-nine states and Washington, DC, scored a 5 or lower out of the 10 key injury-prevention indicators. New York received the highest score of 9 out of 10; the four states that scored the lowest are Florida, Iowa, Missouri, and Montana, scoring 2 out of 10.

“This report provides state leaders and policy makers with the information needed to make evidence-based decisions to not only save lives but also save state and taxpayers’ money,” said Amber Williams, executive director of the Safe States Alliance.

“The average injury-related death in the US costs over $1 million in medical costs and lost wages. Preventing these injuries will allow for investments in other critical areas, including education and infrastructure,” she said.

The complete report is available at

High-Potency ‘Blowtorch’ Marijuana Gaining Ground

A novel form of marijuana involving the inhalation of highly potent tetrahydrocannabinol (THC) created via butane extraction is becoming increasingly common, placing both producers and users at risk for fires and burns, warn US researchers.

The practice, known as dabbing, uses less potent parts of the cannabis plant to create concentrated butane hash oils (BHO), which are crystalized, then heated with a blowtorch so that the vapors can be inhaled.

John M. Stogner, PhD, from the University of North Carolina, at Charlotte, and Bryan Lee Miller, PhD, from Georgia Southern University, in Statesboro, warn that there is a lack of research into the practice, although a number of accidents and injuries have been reported.

“Health care professionals have the responsibility to remind their patients, particularly those who have used marijuana, of the dangers that may be associated with a stronger product,” the investigators write.

“They serve a key role in educating young people that BHO extract use potentially carries risks beyond that of flower cannabis smoking,” they add.

The researchers also advise that “primary care physicians avoid hyperbolic arguments like those of the media that describe dabbing as ‘the crack of pot,’ and instead urge caution.”

“Patients should be advised that research is lacking, information is still largely anecdotal, and the safest option is to refrain from use when definitive answers are absent.”

Flammable, Volitile

The investigators explain that BHO can be produced at home in a process called “blasting,” because it is relatively uncomplicated, needs few resources, and there are a number of instructional videos available on the Internet.

THC and other hydrophobic compounds within the cannabis dissolve into the butane, and once it has evaporated, it leaves behind crystalized resins that can have a THC concentration of up to 80%. This means that less potent parts of the cannabis plant can be salvaged.

However, the authors describe the process as “extremely dangerous” because of the flammable and volatile nature of the butane. This has led to a number of fires, explosions, and severe burns, with the risks comparable to that of producing methamphetamine.

Once the crystals have been created, what is termed as an “oil rig” is set up, in which a titanium rod is heated with a blowtorch to vaporize small amounts of crystals, or “dabs,” which are then inhaled through a glass water pipe.

Alongside the risks of using a blowtorch to heat the titanium rod to over 400º C, there are long-term health risks associated with inhaling solder, rust from oxidized metal parts, and benzene.

The authors stress that there is a lack of research into dabbing. Proponents suggest that it is safer than smoking marijuana, but others believe that there are greater acute risks from inhaling a more potent form of the drug.

Dr Stogner said that it is “very important” to start monitoring practices such as dabbing.

“Our past experience, particularly in America, has been to wait for a problem to develop before we start to monitor whether we have an issue at all…. I think it’s a trend we ought to pay attention to and that might become problematic in the near future,” he said.

Dr Stogner believes that one of the driving forces for dabbing is the novelty, based on the idea that users can create something stronger and have a new experience.

“It’s much higher in terms of THC concentration, and it appears to be faster in terms of speed of effect, and I think those are both desirable traits for certain drug users and one of the things they look for,” he noted.

Consequences of Legalization

What does Dr Stogner think can be done to curb the practice? “There is very little that can done,” he said.

“You have got two or three different avenues you can go policy-wise between legalization, decriminalization, prohibition, and so forth. Each one has pros and cons for marijuana use more generally, but each one has pros and cons for dabbing.”

He explained that in jurisdictions where marijuana has been legalized, the risk that people are going to engage in home production is minimized. However, there is an increased likelihood of usage due to the availability of traders.

The opposite effect occurs in areas where there is prohibition, because prohibition may limit the number of people that are dabbing, but it conversely increases the risks of creating the dabs, because more people engage in the practice.

Looking at the wider topic of legalization, where does Dr Stogner feel that the United States is heading in the longer term?

“I think the way that we are, as a country, handling marijuana now is in an interesting and proactive way,” he said.
“It allows you to run natural experiments by setting policies in different states and determining how those states react in terms of the portion of the population using, the health consequences, and the health benefits.”

“So I see some merits in the nonuniversal policy that the United States has at present.”

However, he stated: “I think that, in many cases, the consequences of legalization were not completely thought out. The idea that other forms, stronger forms might be available, and might be available to very young people, wasn’t considered.”

Refreshing Perspective

Joseph J. Palamar, PhD, MPH, assistant professor in the section on tobacco, alcohol, and drug use in New York University Langone Medical Center’s Department of Population Health, said that the authors provide a “refreshing perspective” on dabbing.

He said that it was particularly important that they mentioned that healthcare providers should provide honest information about the practice and not engage in “scare tactics.”

However, he was concerned about dabbing and the potential risks to users.

“It seems that the process of making this new drug is actually much more dangerous than the drug itself,” he said.

“Marijuana is not known to be one of those harmful drugs. It depends on THC content and so on, but the process of making this [novel] drug is a lot more dangerous than the drug itself.”

He continued: “Most of the time, like with these new drugs, we worry about the drug effect. With this new form of drug, we have to worry more about the manufacturing than the drug itself.”

“But this is all a product of prohibition. If marijuana were regulated, we wouldn’t have kids using blowtorches, possibly blowing themselves up, just for marijuana.”

Dr Palamar explained that if one looks at alcohol prohibition, people were resorting to very high-potency products. “Beer was the big thing before alcohol prohibition in the US, and when alcohol became illegal, people went on to very high-potency liquor,” he said.

“That’s when all the criminal gangs and so on started coming in and overseeing everything. People engaged in riskier alcohol consumption practices underground, in speakeasies, and they were consuming very high–potency products.”

Returning to dabbing, Dr Palamar believes that this high-potency product is being used “because marijuana use is illegal in most of the US,” adding: “You figure, if it’s illegal, you might as well get as much bang for your buck as possible.”

“People turn to harder, more condensed forms of the drug in times of prohibition, and that’s what’s happening with marijuana. People would rather have a small amount of high-potency product than a weaker product that takes up more space and that you’re more likely to get caught with,” he concluded.

Recovery Radio Needs Your Help

Well this last year was a busy time here at Recovery Radio. We had over 600,000 logins to our website and provided audio files that were played over 875,000 times this past year. We added many new speakers and workshops and now have a database of over 1600 audio files comprising more than 100 Gigabytes of data stored online for your use and enjoyment. And use it you are! We are currently serving over 500 Gigabits of bandwidth per month providing these files to the recovery community.
We have users from all around the world logging in to Recovery Radio. Our traffic comes from every continent except Antarctica.

Since our mission here at the Recovery Radio Network has expanded and become more popular, our expenses have risen as well. Because of the popularity of our Podcasts, we have increased the amounts of Internet Bandwidth we are using to the point where our provider felt it necessary to raise our costs just to defray the additional expenses he was incurring., As the result of these increased prices our expenses are starting to exceed our comfort level so something will need to change.
The idea for the Recovery Radio Network was hatched in 2002 when Internet Broadcasting was relatively new. The idea that we could make the huge library of recovery experience widely available relatively cheaply was very appealing. It took about two years of research and development before we were ready to proceed.. This was before podcasting was a stable platform so, we signed on with the Radio 365 network to provide streaming audio broadcasts and went live in February 2004.. This worked well for a number of years The Live 365 network was the largest Internet Broadcaster in the world at that time, hosting over 14,000 stations worldwide, and Recovery Radio was ranked in the top 10% of all stations by number of listeners.The growth was good but it began to cost us additional fees as our bandwidth and server usage increased, We began to look around for more cost effective alternatives when we discovered podcasting. It proved to be precisely what we needed. It was cost effective and allowed us to use distribution channels that were unavailable to streaming audio broadcasters thereby boosting our accessibility to our audience,So in May of 2009 we signed up with as our platform provider and began our first podcast.
We have been successfully using the platform for the last six years and have seen our traffic grow every year. This year we are on track to provide more than 1,000,000 hours of recovery audio to people on five continents. As you might imagine, this level of success comes with a price. That 1,000,000 hours of audio translates into a lot of Internet bandwidth and a very large server farm. has generously agreed to cover over $3,000.00 of unexpected usage out of their own pockets this year because, they believe in and support our mission. However there will be an additional financial shortfall totaling approximately $5,000.00 that will need to be covered for us to continue.
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