Newsletter of The American Society of Addiction Medicine ASAM Cautions White House Against Over-Hasty Approval of Tobacco Settlement G. Douglas Talbott, M.D. On behalf of the officers and members of munity be able to examine what is being rec the Society, I have sent the following letter ommended. to President Clinton, commenting on the proposed tobacco settlement: The health of the nation is too important for this deal to be done in haste. Any legislative Dear President Clinton: proposal which comes out of the discussions the Administration is having with the liti Tobacco is both the leading cause of pre gants in the state suits should be fully aired ventable death and the leading cause of ad and carefully, deliberately reviewed. More diction in the United States today. Working over, the state litigation should be encour out a solution to this problem is too impor aged to continue to unfold. The state case in tant for it to be done in haste, and it seems Minnesota is scheduled to begin in January, -olly to do it before all the facts are known. and it promises to show more clearly than any other the way these companies behave The manufacturers of tobacco products have and the degree to which they can be trusted. never been accountable for the harm their products cause. The main objective of any The tobacco industry must become account legislation in this area must be, finally, to G. Douglas Talbott, M.D. able. Legislation to resolve the tobacco is hold the industry accountable. This is the sues now on the public agenda should be most certain way to reduce the terrible toll turbed by the seeming haste with which considered with great deliberation. Hasty of illness and death from these products. things are moving forward on this matter. action will lead to needless illness and death. Unfortunately, the Proposed Resolution ne Artificial early deadlines to complete action gotiated by some of the states' Attorneys The Society is especially concerned that on this matter only work to the advantage of General with the larger manufacturers falls some of the short-term gains, such as the tobacco product manufacturers. They are far short of this goal. changes in advertising, are being oversold not in the public interest. to members of Congress and the public as While the American Society of Addiction being of greater public health importance (Copies ofthis letter also were delivered to Medicine is open to the possibility that new than they actually are. Vice President Gore, ONDCP Director Gen. federal legislation might make the industry Barry McCaffrey, members of Congress, and accountable, the Society is profoundly dis- The Proposed Resolution has been found John Slade, M.D., FASAM, Chair of the seriously wanting by every medical and pub ASAM Nicotine Dependence Committee.) lic health group of which the Society is I N S I D E aware. Rumors abound of negotiations which are leading to changes in the terms, "The Society is especially • Practice Guidelines I page 2 but there has yet been no public examina • Addiction Medicine News I page 3 tion of these new terms. concerned that some of the • Money for Treatment II/ page 4 short term gains ... are being • Spirituality and HIV I page 5 Any revision to the original proposal will oversold to members of • New in Print I page 6 have to be examined by all interested par • Alcohol Withdrawal Guideline I page 7 ties with great care. There is a profound im Congress and the public A· ASAM On Line I page 15 balance here: the tobacco companies are in as being of greater public •• Chapter Update/ page 16 timately involved in the present discussions, health importance than they • Pain Management Resources I page 17 but the public health community is not. Only • Ruth Fox Fund I page 18 after the industry reaches agreement with the actually are." • Career Opportunities I page 19 Administration will the public health com- o PRACTICE GUIDELINES JAMA PUBLISHES ASAM PRACTICE GUIDELINE ON MANAGEMENT OF ALCOHOL WITHDRAWAL Michael Mayo-Smith, M.D. Significant advances in the management of alcohol withdrawal and treatment of alcohol American Society dependence were signaled with publication in the Journal of the American Medical Asso of ciation of a clinical practice guideline developed by ASAM on the "Pharmacologic Man Addiction Medicine agement of Alcohol Withdrawal: A Meta-analysis and Evidence-Based Practice Guide line" (lAMA 1997;278(2):144-151). The ASAM Guideline was developed by a group of ASAM is a specialty society of physicians physicians including specialists in addiction medicine, primary care physicians and re concerned about alcoholism and other searchers in alcohol withdrawal drawn from institutions around the country including addictions and who care for persons Harvard, Yale, and Johns Hopkins Medical Schools. The evidence-based process used in affected by these illnesses. developing the Guideline incorporated the latest recommendations on clinical practice guidelines from such organizations as the Institute of Medicine, the Agency for Health ASAM News Care Policy and Research, and the American Medical Association. is an official publication of the American Society of Addiction Medicine, The review demonstrated that a certain class of medications, the benzodiazepines, have and is published six times a year. been proven to both lessen the severity of alcohol withdrawal and prevent major complica Please direct all editorial and advertising tions including seizures and delirium tremens. In addition, it was found that individualiz ,I' inquiries to ASAM News, c/o the ASAM office. ing therapy using objective withdrawal seve1ity scores greatly reduced the amount of medi cation needed, and the duration of treatment, without lessening safety. Surveys have shown Officers that this approach is largely underutilized in the field. President I! G. Douglas Talbott, M.D. For your copy of ASAM's new Practice Guideline on the Pharmacologic Management of Alcohol Withdrawal, i President-Elect Marc Galanter, M.D., FASAM see the pull-out section beginning on page 7 of this issue of ASAM News. II Immediate Past President David E. Smith, M.D., FASAM The Guideline, derived from a careful analysis of published scientific studies, is strongly A I' evidence-based. All scientific studies published in the medical literature regarding phar- Secretary macologic management of alcohol withdrawal were identified and carefully reviewed. While Andrea G. Barth well, M.D. previous individual studies have suggested that benzodiazepines lessened the severity of Treasurer alcohol withdrawal and prevent major complications, the opportunity to pull together a James W. Smith, M.D. large number of studies from the literature and combine their results, allowed this finding I to stand out in a striking way. The review also found that, although dozens of other medi Chair, Publications Committee I Elizabeth F. Howell, M.D. cations have been used to treat alcohol withdrawal, none have been proven to be as effec tive as the benzodiazepines. Newsletter Review Board LeClair Bissell, M.D. This Guideline is one of several evidence-based guidelines being developed by ASAM's Sheila B. Blume, M.D. Committee on Practice Guidelines to strengthen the scientific foundation of addiction treat Max A. Schneider, M.D. ment and improve the care of patients with these disorders throughout the country. Marvin Seppala, M.D.
Executive Vice PresidenUCEO James F. Callahan, D.P.A. VOTE 425 ON THE AMA SPECIALTY SOCIETY BALLOT
Founding Editor, 1985-1995 Michael M. Miller, M.D., ASAM Delegate to the AMA Lucy Bany Robe The American Medical Association is again asking AMA member physicians to indi cate the medical specialty society they want to represent them in the AMA House of Editor Delegates. Bonnie B. Wilford Ballots must be received by December 31 , 1997. Voting can be done in several ways: Subscriptions Free to ASAM members; 0 Faxing a ballot reply card that was attached to the October 13 issue of AMNews; $25 a year (6 issues) to non-members. Order from the ASAM office at 0 Calling a toll-free phone number: 888/200-5309; or 30 l/656-3920, or Fax 301/656-3815. E-Mail: [email protected] 0 E-mailing the choice to [email protected]. e , http://www.asam.org However you cast your ballot, remember to "Vote 425" for ASAM as your representa 4601 North Park Avenue Upper Arcade, Suite 101 tive medical specialty society! Chevy Chase, MD 20815 - ASAMNews 2 October I November 1997 ADDICTION MEDICINE NEWS MILITARY MANAGED CARE HEROIN USE IN U.S. DOUBLED SINCE 1994 ewiLL USE ASAM Heroin use has never been higher in the U.S., and it is spreading rapidly from small towns to major cities, according to a report pub "GOLD STANDARD" lished in USA Today. Heroin is cheap, pure and plentiful in the U.S., . · .. lements of the military heath care sy tem could be with purity of the street drug at record levels--10 times higher [f the V~U ' I US "' . . · . b · b · than it was in 1980. This more potent form is easy and inexpensive · ed . Ldie1 marchmg 10 um. on, then su tance a u e treat- view . . asd't' so ally ba been the recrUit· h av ·m g trou bl. e k·eep ·m g up to smoke, making it more attractive to new users. The U.S. Drug mcnttJaJIOO , d lJ 1 b "[j with the group. But as 1 ~1anage.d care gra u~ y enve ~pdi L. e ~11 - Enforcement Administration reports that twice as many people . · treatment l expected to evo 1ve mto a mu 11 sctp mary smoked heroin in 1995 as in 1994. Heroin deaths also are at their la1y, a ddJC11 0 11 . . , . • 1 1 • y ·tem of care steeped in the field most w1dely accepted gmde- highest rate ever. "The same criminal structure that is pushing 240 metric tons of cocaine into America is also aggressively marketing lines. heroin to a new generation of users," said Gen. Barry McCaffrey, Substance abuse has been off to the side in the military health care Director of the Office of National Drug Control Policy. system," Roger Hartman, healt~t policy ana\y lin the Departm ~ nl of Defense's Office of the ASSJstanL Secretary for Heal th Affatrs, MORE U.S. WOMEN DRINK WHILE PREGNANT told ADA W. "Our programs of treatment have been very service specific; thaL i , the Army, Navy and Air Force all have done their More pregnant women were drinking in 1995 than in 1991, raising own thing. The other feature was a one-si.ze-fi.ts-aU' approach to the risk that more babies will suffer mental retardation, learning treatment, Hartrmm continued. "There wa four-week re iclential disorders and other problems associated with in utero exposure to treatment if that was indicated, and there was a comparable stay for alcohol, according to a new study from the Centers for Disease outpatient. Those were about the only two choices." Control and Prevention. A telephone survey by the CDC found that 3.5 percent of 1,313 pregnant women in 1995 said they had had But a policy memorandum issued earlier this year indicates that the seven or more drinks per week, or hinged on five or more drinks at old system is changing in a big way. As the military's medical pro once, within the preceding 30 days. That represents an increase from gram for active-duty members, retirees and qualified family mem 0.8 percent of 1,053 pregnant women surveyed in 1991. bers becomes a managed care system known as TRICARE, sub stance abuse treatment will grow to resemble the continuum of care From the sample results, the researchers project that 140,000 preg outlined in AS AM's Patient Placement Criteria, which come clos- nant women nationwide were frequent drinkers in 1995, compared eest to being the nation's clinical standards for addiction treatment. with 32,000 women in 1991. The CDC also estimated that 16.3 percent of pregnant women surveyed in 1995 had at least one drink "We pretty much recognized that ASAM is the gold standard in the in the preceding month, compared to 12.4 percent in 1991. The industry right now," Hartman said. reason for the increase is unclear, but• CDC researchers plan to re examine the survey to dat'a in an effort to pinpoint causes. Under TRICARE, the continental United States has been divided into 12 regions for health care services; in each region, one branch TEEN SMOKING UP SHARPLY of the military or one facility has the lead role in overseeing care. Seven regions have managed care contracts already in place, with Researchers calculate that teenage smoking rates, after declining in the remainder expected to have contracts by the end of this year or the 1970s and leveling off in the 1980s, have climbed sharply over early 1998, Hartman said. the last five years.
Hartman described the evolving substance abuse treatment sys Although everything from why the trend began to what might stop tem as offering "a full range of services provided by requisite it is in dispute, it adds up to a huge health problem for the country professionals," including certified substance abuse counselors, and a public relations disaster for the tobacco industry. Indeed, the mental health professionals and primary care physicians. With trend has played a crucial role in driving the once intractable indus ASAM's patient placement criteria as a guide, the Department try into negotiations for a global settlement with regulators and its of Defense will be seeking to place clients in the least restric legal ad-age smoking rates are still lower than in the 1970s. But the tive setting appropriate to their case, with civilian providers percentage of 12th-graders who smoked daily last year jumped 20 playing a prominent role. percent since 1991, to 22 percent, according to the most recent edi tion of the University of Michigan's Monitoring the Future Survey. Hartman, who worked in the Navy's drug and alcohol program The rate among lOth-graders jumped 45 percent, to 18.3 percent, for 10 years, says TRICARE's regional approach will result in and the rate for eighth-graders is up 44 percent, to 10.4 percent. a much more efficient system of substance abuse treatment ser vices. In the past, active-duty members who were diagnosed as Five million people now younger than 18 will eventually die of having addiction problems often had to be sent halfway across tobacco-related illnesses, at current smoking rates, according to the the country for Lhe appropriate re idential treatment, he said. most recent projections from the Centers for Disease Control and Under TRICARE, tine per. o nnel ·LiU will have some involve- Prevention in Atlanta. Rising youth smoking rates have been cited ..ent, b.ul aU treatment and aftercare ervices will be overseen by the Food and Drug Administration and President Clinton as evi by medtcal per onnel, Hartman sajd, dence that the industry is marketing its products to youth and should by restricted by the FDA. They are also fueling demands in many Reprinted with permission from Alcohol and Drug Abuse Weekly, states and in the Congress for higher taxes on tobacco, based on 9(14):1. Copyrighl 1997 by Manisses Communications Group, research showing price increases typically discourage teen smokers 800/333-7771. more than adults.
Volume 12, Number 5 3 ASAMNews FROM THE PRESIDENT-ELECT MONEY FOR TREATMENT II: Spring deliberately uses its crite ria for medical necessity, and that CLASS ACTION SUITS these criteria are more restrictive and impose more preconditions -A ROLE FOR YOU? than those described in the pub Marc Galanter, M.D., FASAM licly available benefit documents. How many times have you been on the phone with a representative Not only will the lawsuits seek to of managed care and been told that your treatment plan is not ac enforce the criteria described by cepted? How can we in addiction medicine address this un- "man Blue Cross, they will attempt to age" -able problem? correct the harm from this prac tice by having all prior denials Fortunately, the time is ripe for us to take steps to limit the way reviewed using the Blue Cross cti managed care companies can compromise our patients' care. The teria. public and their representatives in government are beginni11g to understand why doctors should not be blocked from making their ASAM's Executive Committee own medical judgments. In fact, requirements are being impo ed has decided to provide you with on managed care plans to provide a fairer ystem of appeals for the following information so emergency care and for inadequate care, as when needed ho pital that, a. an independent practitioner, you can decide wheU1er you izntion is denied. Recent investigation of managed care plan ' op wi h to bring any cases to the attention of dte law firm handling the eration suggest that numerous such abu e have occurred. cia action uits, alth.ough ASAM as an organization is not laking a formal po ition on U1e uits at this Lime. In "Money for Treatment I" (May-June ASAM News), we consid ered the many roles ASAM has played as an organization to assure Members of ASAM have been invited by Ute law fum pres ing Ut proper coverage for addiction treatment. In this column, we will suits to provide clinical examples of the practices being alJeged. The con ider one way that individual phy ician can confront corporate attorneys have asked for case l1i toties of patient who could ring wrongdoers: namely, the cla . action lawsuit. 1n the adru,ction field, tdl in order for lhe class actions to ucceed. They will repr ent pa the effectiven ss of this approach ha been an1ply evidenced by to tient who: (I) are covered under a health in urance plan i ue I or bacco. Individual compromised by billion-dolJarpurveyors of ciga adm.i11i stered by a Blue Cros plan, and (2) have been denied coverage rette. have gotten their day in cotu'l when repre en ted as a group. for ubstance abu. e lrealment at any tim due to a detetmination by Green Spring that the trealment was not medically neces ary. e Here are some particulars about one relevant set of lawsuits, and information on how you can contact the attorneys who are under If you have uch a patient in your practice, you can prepare a ase taking this initiative if you have relevant information. ummary with blinded patient identity, giving particulars of (1) th e patient's characteristics and diagnosis, (2) U1e indication for care, Up to 23 class action lawsuits are being considered against Blue Cross and (3) the denial of care, so that its suitability can be reviewed. plans that "carve out" substance abuse and mental health from their Patient identification might later be undertaken, with the patient's managed care operations and then use Green Spring Health Services, consent, if the case is added to the suit. Inc., to review the appropriateness of proposed treatment. The under lying allegation is that patients are being denied needed care because You should send this material directly to Edward Camot at the law the criteria u. cd by Green Spring to evaluate a11 inpatient tay are fitm of Camot, Zapor & Klassen, P.C., Suite 290, 1370 Piccard more restrictive than those spelled oul in the description of benefits Drive, Rockville, MD 20850-4304; or phone 301/258-1994 or fax patien received from Blue Cross. The uit would allege that Green 301/948-2155.
PSYCHIATRISTS IN MEMORIAM LULheran Medical Center is a community based t eac hin ~ hos pital dis tinguished by a strong Long-time ASAM member Julian F. Keith, M.D., died July 18, 1997, after a long academic affiliation with the SUNY Health Science Center in l3rooklyn. illness. During his illness, Dr. Keith continued his leadership activities in the field of addiction medicine, which he served most recently as Director of Alcohol and Qlrrently, we have positions available for full time Inpatient Psychiatrists and for Evcnin['/Weekend Other Dmg Services in the North Carolina Department of Human Resources. psychiatric coverage in our newly created Department of Behavioral Health. NY license Dr. Keith is survived by his wife, Sue A.nn Keith, and by his five sons and one and _geriatric or addiction experience required. Second language skills in Spanish, Russinn. daughter. The family has requested that memorials be directed to the Hazelden Arabic, or Olinese preferred. Foundatlon (Center City, MN 55012-0176)' the Julian F. Keith Family Merucin~ Vi iting Pn~ fessor hip at the Bowman Gray 'school ofMedicine (Win ton-Salem, Pl ease fax (718)630-8593, or forward to: David Brizcr, MD, Diredor of Behavioral Heall l~ C 27157); U1e Julian F. Keith Prevention Advoca y Center (c/o Sue Gray. UNC Lutheran Medical Center, ISO 55th Street, Campu , .Box 7470, Chapel Hill, NC 27599); dr tJ1e Ho pice of Wake Countr Brooklyn, NY U220. EOE l\ltiF/DN (4513 Creedmoor Road Raleigh 27612). m Lutheran Medical Center lill A Higher Standard of Caring
ASAMNews 4 October I November 1997 MEMBERS SPEAK OUT THOUGHTS ON SPIRITUALITY AND HIV INFECTION . r,v. Mm·(J an, M.D. ,. Ie.s v . o d' t-Scientific Conferenc~ increased and if the likelihood of contract ing with the infection. 12 Step meetings for E
MEMBERS IN SERVICE TO ASAM
Dr. Gitlow Wins Caron Award Dr. Schneider to Chair NCADD !he ~a ron Foundation bas honored Stanley E. Gitlow, M.D., with Max A. Schneider, M.D., FASAM, has been elected chair of the ~ Rtch ~~ rd J. ~aron Aw~rd o~Excellence. In making the award the National Council on Alcoholism and Drug Dependence, Inc. ouncla,uon ~lt~d Dr. G1Uow "profound impact on the advance- (NCADD) for a two-year term, to begin January 1, 1998. Founded -ment of Ad~tctton Medicine.' in 1944, NCADD and its national network of affiliates advocates prevention, intervention and treatment and is committed to ridding In commentmg on the_ award, ASAMPresidenL G. Dougla Talbott, the disease of chemical dependency of its stigma and its sufferers M.~., .n?ted that Dr. Gltlow has "touched the Hve. of unrold number of their denial and shame. of mdlVlduals and families affected by chemicaJ dependency.' The award was to be presented at the Caron Foundation's November 6 Dr. Schneider, who is a past president of ASAM, has served on the annual benefit. NCADD board since 1983.
Volume 12, Number 5 5 ASAMNews NEW IN PRINT
ALCOHOL AND WOMEN AND ALCOHOL: THE CARDIOVASCULAR SYSTEM ISSUES FOR PREVENTION RESEARCH
Number 31 in the Research Monograph series from the National NlAAA' Research Monograph o. 2 present cunentre earch. - Institute on Alcohol Abuse and Alcoholism, Alcohol and the Car the area of alcohol use amor1 g women, and provides recommen d "~ diovascular System, presents the results of state-of-the-art research tion for future tudie, Lhal ould better erve thi population.(, a~ on the consequences of both moderate and immoderate consump ic include alcohol u e aero the life pan, alcohol use in the work tion on the heart, blood and blood vessels. The book is divided into place, alcohol-related birth defects drinking and driving, parentin major sections on Epidemiological Studies, Clinical Studies, Bio intervention for preventing alcohol and dmg u e among childreng chemical and Molecular Studies (Alcohol and the Heart, Alcohol ru1d the influence of genetics, sexuaUty and violent victimizatior~ Interactions with Cardiovascular Risk Factors, Alcohol and Blood • on women' alcohol use . . 61 pages; ingle copie · are avai lable wi u1 Vessels), andAlcohollnteractions with Medications. Edited by Sam out chru·ge. Research Monograph No. 32-Wom.en and Alcohol: Is Zakhari, Ph.D. and Momtaz Wassef, Ph.D., the 712-page book is sues f or PreventionResecrrch, NIH Publication No. 96-3817. Order available at no charge from NIAAA. Research Monograph No. 31- from the N!AAA Scientific Communications Branch, Office ofSc i Alcohol and the Cardiovascular System, NIH Publication No. 96- entific Affairs, 6000 Executive Blvd., Suite 409, Bethesda, MD 4133. Order from the NIAAA, Scientific Communications Branch, 20892-7003. Office of Scientific Affairs, 6000 Executive Blvd., Suite 409, Bethesda, MD 20892-7003. EPIDEMIOLOGIC TRENDS IN DRUG ABUSE ASSESSING DRUG ABUSE WITHIN AND The Advance Report is a synthesis of findings presented at the 42nd ACROSS COMMUNITIES meeting of the Community Epidemiology Work Group (CEWG) and the 3rd meeting of the International Epidemiology Work Group Edited by Nicholas J. Kozel and Dr. Zili Sloboda of NIDA's Divi (JEW G) on Drug Abuse, held in Washington, DC, in June 1997. The sion of Epidemiology and Prevention Research, this guide was de CEWG is a network of epidemiologists and researchers in the U.S., veloped as a resource for state, county, city and local organizations sponsored by the National Institute on Drug Abuse, that meets twice a that are interested in developing the capacity to identify and moni year to review cunent and emerging substance abuse problems. At the tor drug abuse patterns and trends. Based on the Community Epi most recent meeting, members reported that use of cocaine demiology Work Group (CEWG) model, the methods described in hydrochoride and crack, while still at high levels, decreased in 17 of the guide can be used to collect and analyze data to assist in formu the 21 CEWG areas. Heroin use, on the other hand, increased in 17 lating public health policy, drug abuse prevention and treatment areas. Methamphetamine pattems were variable. Indicators of mmi-A . resource management, needs assessments and research plans, and juan a u ·e show a continuation of the dramatic increases reported over. public education campaigns. 100+ pages; single copies are avail the past several years. The 25-page report is available at no charge able without charge from NIDA. Assessing Drug Abuse Within and from NIDA. Advance Report: Epidemiologic Trends in Drug Abuse Across Communities: A Guide for Local Community Epidemiology Report ofthe Community Epidemiology Work Group, June 1997. NIH Work Groups, May 1997. Order from George Beschner, Project Publication No. 97-4206. Order from Ms. Marcia Meth, Johnson, Director, The CDM Group, Inc., 5530 Wisconsin Ave. , Suite 1600, Bassin, Shaw Inc., 8630 Fenton St., Suite 1200, Silver Spring, MTJ Chevy Chase, MD 20815; Fax 301/654-2210; or order from 20910; Fax 301/587-4352; or order through the CEWG Home Page gbeschner@ cdmgroup. com. at www.NIDA.NIH.GOV or www. CDMGROUP. COM/CEWG.
Certification Reminder! The standard deadline for the ASAM Certification Application is January 30, 1998. Late registration, at an extra fee, will be available through April 30, 1998. This will allow attendees at the ASAM Annual Medical-Scientific Conference to apply to sit for the examina tion. The next Certification/Recertification Examination for physicians in addiction medicine is to be offered Saturday, November 21, 1998, at three sites: Atlanta, GA; Newark, NJ; and Los Angeles, CA.
Physicians who wish to sit for the examination must complete and submit an application. All applications will be reviewed and candidates notified by mail as to whether they qualify to sit for the examination. Physicians who pass the examination become ASAM Certified/Recertified in Addiction Medicine. Since the examinations first were offered in 1986, 2,939 physicians have passed the examination, including many of the nation's top addiction treatment professionals.
ASAM certification is recognized by the National Committee for Quality Assurance (NCQA), which in its 1997 standards for credentialing and recredentialing requires that behavioral health care organizations accredited by NCQA have credentialing proce dures that assure that "psychiatrists and/or physicians who are certified in addiction medicine" are available to care for patients.
Fellows Reminder! Applications for fellow status (FASAM) will be accepted through December 31, 1997. ASAM inaugurated the Fellow program in 1996 to recognize substantial and lasting contributions to the Society and the field of addiction medicine. Candidates must meet - certain criteria to quality for Fellow status: they must have been an ASAM members for at least five consecutive years; (2) they must be ASAM-c ertified; (3) they must have taken a leadership role in ASAM through committee service, or have been an officer of a state chapter; and they must have made and continue to make significant contributions to the addictions field. To date, a total of 108 member physicians have been elected Fellows of the American Society of Addiction Medicine.
ASAMNews 6 October 1 November 1997 1 of the American Medical Association July 9. 1997 Volume 278 Copyright 1997. American Medical Association JAMA ® Tile Journa Reprinted from
RevieWS • Pharmacological Management of Alcohol Withdrawal A Meta-analysis and Evidence-Based Practice Guideline
. F Mayo-Smith, MD, MPH; for the American Society of Addiction Medicine M1cllael · . G up on Pharmacological Management of Alcohol Withdrawal worklllQ ro
Objective.-To provide an evidence-based practice guideline on the pharma- documented, even among specialists in 1 cal management of alcohol withdrawal. the field, with a wide range in choice of co ~;~a Sources.-English-language articles published before July 1, 1995, iden medication, approaches to medication de livery, and method of patient monitoring.U tified through MEDLINE on "s.ubstance withdrawal-ethyl alcohol'' andre sear~~ Recommendations from authoritative view of references from identrfred artrcles. sources, such as medical and surgical text study Selection.-Articles with otiglnal data on human subjects. books, vary even more widely, with rec Data Abstraction.-Structured review to determine study design , sample size, ommendations for agents that have never interventions used, and outcomes of withdrawal severity, delirium, seizures, been tested in clinical trials7 or for ap completion of withdrawal, entry into rehabilitation, adverse effects, and costs. Data proaches that have been shown to result from prospective contmlled trials with methodologically sound end points corre in administration of unnecessary medica sponding to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edi tion.8 Given the frequency with which this /ion, were abstracted by 2 independent reviewers and underwent meta-analysis. condition is encountered by physicians, Data Synthesis.-Benzodiazepines reduce withdrawal severity, reduce inci the wide variety of settings in which it dence of delirium (-4.9 cases per 100 patients; 95% confidence interval, -9.0 to occurs, and the variation in the way it is managed, we believed an evidence-based - 0.7; P=. 04), and reduce seizures (-7. 7 seizures per 100 patients; 95% confidence guideline would have widespread utility. interval. - 12.0 to - 3.5; P=.003). Individualizing therapy with withdrawal scales re The purpose of Lhi review and guide sults in administration of significantly less medication and shorter treatment line, therefore, is to aid physicians in pro (P .001 ).13-Biockers, clonidine, and carbamazeplne ameliorate withdrawal sever viding the appropri1Jte pharmacal. gical ity, but evidence is inadequate to determine their effect on delirium and seizures. management of alcohol withdt·awal. Thi Phenothiazines ameliorate withdrawal but are less effective than benzodiazepines guideline do s not address treatment of in reducing delirium (P=.002) or seizures (P< .001 ). the patient who is examined after hav Concluslons.-Benzodiazepines are suitable agents for alcohol withdrawal, ing an alcohol withdrawal eizureorwho with choice among different agents guided by duration of action, rapidity of onset, has already develop I alcohol with and cost. Dosage should be individualized, based on withdrawal severity measured drawal delirium (delirium tremens), or by withdrawal scales, comorbid illness, and history of withdrawal seizures. the optimal setting for withdrawalman agem nt(inpati ntoroulpaLient). Thes clonidine, carbamazepine, and neuroleptics may be used as adjunc ~-Blockers, are imporLant i ues and will be ad trve therapy but are not recommended as monotherapy. dress cl in separate guideline . The rol JAMA. 1997;278:144-151 of phenytoin in alcohol withdrawal is the topic of a guideline already published.n ALCOHOL dependence continues to be Physicians in all areas of medicine there ~ majoqlublic l~ealth probl m and among fore frequently encounter the problem of METHODS tbs many a ctat d medical problem i managing withdrawal, particularly as Selection of the Topic u well-cha~·acterized withdrawal yn medical encounters, such as hospital 144 JAMA, July 9. 1997- Vol 278, No. 2 Pharmacological Management of Alcohol Withdrawal- Mayo-Smith et al Table 1.-Method of Grading Levels of Evidence Table 2.-Prospective, Placebo-Controlled Trials Examining the Effectiveness of Be nzod· and Recommendations* Reducing the Incidence of Delirium or Seizures" •azepines Levels of evidence No. of Patients Level I studies Randomized trials with low ------~==-~With Delirium/No. of ~--=- '" false-positive and low Source, y Intervention Patients in Group false-negative errors Rosenfeld and Bizzoco,20 1961 Chlordiazepoxide 2130 Level II studies Randomized trials with high : false-positive and/or high ~==~~~~~~5 ~--~P~Ia~c~e~bo==~~------~2/~30~------false-negative errors Sereny and Kalant,' 1965 ;::C;-hl_o-;rd.:..la_z....:epo'--x-'ld...:.e___ _ ---:0:::/2-:-4______'0i24---.~o12 4 Level Ill studies Nonrandomized, concurrent ~~~~~~-----~P~I~ac~e~b=o ~~~------t' i~1 ~1 ~------~~ cohort comparisons Kaim et al," 1969 C;::-;-hl...:.or -;d-•ll_z....:epo'--x-''d...:.o ______-::lt-::11-:::0:-3------li103--- Level IV studies Nonrandomized historical Piacebo 8/130 9:1'3o-- cohort comparisons RR~0 . 16; 95% Cl, RR ~o 14 ; 95% Ct Level V studies Case series without controls 0.02-1.24 0.02-1 09 ' P=.08 P- 046 Recommendations Zilm et al," 1980 Grade A Supported by e- 1 level t ~C~h=lo~rd~ia~z_e~po_x_id_e______---:0 ~/1~5~------~0~Il~s------studies or by a ~~~~~~~------~P~I~ac~e~b...:.o=------_...:.0/_1...:.5 ______~21~15~~ meta-analysis in which the Sellers et al," 19830;::;::ia::-ze::p :-a_m______::,Oi:,:2~ --_ lower limit of the confidence 5 interval for the effect ol Placebo 4125 - treatment exceeds the Naranjo et al, 67 1983 Lorazepam 0115 - minimally clinically Placebo 2115 significant benefit Summary and Benzodiazepine Risk difference with Risk difference Wlth- Grade B Supported by either e- 1 level II meta-analysis vs placebo benzodiazepine: beozodiazep1ne; studies or by a - 4.9 cases of delirium/ -7.7 cas ol se i ~ures.r meta-analysis in which the 100 patients 100 patients estimate of treatment effect 95% Cl, -9.0 to -0.7 95% Cl, - 12 to _ o 3 5 exceeds the minimal P=.04 P<.001 clinically significant benefit but the lower limit olthe ':' RR indicates relative ri sk; Cl, confidence interval; and ellipses, data not reported confidence interval does not Grade C Supported by data other than documented reporting of the end point in June 2001, unless new information 1·e prospective controlled trials, question underwent further review, with quires revision before then. including secondary analyses of level I or II 2 reviewers independently extracting studies data from each article. Differences re RESULTS 16 ported in individual studies were ana Original data were found in 1:34 ar *Data from Cook et al lyzed by means of the Fisher exact test ticles,1i-I:>o which included65 prospective and 95% confidence intervals for the rela controlled trials and involved 42 different sponding to the Diagnostic and Statisti tive risk calculated by means of Taylor medications. In the following sections, ' cal Manual ofMental Disorders, Fow·th seriesY When appropriate, meta-analy data on different agents are reviewed. Edition, definition,l''1PP 1m -Hml (2) alcohol sis was performed by means of a random 1 wiLhdrawal d lirium, corresponding to effects model,1' -1" with risk differences Benzodiazepines and Other the Diugnosiic ancl lcttistical Manual of used as the measure of effect. All test,s Sedative-Hypnotic Agents Mental Di ·orders Fowth Edition, defi were 2 tailed, and differences were con Six prospective trials involving 5 dif ni tion , 11 ~ r•l'1 t;11 '~:t1 (3) wi hdrawal seizures, sidered statistically significant when ferent agents all demonstrated that ben (4) completion of withdrawal, (5) entry Ps;.05. zodiazepines are more effective than pla inlo r habililatio11, (6) adver e effects, cebo in reducing the signs and symptoms Recommendations 6 67 61 150 and (7) cost. Acqui ition co · were de of alcohol withdrawaJ.2 •41· ·m· · Sum termined by averaging wholesale prices Recommendations based on the evi mary and meta-analysis of prospective, listed in the Red Book. 11 dence were drafted and graded accord placebo-controlled trials (Table 2) also 11 ing to a published system (Table 1). ; In demonstrated a highly significant reduc Options several areas it was recognized that a tion of seizures (risk reduction of7.7 sei Pharmacological management was single recommendation could not be for zures per 100 patients treated; P = .003) as defined as the use of any pharmacologi mulated to guide the treatment of all pa well as delirium (risk reduction of 4.9 cases cal agent to affect one or more of the tients, but that the decisions should be of delirium per 100 patients treated; outcomes listed above. Different strat guided by a series of clinical consider P=.04). egies for administering medication were ations. In such areas the level of evidence Trials comparing different benzodiaz reviewed when data were available. supporting these considerations was epines demonstrated that all appear simi identified. In formulating recommenda larly efficacious in reducing signs and Review of the Evidence tions, greatest value was placed on pa symptoms of withdrawal.* However, The English-language medical litera tient safety, followed by facilitation of there is some evidence that longer-acting ture was reviewed by searching treatment of alcohol dependence, pa agents may be more effective in prevent MEDLINE with the key words "sub tient comfort, and then cost. ing seizures.t:m.t 4!1 A summary ofprospec stance withdrawal syndrome, ethyl alco tive controlled trials (Table 3) also dem hol" from MEDLINE's initial entries in Guideline Review onstrates a trend in this direction. There 1966 through June 1995. References from The draft guideline was sent for re are few data on the comparative efficacy selected articles and reviews were also view to first authors of articles from the in reducing delirium. 'Pharmacological examined. Articles were considered only past 10 years that met inclusion criteria data and clinical experience1'm suggest if they involved human subjects and in and to representatives of 68 medical or that longer-acting agents can pose a rislc cluded clinical data. Articles that met ganizations. The American Society of of excess sedation in selected groups, in- fJ these criteria underwent structured re Addiction Medicine board of directors view. Prospective controlled trials with approved the final version in June 1996, methodologically sound end points and with review and revision scheduled for 'References 26 , 63, 68, 70, 77 , 88, 90 . 98 . 150 JAMA, July 9, 1997- Vol 278, No. 2 Pharmacological Management of Alcohol Withdrawal-Mayo-Smith et al 145 Table 3.- Prospective, Controlled Trials Exam ining the Effectiveness of Different Benzodiazepine Agents ·tl narl(ed JtJHise\1'1 11 . in Reducing the Incidence of Seizures"' llcrl.\' ;lilt - .. •uYenls, hoW- . the l . ·tcllil!-l."n 1 . •ltl JUl 1 on•7m·· . Jl s1nooL l 1 No. of Patients Wilh Seizures/ ' If · II '· ' ,., )Vf'I'H • Source, y Intervention No. of Patients in Group "' ·rt . u·ibntc Io :HI ,'·, h l<:s!< r eHil- r un r ·t· ,, 1 Solomon et al, 70 1983 Chlordiazepoxide 0/25 · \<' • wal t•llll " • , ptnms."'' . - "tthclr.ll ,. rr twnntl s.\ ~11 -,, the cholc Lorazepam 2/25 ujt 1 o · 1 ·nLtull 1 ~ Wilson and Vulcano," 1984 Chlordiazepoxide 5/50 t III ul hal' emI _"'~ I ·• .' I h(•ir p ll >ntial .. or /~ '\,zoc l i:JZ(:JIIIl.c '" ctoubl -blind, ran- Alprazolam 9/50 Ritson and Chrck, 96 1986 Diazepam ? ·os tJ~' ·W "''•. . . 1 own thal 0/20 ·thLI~ '• I 1 JJ •dLn 146 JAMA, July 9, 1997-Vol278, No 2 Pharmacological Management of Alcohol Withdrawal- Mayo-Smith et al Table 4.-Prospective, Controlled Trials Examining the Effectiveness of Neuroleptic Agents in Reducing the Incidence of Delirium or Seizures :· No. of Patients With Delirium/ Source, y Intervention No. of Patients in Group Thomas and Freedman," 1964 Promazine 4/34 ------~~------~P~ar~al~d~eh2y~de~------O~I3~3~------======-----==: 25 Sereny and Kalant, 1965 ;_P:.::ro~m:.::a=:zi~ne=------1-:/2-:3------.:2::_!23 ;_P:.::Ia=ce:.::b:.::o______1-:/-:11-:------~ ------~C~hl~or~d~ia~ze~~~xi~d e~------0~12=4~------~~ Chambers and Schultz," 1965 Promazine 5/34 =o:.::~=:le~p=a~m~------.:0~/~3~~ ------~C~hl~or~d~la~ze~po~xi~de:.,______~~~ ------~0~/~34------Kaim et al," 1969 =C~hl:::o:!:rP.:..:'o:::rn.::a:::zl::.:ne=------:7_19_a______.;_,12:::. 1.:::9s---._::.__ ;_P:.::Ia=ce:.::b:.::o ______8-:/1-:3_o ______9:::,/~13~0------~- Chlordiazepoxide 1/103 1/103 -- Chlorpromazine vs chlordiazepoxide: Chlorpromazine vs chl ord a RR=7.4; 95% Cl, 0.9-54 RR=12 6; 95% Cl, 1 _1 zepox,de , 6 95 P=.03 P= 001 Summary and meta-analysis Phenothiazine vs placebo Risk difference, phenothiazine vs placebo: Risk diflerence: +4,6 cases 0 ~ 0.0 cases of delirium/1 00 patients 100 patients with phenothiall ~uro&/ 95% Cl, -5.8 to +6 .6 95% Cl, -2.6 to + 11 9 ne P= .92 P=.19 Phenothiazine vs cross-tolerant Risk difference: +6.6 cases of delirium/ Risk difference: +11.4 cases of 50 ~ medication (benzodiazepine 100 patients with phenothiazine 100 patients with phenothiazine or paraldehyde) 95% Cl, +2.4 to +10 8 95% Cl, +6.2 to +16 6 P=.002 P<.001 * RR indicates relative risk; Cl , confidence interval; and ellipses, data not reported 7 11 - withdrawal. Furthermore, delirium is a mild to moderate withdrawal.':u. '· H.I:lG zin , JAMA, July 9, 1997-Vol 278, No. 2 Pharmacological Management of Alcohol Withdrawal-Mayo-Smith et al 147 derly weJ:e identif'i d. imilarly, no stud equately t1·eated by p1·oviding only a , Trearrnent speelfrc ie. on managing withdrawal in pregnant il.xed tandardized do e for all patients. wom n were identified. Ethyl alcohol i T1·ea.tment should allow fo1· a degree of a well-lmo'< n t ratogen, to be a \•oided in individualization o patient can receive "of CIWA•Ar on bY rru!llllo pregn,ant. women. rr.a R trospeclive tud lm·ge amounts of meclic.ation rapidly if r'l•nr vary 4·,.. 8 10 lot 24 h;tKI ie have indicated a ri It of congenital needed (grade A recommendation). ~ · I>OS ~~~r~~enl5 ns ne!KI .-...,uom•l • ns malformation with both benzodia1.epine In ub tance abu treatment pro- " - red rogtfTI mec:ucalfons 1 7 1 17 om- •lOll ' '''" touo•·llng o and bilrbiturat 1 • ~ and a t·ecent tudy grams, bhe useof tructw·ed a essment r 1 0 CIWA·/It IS ·,- a , ~ I!OUI wr•on 50 rOO m~ ·tl o indicated an a sociation of intelli cales, ·uch as the IW A-Ar, for initial , difU.t!po~ldO1 , gence d !'ici'ls with in utero exposw·e to assessment and subsequent monitoring CillO' ,., 1o -20 rn 148 JAMA, July 9, 1997-Vol278, No 2 Pharmacological Management of Alcohol Withdrawal- Mayo-Smith et al ule therapy, with the provision of addi enle1·, Mtmch~.s l 1', Nil, ~ nd Hru·vn•·1l Medical 17. Lates VG, [,;1:sug:nn L. t:m,~ GM lr tional medicine when symptoms are not ·hool, Bo~Lon. Ma ·s: Paul Cu·hm:111. J1·, ~10, New FloresJ. Aconlrollccllriulofehlol')ll' ' tlcl"n'"l 11 York, NY; Arnold J. Flfll , MD, Mal'lborough Hospi mazine in the lllllnagemlllll uf 149 JAMA. July 9. 1997- Vol 278, No 2 Pharmacological Management of Alcohol Withdrawal- Mayo-Smith et al hoi withdrawal. J Clin Psuchoplramw.col. 1983;3: 86. Kraus ML, Gottlieb LD, Horwitz RI, Anscher , , W·IJ!Il'"'' AMI. f!c · 1K:'i-187. M. Randomized clinical trial of atenolol in patients ·k fB , Jl tlt•n I / · trent· , 1 1 iw-<·ll'l~h l e 65 . .Jaffe JH, Ciraulo OA, Nies A, Dixon RB, Mon with alcohol withdrawal. N Engl .I Med. 1985;313: • · • ~"" r 1It" •. , .. ,.,.. l.twl<'' 1" 1J ,~er" ,1/••ut D•s. 1 I• If• ,,.nl' 1 11~ 1 hrll'"" ' 11 1. ' roe LL. Abuse potential of halazepam and of diaz 905-910. ukt'hu epam in patie nts recently treated for Hcute alcohol 87. Man hemP, Nilsson LH, Moberg A, WadsteinJ, ,. fv• • ''li'! . tllt1111 MH . ltlll1l· ;.,.,,,,,. ; · I ll·;~ ;;.Jo'n olta~ H.JII ·:: ~IV alcohol with· withrlmwal. C/iu Pl1o mwcolThel', 1983;34:623-(i30. Hol 150 JAMA, July 9, 1997- Vol278, No. 2 Pharmacological Management of Alcohol Withdrawal- Mayo-Smith et al ment of alcohol withdrawal in a large general hos 131. Pol S, Nalpas B, Berthelot P. Dexamethasone 15~ . Wolf KM •. Shaug-hnessy AF, Middleton , pital. Alcohol Clin Exp Res. 1988;12:360-364. for alcohol withdrawal. rblll Intern illed. 1991;114: Prolonged cleltrmm reqmring mas ·, , . 1ll '· 81 11 108. MassmanJE, Tipton DM. Signs and symptoms 705-706_ me<1 1.ca t·1011. •J A Jll B oanI Fa111 P,.att. el'J'i": ' "''' :.·- 0 r assessment: a guide for the treatment of the alcohol 132. Sullivan JT, Swift RM, Lewis DC. Renzotliaz 504. '. ·• 3 ···J 0 ~ - withdrawal syndrome. J Psychoactive Dmgs. 1988; epine requirements during- alcohol withdrawal syn 155. Lu"' eaver WC, AndPJson K Hm DN 20:443-444. drome: clinical implications of using a stanrlanlizc JAMA. July 9, 1997- Vol 278. No.2 Pharmacological Management of Alcohol Withdrawal-Mayo-Smith et al 151 Printed and Published in the United States of Amenca ASAM ON LINE ASA~:~~~!.~~-~!s~~!'!!rOF AG E: LOGS 1 0,000 VISITS Wtf/JCI/11 • ··t d ASAM s web site at http://www.asam.org, soon, an MRO Channel. A Conference Channel provides links If' you have 1101 . " 15 ~t full advantage of your membership. 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ASAM also has sold publications and conference registrations to people new to The site also contains lists of ASAM staff (with E-mail addresses the addiction field who found the organization on the World Wide and areas of responsibility), Committee chairs, Board members, and Web. state chapter dues. It's all there--only a few clicks away! For all of these reasons, you should take full advantage of what our Special sections on important topics, including a Nicotine Chan Website brings to your membership and visit us soon at http:// nel , State Chapter Channel, Physician's Health Channel and, www.asam.org! ~~,,~••• ~ ~ KAISER PERMANENTE More people turn to us for good health. Colorado- The Colorado Permanente Medical Group (Kaiser Permanente) is seeking a full-time physician to serve in our chemical dependency programs beginning July 1998. Candidates must be board certified in either internal medicine or family practice and be certified in addiction medicine. They should enjoy participating as active members of treatment teams and appreci ate sharing treatment decisions with care providers from multiple disciplines. Clinical responsibilities include inpatient and outpatient detoxification for alcohol and other drugs of dependence; inpatient con sultations for dependency and withdrawal problems; outpatient pharmacotherapy for addictive diseases; consultations for prescrip tion drug dependency and for chronic pain syndromes; and a supportive, educational role with primary care providers, assisting the development of system-wide identification and intervention programs for alcohol and drug use problems. Kaiser Permanente of Colorado serves 330,000 members, using 450 staff physicians in 18 facilities in the greater Denver metropoli tan area. We are proud of the excellent care we deliver and of the high level of satisfaction our members report. We actively support clinical research and outcome evaluation programs to maintain our preeminent position both locally and nationally. Colorado's environmental and recreational opportunities match the exceptional quality of our health care organization. Contact: Physician Recruitment Colorado Permanente Medical Group 10350 East Dakota Avenue Denver, CO 80231-1314 303/344-7302 EOE,M/F,V/H Volume 12, Number 5 15 ASAMNews ASAM CHAPTER UPDATE California Illinois School of Medicine. peak.er will includ Chapter President: William Brostoff, M.D. Chapter President: Martin Doot, M.D. A AM Pre ident G. Douglas Talbott, M.D e Regional Director: Gail Shultz, M.D. Regional Director:Andrea Barthwell, M.D. and Dr. Velesqucz of the Univer' ity fTex ., At CSAM's annual meeting and State of the ISAM will sponsor a pre-conference work Additional information is available froru D : Art conference, November 5-8 at the Miyako shop in connection with its annual meeting Fi cherat 800/536-4900, ext. l30. '· Hotel in San Francisco, Gail N. Shultz, M.D., (scheduled for November 21-22) in Chicago. will be installed as the chapter's 12th Presi At the annual meeting, the chapter will Virginia dent. present its lifetime achievement award to Dr. Chapter President: James Leonard. William McConahey, M.D. For one part of the conference, the planners Regional Director: Paul Earley, M.D have designed something new: a series of ISAM also is planning a program for primary The Virginia chapter' l998 annual me Ling very brief presentations called "Epitomes of care physicians for its Midwest Clinical Con has been et for April 30-May 2, 1998, at Progress." Each speaker will review one area ference, scheduled for February 20-22, 1998. the Fort Magruder Inn and Conference er _ of patient care where emerging information ter in Williamsburg. Concurrent with the is leading clinicians to consider new ap Michigan annual meeting, the chapter and the Farley proaches. In just 12 minutes, the speaker will Chapter President: Thomas Haynes, M.D. Institute will co-sponsor a conference on "A first describe the traditional thinking, then Regional Director: Norman Miller, M.D. New Approach for Impaired Healthcare Pro summarize the newly available data and its Chapter members are planning an educa viders: The Virginia Intervention Program." clinical relevance. Each segment will close tional conference for the Detroit area in late Conference speakers are to include the in with the speaker's recommendation as to March or early April1998. The chapter also tervention program's administrator and whether it is time to change the practice or has elected a new slate of officers, who are: medical director. Inquiries about the confer await further data. For each topic, the course President, Thomas Kane, D.O.; President ence may be directed to Ernie Leclerc at the syllabus will contain one review article and Elect, Stephen Bendix, M.D.; Immediate Farley Institute (800/950-6688). Contact an annotated bibliography. Ten different top Past President, Thomas Haynes, M.D.; Sec person at the Virginia chapter is Dorothy G. ics will be reviewed in the series, including retary, Martin Gleespen, M.D.; and Trea Tompkins, M.D., who can be reached at rapid opioid detoxification, aggressive phar surer, Herbert Malinoff, M.D. 804/243-4646. macologic treatment of alcohol withdrawal, and kindling. New York Region VIII Chapter President: Merrill Herman, M.D. Region VIII will hold its first annual meet- Florida Regional Director: ing February 11-13, 1998, at Honolulu, Ha- A Chapter President: Richard Keesal, M.D. Lawrence Brown, Jr., M.D. waii. For program information, contact Dr. • Regional Director: Rick Beach, M.D. With the assistance of Herbert Peyser, M.D., Gerald McKenna at 808/246-0663. For ho- FASAM's 11th Annual Conference is sched New York State trustee for the American tel reservations, callS00/645-5687. uled for January 23-25, 1998, in Orlando. Psychiatric Association, Dr. Merrill Herman Agenda and registration information is avail has met with the Executive Committee of INTERNATIONAL able from Robert Donofrio at the FSAM the American Psychiatric Association for the office, 904/484-3560. purpose of forging a link between the New Iceland York Society of Addiction Medicine and the Contact Person: Person G. Bjornsson, SAA Georgia APA in the furtherance of mutual goals re Regional Director: Peter Mezciems, M.D. Chapter President: John D. Lenton, M.D. lated to legislation, managed care, and edu Iceland hosted the SAA 20th Anniversary Regional Director: Rick Beach, M.D. cational initiatives. Conference on Alcohol and Substance Chapter President John Lenton, M.D., has Abuse, October 16-18, 1997. ASAM been appointed to the Governor's Joint Study Oregon representatives participating in the confer Committee on the Prevention and Treatment Chapter President.Douglas L. Bouvee, M.D. ence were Drs. Sheila B. Blume, David E. of Substance Abuse. The language of the Regional Director: Smith, and Norman S. Miller. For informa Senate resolution creating the study commit Richard E. Tremblay, M.D. tion on the Iceland chapter activities, con tee specifically called for representation ORSAM had an excellent quarterly meet tact Person G. Bjornsson, SAA, at one of from the Georgia ASAM chapter. ing in September in Tualatin, with Greg the following: telephone (+354) 567-6333; Clark, Ph.D., giving a stimulating talk on fax (+354) 567-6615; Website: http:// the early treatment of depression in patients www.this.is/saa; or E-mail: [email protected]. Advertise in who present for treatment of alcoholism. ASAMNews! Upcoming activities for the chapter include Panama December elections for two Board positions Contact Person: Saul Alvarado, M.D. Published six times a year for currently held by Douglas Bouvee, M.D. and Regional Director: Peter Mezciems, M.D. 3,500 physicians specializing in Robert Senft, M.D. ASAM Past President David E. Smith, M.D., addiction medicine. brought greetings from the Society to the 9th South Carolina Annual Chemical Dependency Conference For rates and deadlines, Chapter President: Timothy L. Fischer, D. 0. of the Panamanian Socjety of Addiction call Bill Brown at the ASAM fl Regional Director: Richard Beach, M.D. Medicine, held in Augu tl997. Pictur d 1n office: South Carolina has scheduled a chapter Lhe photo are (left to right): Panamanian meeting for December 6, 1997, in conjunc S ciety members Carlos Smith, M.D. 301/656-3920 tion with a conference the chapter is co-host Carlo Del Rey, M.D. Dr. Smith, and Saul ing with the University of South Carolina Alvarado, M.D. ASAMNews 16 October 1 November 1997 COMMITTEE REPORTS riJtmong the World's Leading Conferences WEB SITES OFFER " on Alcohol and Drug Addiction. " RESOURCES ON MANAGEMENT OF PAIN Seddon Savage, M.D., Chair Committee on Pain Through a recently established ASAM Website link, ASAM members and others can easily access extensive resources on pain and pain management. After signing on to the ASAM website at http:// AN INTERNATIONAL CONFERENCE FOR www.asam.org, a virtual world of pain management resources can be accessed by ALCOHOL AND DRUG ADDICTION PROFESSIONALS opening "Web Site Links of Interest," then "Treatment and Recovery Resources," then "Worldwide Congress on Pain." Or, to en DECEMBER 3 - 6, 1997 ter directly, sign on to www.pain.com. The Worldwide Congress on Pain is in part com THE MARRIOTT MARQUIS, ATLANTA, GEORGIA mercially funded, carries significant adver tising and is most directly focused on an esthesia management. However, the site SECAD/97 TOPIC AREAS also provides a valuable entry point into the broader world of pain management. ADOLESCENT TREATMENT • MANAGED CARE • ELDERLY ADDICTION CHRONIC RELAPSE • DOCUMENTATION • ETHNICITY & TREATMENT From the Worldwide Congress on Pain, SPIRITUALITY • THE FAMILY • RISK MANAGEMENT • SEXUAL ADDICTION physicians can link to most pain organiza tions (the American Pain Society, the COGNITIVE BEHAVIOR APPROACH • TREATING SPECIAL POPULATIONS American Academy of Pain Medicine, and EFFECTIVE TREATMENT IN THE CORRECTIONS ENVIRONMENT the International Association for the Study COMPULSIVE GAMBLING • ETHICS IN ADDICTION COUNSELING of Pain all sponsor useful sites), obtain lists of pain clinics and pain treatment provid WOMEN'S ISSUES • PEER ASSISTANCE GROUPS ers in many locations, obtain lists of pain publications, and discuss pain issues with other physicians through chat rooms and 3Vz DAYS OF LEADING-EDGE MEETINGS, WORKSHOPS & EXHIBITS fmums. Extensive resources on pain can be SECAD PRESENTERS ARE AMONG THE WORLD'S PREMIERE ADDICTIONS EXPERTS found at www.pain.com EXTENSIVE EXHIBIT & NETWORKING AREAS THE WORLD CLASS MARRIOTT MARQUIS, ATLANTA The ASAM Committee on Pain and Ad dictive Disease currently is working with Webmaster Bill Hawthorne, M.D., to set 22.0 CME CATEGORY l CREDITS AWARDED up reciprocal direct links from the ASAM Website to the American Pain Society and the American Academy of Pain Medicine. PLAN TOAITEND••• SECAD/97 CONFERENCE INFORMATION FoR A PROGRAM & .-\St\M -3 As with most Internet sites, finding re REGISTRATION MATERIALS NAME: ______sources that are consistently useful may CALL, MArL OR FAX TODAY: require some exploration. The library at the Worldwide Congress on Pain seems lim PROF. DISCIPLINE: ------1-800-845-1567 ited in some areas and at least some of its OUTSIDE U.S. 404-814-5859 ORGANIZATION: ______a1ticles are condensations that differ sig FAX 404-814-5877 nificantly from the originally published Preliminc~ry coriferenre it~fonJJalioll ADDRESS: ______is subjefllo change, versions. Similarly, the list of pain meet ings is incomplete. However, more com ~~~~~~ CJTY: ______STATE : -~-ZIP: _____ plete lists of meetings and educational op SECt\D/97- IS PRESENTED BY Mail to: SECAD/97, Charter Behavioral Health Systems, 3414 Peachuee St., Suite 1400, portunities can be identified by exploring CHARTER BEH,\VIORAL Atlanta, GA 30326 • Phone: 800-845-!567 or 404-814-5859 ' Fax: 404-8 14-5877 the resource links. Addictionists who want HEALTH SI'STEMS information on pain should be able to find VISIT OUR NEW WORLD WIDE WEB SITE: www.charterbehavioral.com/secad97 whatever they need by using this point of entry. 17 ASAM News RUTH FOX MEMORIAL ENDOWMENT FUND Dear Colleagues: As we approach the last few months of the year, it is time for you to review your financial affairs while there still is time to take steps to maximize tax savings and other benefits before the year's end. You will soon be receiving the Ruth Fox Memorial Endowment Fund year-end letter and brochure, Giving at Year-End 1997. This brochure offers a number of ideas you might want to consider when planning your charitable gifts for 1997. We hope that you will remember the Endowment Fund in your plans. Special thanks to The Yasuda Bank and Trust Company (USA), New York City. They have made another contribution to the Endowment Fund, bringing their total contributions over the years to $10,000. We are very grateful to the bank's officers for their ongoing support. For contributions, pledges, or information about making a planned gift (bequests, insur ance, stock, pensions), contact Ms. Claire Osman at 800/257-6776. Ruth Fox Max A. Schneider; M.D., FASAM Donor's Circle (up to $2,999) (1895-1989) Chair; Endowment Fund Kenneth Martin Bahrt, M.D. William A Bemard, M.D. Jasper G. Chen See, M.D. Michael F. Bierer, M.D. Chair Emeritus, Endowment Fund Jonathan D. Book, M.D. Joyce E. Braak, M.D. Claire Osman Bums M. Brady, M.D. In Memory of Sylvia Heit, Director of Development Steve J. Brasington, M.D. Mother of Dr. Howard Heit Bao Q. Bui, M.D. Mr. & Mrs. Steven Grossman Total Pledges: $2,199,821 William R. Bullock, M.D. Mr. & Mrs. Gary Haas Rodney V. Burbach, M.D. Flora Haberman New Donors, Additional Pledges Dolores Burant, M.D. Aaron Handler and Contributions Roger L. Cambor, M.D. Mr. & Mrs. Richard North June 15-August 15, 1997 Otto E. Campos, M.D. Mr. & Mrs. Andrew Sheren Neil A Capretta, D.O., FASAM In Memory of Lonnie Smith, Circle of Friends Ronald N. Padgett, M.D. ($3,000-$4,999) Barry S. Solof, M.D. Father of Ed Smith Michel A Sucher, M.D. Ron V. Taravella, M.D. Michael E. Bohan, M.D. UC San Francisco Faculty Position Medical Director of Outpatient Substance Abuse Services The Department of Psychiatry at the University of California, San Francisco (UCSF) seeks a Medical Director of the Outpatient Substance Abuse Services (OSAS), at San Francisco General Hospital (SFGH), a major teaching hospital ofUCSF. This clinician teacher position is in the Clinical series at the Clinical Instructor, Assistant or Associate Clinical Professor level, and is available on July 1, 1998. The ideal candidate will be a Board-certified or -eligible psychiatrist with a commitment-to an academic career as a clinician teacher, and a demonstrated interest and cultural competence in working with underserved, culturally diverse populations in a public setting. Candidates who have completed a fellowship in Substance Abuse or Addiction Psychiatry are preferred. Possession of a Certificate of Added Qualifications in Addiction Psychiatry or American Society of Addiction Medicine certification is highly desirable. California licensure is essential. Demonstrated leadership, administrative, and supervisory experience, and experience in working with patients with HIV or other medical or psychiatric problems which complicate substance abuse, is required. Duties involve direct patient care, clinical supervision, and organization of outpatient medical services for patients with substance abuse. The position requires strong organizational and writing abilities, and interpersonal skills. Research inter est is highly desirable. Applications must be received by January 20, 1998. Please send letter of interest, curriculum vitae, and three current letters of reference to Mark Leary, MD, Search Commitment Chair, c/o Susan Brekhus, Department of Psychiatry-7M36, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA 94110. UCSF is an Equal Opportunity I Affirmative Action Employer. Women and minorities are strongly encouraged to apply. ASAMNews 18 October I November 1997 Position: Physician, Clinical Director-Institution ADDICTION Location: Orofino, in scenic North Central Idaho UCSF Faculty Position Idaho Department of Health and Welfare, Attending Psychiatrist, MEDICINE State Hospital North, is recruiting a Clinical Di rector for its 60-hed Adult Psychiatric Hospital Outpatient Substance At Kaiser Permanente, the excellence of our with Drug Dependency/Dual Diagnosis Program Abuse Services physicians is reflected in the quality of our health components. The Hospital will hire a Board Cer • care. Join our team and you'll enioy: tified psychiatrist who is seeking an opportunity for a progressive and innovative practice in the • The resources and rewards that only treatment of patients who are severely mentally The Department of Psychiatry at the an industry leader has to offer ill and drug dependent. A physician with exper University of California, San Fran tise in addictions treatment is desired. cisco (UCSF), is searching for an • Outstanding compensation and State Hospital N01th is one of two state hospitals Attending Psychiatrist for the Outpa benefits in Idaho, and an impottant link in the State and Re tient Substance Abuse Service gional Mental Health network. The Hospital values (OSAS) at San Francisco General • And the opportunity to be part of a participative and collaborative management, and Hospital (SFGH), a major teaching dynamic medical group providing health team approach to treatment. hospital of UCSF. This clinician care services to over 2.5 million The Hospital is located on a beautiful campus in members in Southern California a modem facility only two years old. Orofino is an teacher position is in the Clinical se attractive rural community located on the Clearwater ries at the Clinical Instructor or As For more information, please send CV to: Kaiser River at the base of the Selway-Bitterroot Wilder sistant Clinical Professor level, and Permanente, SCPMG, Dept. ADVE, ness Area. Professionals enjoy a quality lifestyle and will be available July 1, 1998. The outdoor recreational activities. Walnut Center, Pasadena, CA 91188- ideal candidate will be a Board-cer 8013, FAX (626) 405-2675. The compensation package includes competi tified/Board-eligible psychiatrist with tive salary, relocation assistance, and excellent State benefits. For more information, contact a commitment to an academic career as a clinician-teacher, and demon e 4' e KAISER PERMANENTE® Debbie Manfull, Assistant Administrator, State i&.\1,~ Southern California Permanents Hospital North, 300 Hospital Drive, Orofino, ID strated interest, commitment, and l!!r' ::::::1 Medical Group 83544. Phone 208/476-4511. cultural competence in working with underserved and culturally diverse e...------, populations. California licensure is essential. Required: an interest in ~ DEPARTMENT OF ~ VETERANS AFFAIRS WASHINGTON STATE substance ~buse, dual diagnosis of (NO STATE psychiatric disorders and substance Psychiatrist INCOME TAX) abuse, and medical/psychiatric issues The Veterans Affairs Medical Center at Mem including HIV/AIDS; the ability to phis has a vacancy for board certified psychia work effectively with cocaine- and trist to serve as Medical Director of the Chemi Staff Certified Addictionist heroin-dependent patients in outpa cal Dependency Center. Incumbent should pos sess knowledge, familiarity and an interest in (Must be ASAM certified) tient substance abuse treatment; the area of rehabilitation and acute care of vet needed for non-profit organiza strong organizational and writing erans with a variety of addictive disorders and abilities, and interpersonal skills. theoretical knowledge of program structure tion approximately one hour Research interest is highly desirable. and quality. The Medical Center provides pri from Seattle, college town with mary, secondary and tertiary care for the nearly performing arts center. Physi quarter-million veterans who reside in a 53 Applications must be received by county area across West Tennessee, North cian must be team player with January 20, 1998. Please send letter Mississippi, East Arkansas and Southwest interest in program development of interest, curriculum vitae, and Kentucky. Psychiatric Service Programs in clude: Psychiatric evaluation/admission unit, and community liaison. names, addresses, and telephone numbers of three references to Mark acute units, mental health clinic, substance Salary opportunity with all abuse, PTSD and day treatment. Opportuni Leary, MD, Search Committee Chair, benefits including malpractice ties for research and academic appointment at c/o Susan Brekhus, Department of University of Tennessee, Memphis, College of insurance, 4 weeks vacation. Medicine, consistent with experience. Licen Psychiatry-7M36, San Francisco sure in any state required. Send CV to Rich General Hospital, 1001 Potrero Av ard P. Johnson, M.D., Chief, Psychiatry Ser Eva Page & Associates enue, San Francisco, CA 94110. vice or call901/577-7278. Physician Recruiting UCSF is an Equal Opportunity/Af The Veterans Affairs Medical Center 800/833-3449 (WA State) frrmative Action Employer. Women Where excellence is a tradition and minorities are strongly encour 1030 Jefferson Avenue or fax CV to 360/647-8006 Memphis, Tennessee 38104 eva@ nwmedicalrecruiting.com aged to apply. An Equal Opportunity Employer Volume 12, Number 5 19 ASAMNews CONFERENCE ASAM STAFF NOW ONLINE In addition to accessing ASAM's web page, cASAM CALENDAR members can reach any ASAM staff member via E-Mail, at the following addresses: 1 9 9 7 1 9 9 8 ;j· James F. Callahan, D.P.A. November 5-8 Apri117-19 Exec. Vice President/CEO CSAM State of the Art Conference 29th Annual ASAM JCALL@ ASAM.ORG San Francisco, CA Medical-Scientific Conference Contact CSAM at 510/428-9091 New Orleans, LA Susan Blaz Office Manager November 14-16 23 Category 1 CME credits SBLAZ@ ASAM.ORG ASAM MRO Conference Seattle, WA July 16-18 William Brown, C.P.A. 19 Category 1 CME credits ASAM MRO Course Accountant San Diego, CA WBROW@ ASAM.ORG 1 9 9 8 19 Category 1 CME credits October 22-24 Catherine Davidge February 18-22, 1998 Review Course in Addiction Medicine Director of Membership Southern Coastal Conference: Chicago, IL CD AVI@ ASAM.ORG A Medical-Legal Conference on Addiction 21 Category 1 CME credits (jointly sponsored by ASAM) Caprice Falwell Jekyll Island, GA November 5-8 Membership Assistant [email protected] February 19 11th National Conference on Nicotine Dependence Forensic Issues in Addiction Medicine Linda Fernandez Atlanta, GA Marina del Ray, CA 17.5 Category 1 CME credits Asst. Director of Meetings & Conferences 6 Category 1 CME credits [email protected] February 20-22 ASAM MRO Course November 21 Joanne Gartenmann Atlanta, GA Certification/Recertification Examination Exec. Assistant to the Exec. Vice President 19 Category 1 CME credits Atlanta, GA [email protected] e April16 LaGuardia, NY Los Angeles, CA The Ruth Fox Course for Physicians Sandy Schmedtje Metcalfe 5 Category 1 CME credits New Orleans, LA Director of Meetings and Conferences 7 Category 1 CME credits SMETC@ ASAM.ORG April16 1999 Christopher Weirs Forum on AIDS and Addictions Credentialing Project Manager New Orleans, LA April16-18 CWEIR@ ASAM.ORG 7 Category 1 CME credits 30th Annual ASAM Medical-Scientific Conference Bonnie B. Wilford New York, NY Editor, ASAM News BBWILFORD@ AOL.COM BONUS! (MRO) Training Courses Readers of ASAM News will find a bo nus enclosed with this issue: a handy ref February 20-22, 1998 erence card on "Screening and Briefln Atlanta, Georgia terventions for Alcoholism." July 16-18, 1998 Developed by ASAM (with the support of an unrestricted educational grant from San Diego, California DuPont Pharma), the card summarizes the best current advice on patient screen November 13-15, 1998 ing and follow-up techniques, including Toronto, Ontario, Canada the CAGE. R~ahders are encouraged to share the cards tiJ Wit medical students and colleagues in cASAM primary care. For information on obtain- ing additional cards, contact the ASAM office.