VOL.83 NO.5 June 2010 SAN FRANCISCO MEDICINE J O U R N A L O F T H E S A N F R A N C I S C O M E D I C A L S O C I E T Y

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SAN FRANCISCO MEDICINE June 2010 Volume 83, number 5 Addiction and recovery: from neurons to national policy

10FEATURE Physician ARTICLES Invictus 4MONTHLY Membership COLUMNS Matters

12 ADon Time Kurth, of Critical MD Change: Drug Addiction, Addiction Services, and 7 President’s Message Public Policy

Michael Rokeach, MD, and Steve 14 PhilipSan Francisco R. Lee, MD, Roots: and Dorothy The Evolution Lee of Addiction Medicine 9 EditorialHeilig, MPH

16 DavidIntegrating E. Smith, Substance MD, FASAM, Abuse FAACT and Mental Health Treatment into David Pating, MD, and David E. Primary Care 40 HospitalSmith, MD News

38 In Memoriam 18 RobertHealth M. Care McCarron, Reform DO; and Sergio Substance-Use Aguilar-Gaxiola, Disorder MD; Parityand Caitlyn Meltvedt

38 ClassifiedNancy Thomson, Ad MD 20 ThomasAdolescent J. Brady, Substance MD, MBA Abuse: A Blueprint for California

22 MarijuanaTimmen L. Cermak,Facts: The MD Risk of Addiction 36OF INTERESTBook Review: The Pain Behind Addiction—and a Miracle Cure?

24 NotTimmen the Right L. Cermak, Prescription MD 37 PublicSteve Heilig, Health MPH Report: SFDPH Public Sector Services for 25 LynnNew Frontiers:Ponton, MD, Treatment and Sam Judice, for Homeless MD Substance Abusers under the Substance Abuse Disorders Mental Health Services Act

Robert P. Cabaj, MD, and David 27 BarryOpioid Zevin, Analgesics: MD, and Addressing David Pating, Risks MD and Benefits in Clinical Practice 39 BookHersh, Review: MD In the Realm of for Treatment of Chronic, Nonmalignant Pain Hungry Ghosts

29 PropositionElinore F. McCance-Katz, 36: Ten Years MD, Later PhD Can We Learn from Experience? 42 FromErica Goode,the CMA MD Foundation: Diabetes and Cardiovascular Disease Guide for Physicians 31 BigMargaret Alcohol’s Dooley-Sammuli New Products: and New Peter Media Banys, for MD, Youth MSc

Carol A. Lee, Esq. 33 LessonsSarah Mart, in Urban MS, MPH Survival: A Hustler Tells All Editorial and Advertising Offices: 1003 A O’Reilly Ave., San Francisco, CA 94129 Phone: (415) 561-0850 extension 261 e-mail: [email protected] Web: www.sfms.org Eisha Zaid Advertising information is available by request.

www.sfms.org April 2010 sAn frAncisco medicine 3 MeMbershIp MaTTers

June 2010 Volume 83, number 5 A SAmpling of ActivitieS And ActionS of intereSt to SfmS memberS

Guest Editors David Pating and David E. Smith Managing Editor Amanda Denz sfms provides online classified Copy Editor Mary VanClay Ads to the medical community! notice set in at least 14-point type and placed immediately above the patient’s

EDItORIAl BOARD The SFMS now offers online classi- signature line. Obituarist Nancy Thomson fied ads for health care-related postings, The SFMS will provide its members Stephen Askin Shieva Khayam-Bashi such as medical office space for rent, with sig nag e; you can also obtain print- Toni Brayer Arthur Lyons job openings, and more. They’re afford- able signage directly from the Medical Linda Hawes Clever Ricki Pollycove able, and SFMS members receive a great Board. If you are interested in receiving a Gordon Fung Stephen Walsh discount! sign, contact Therese Porter in the Mem- Erica Goode Contact Jonathan Kyle at jkyle@sfms. bership Department at (415) 561-0850 org or (415) 561-0850 extension 240, or fTc Again delays implementation extension 268 or [email protected]. SFMS OFFICERS see www.sfms.org/classifieds, for more of red flag rule President Michael Rokeach california information. physicians will Be President-Elect George A. Fouras required to notify patients of Secretary Peter J. Curran license AMA has filed a lawsuit to stop the Treasurer Keith E. Loring Federal Trade Commission from extend- ImmediatePastPresident Charles J. Wibbelsman ing its “Red Flag Rule” to physicians. The A new regulation, effective June 27, rule, after yet another delay, is now sched-

SFMS Executive Staff 2010, will require p hysicians in Califor- uled to take effect on December 31, 2010. Executive Director Mary Lou Licwinko nia to inform their patients that they are As you know, the Red Flag Rules re- DirectorofPublicHealth&Education Steve Heilig licensed by the Medical Board of Califor- quirefinancial institutions and “creditors” Director of Administration Posi Lyon nia, and to include the board’s contact to implement identity theft detection and Director of Membership Therese Porter information. The information must read prevention programs. Despite objections Director of Communications Amanda Denz as follows: from CMA, AMA, and others in organized medicine, the FTC insists that physi-

Board of Directors NOTICE TO CONSUMERS cians who regularly bill their patients Term:Jan2010-Dec2012 Roger Eng Medical doctors are licensed and regu- for services (including copayments and Gary L. Chan Thomas H. Lee lated by the Medical Board of California coinsurance) are considered “creditors” Donald C. Kitt Richard A. Podolin (800) 633-2322 and must develop and implement written Cynthia A. Point Rodman S. Rogers www.mbc.ca.gov identity theft prevention programs for Adam Rosenblatt their practices. Lily M. Tan Term:Jan2008-Dec2010 The purpose ofthis new requirement AMA’s lawsuit asks for a declaratory Shannon Udovic- Jennifer H. Do is to inform consumers where to get in- judgment finding the rule is unlawful and Constant Shieva C. Khayam-Bashi formation or go with a complaint about void as applied to physician members of Joseph Woo William A. Miller California medical doctors. medical associations and state medical Jeffrey Newman Physicians may provide this notice societies. The lawsuit does not, however, Term:Jan2009-Dec2011 Thomas J. Peitz through one of three methods: suspend the December 31 deadline. Prominently post a sign in an area of See the CMA members-only sec- Jeffrey Beane Daniel M. Raybin Andrew F. Calman Michael H. Siu their offices consp icuous to patients, in at tion at www.cmanet.org for a free Red Lawrence Cheung least 48-point type in Arial font. Flag tool kit and a webinar detailing the Include the notice in a written state- clinic regulations. by the Bay medical CMA trustee Robert J. Margolin ment, signed and dated by the patient director: part-Time position AMA Representatives or patient’s representative, and kept in H. Hugh Vincent, Delegate that patient’s file, stating that the patient Robert J. Margolin, Alternate Delegate understands the physician is licensed and Clinic by the Bay (www.clinicby- regulated by the Medical Board. thebay.org) is a free, volunteer-powered Include the notice in a statement health care clinic in San Francisco. Slated on letterhead, discharge instructions, to open in late summer 2010 in the Excel- or another document given to a patient sior, the clinic is based on the successful 4 sAn frAncisco medicine April 2010 or the patient’s representative, with the national model Volunteers www.sfms.org in Medicine MeMbershIp MaTTers

A public Health and safety Ap- proach To drug policy (www.volunteersinmedicine.org), which generous endowment to UCSF upon engages retired and practicing doctors, his death. The award, which includes a nurses, and nonmedical volunteers to substantial cash prize, goes every other July 8, 2010 9:30 a.m. to 4:30 p.m. provide compassionate care free of year to two Bay Area psychiatrists, one The Center for Healthy Communities charge to the working uninsured in their a community-based practitioner and the The California Endowment communities. We have secured a facility other an academic psychiatrist. Los Angeles, CA and have a volunteer Medical Advisory The Royer Award for excellence in With 30,000 people locked up for Board that is planning clinic services and academic psychiatry will be awarded a nonviolent drug offense in California, protocols. We plan to open on Tuesdays to Dr. Kristine Yaffe, who has made ex- prisons are bursting at the seams and and Thursdays. We seek a seasoned and traordinary contributions to the field of busting our budget. And yet drug preven- dedicated primary care physician to lead geriatric psychiatry. The Royer Award tion and treatment funding is suffering the final phase of clinic development and for excellence in community psychiatry devastating cutbacks, making treatment oversee ongoing quality assurance and goes to Dr. Steven Walsh. Dr. Walsh has hardertofindthanever. Californiaisover - clinical care of patients. This salaried devoted his career to public service. He due for a new approach to drug policy. Co- position is part-time (16 hours per week). is an outstanding clinician and teacher hosted by the Drug Policy Alliance and the Competitive salary based on experience. who has served in multiple leadership California Society of Addiction Medicine, For more information, please contact roles, including the presidencies of the New Directions California will convene a Elizaformer Gibson sfms at [email protected]. president, steve San Francisco Medical Society, Northern range of stakeholders and explore a com- walsh, md, wins royer Award! California Psychiatric Society, and UCSF prehensive, balanced approach to drug Association of Clinical Faculty; and dele- policy, which recognizes that successful gate to the California Medical Association, strategies include prevention, harm Congratulations to former SFMS the California Psychiatric Association, and reduction, treatment, and public safety. president Dr. Steven Walsh for winning the American Psychiatric Association. Join us to begin moving our state’s the Royer Award for outstanding contri- He has authored many successful policy drug policy in a new direction: www. butions to the field of psychiatry. initiatives related to increasing privacy csam-asam.org. Oakland physician J. Elliott Royer protections for our patients and increas- established the award in 1962 with a ing funding for uninsured patients. Get Your Copy of the 2010­11 Membership Directory and Desk Reference Today!

This new and improved health care resource contains a comprehensive listing of SFMS members with their specialties and contact information. It is also packed with helpful resources that no medical office should be without!

SFMS members receive one copy free as a membership benefit!

In an effort to make this great resource accessible to everyone, we’ve reduced the price. Members can now purchase additional copies for only $25 each and nonmembers now pay only $50.

To order a copy of this year’s Directory, or to inquire about advertising in next year’s edition, contact Jonathan Kyle at (415) 561­0850 extension 240 or [email protected].

4 sAn frAncisco medicine April 2010 www.sfms.org www.sfms.org June 2010 sAn frAncisco medicine 5 SAN FRANCISCO MEDICINE_05_01_10_ 8.5x11 / 4C 0UBC8364PRV_Tree_SFM_8.5X11.indd

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49319_SFM.indd 1 3/25/10 2:12:40 PM presIdenT’s Message

Michael Rokeach, MD, and Steve Heilig, MPH

Attorneys for the Afflicted

D rug addiction—and let’s be clear from the start that we for the disease model of addiction and effective treatment and are talking about drugs both legal and illegal—has been prevention, this becomes even more true. likened to a form of slavery. A strong choice of words, Addiction can strike people of all walks of life. But we will yes, but not too strong for the impact severe addiction can have note that when physicians argue for better approaches and re- on a person’s life: helplessness, destruction, and despair are all sources on behalf of some of their most afflicted patients, many common. To all that, add denial, both in the addicted person and of whom have been left with nothing other than hope, those phy- among friends, colleagues, and our broader culture as a whole, sicians truly take on the role the legendary nineteenth-century and it’s not so surprising that the AMA years ago identified drug physician and “father of modern pathology” Rudolph Virchow abuse, including that of alcohol and tobacco, as our nation’s big- defined as “the natural attorneys of the poor.” gest public health problem. We have been pleased and proud to turn over this issue of San Francisco has long been known as a hard-drinking, our journal to two local guest editors who embody all that is hard-drugging town. This has been true from the Gold Rush impressive about the rise and success of addiction medicine. onward through Prohibition and the 1960s Haight-Ashbury David E. Smith, MD, and David Pating, MD—”Big Dave and Little “hippie” explosion. Our city’s rates for abuse of substances Dave,” as they have referred to themselves during this editorial from tobacco to heroin have historically been among the high- process—are beyond renown in their specialty and commu- est anywhere. Clearly there are many serious health and other nity. Smith we should all know as the founder of the landmark consequences as a result. Haight-Ashbury Free Medical Clinic, which he started right out Thus it’s perhaps not surprising that San Francisco’s of UCSF medical school. Pating is head of addiction medicine at medical and public health leaders have long been pioneers in San Francisco’s Kaiser Permanente. Both have been tireless ad- addressing addiction issues. SFMS advocates were movers and vocates for their field, presidents of addiction medicine specialty shakers in getting the AMA to make the statement referred to societies, and holders of a dizzying array of positions wherever above; in the initiation, growth, and acceptance of addiction drug and alcohol policy, prevention, practice, and funding are medicine as a legitimate specialty; in recognizing addiction as debated. They exemplify the ideal role of the physician and a disease with identifiable etiology, symptoms, and treatment; clinician, researcher, and, yes, “natural attorney” for their own in the banning of smoking in restaurants (before the rest of the patients and those of others. state and nation); in the acceptance of needle-exchange pro- There is already an official David E. Smith, MD, Day in San grams as a means of both interrupting transmission of HIV and Francisco, and someday there is likely to be a Pating Day as well. as a bridge to treatment; in recognizing and treating physicians We all owe these two Daves a lot. who themselves exp erience problems with drugs or alcohol; in They’ve assembled for us here an impressive monograph developing sound approachestothe ongoing “medical cannabis” of addiction medicine. The authors herein, from the SFMS and controversies; in raising awareness about emerging new drugs beyond, pull few punches in describing what has been accom- such as MDMA or “ecstasy” and others; in removing tobacco plished to date and what still needs to be done. The hopechallenges products from pharmacies; in advocating for justifiable alcohol remain, and some are daunting. But many of those who have tax increases to help compensate for the real costs of drinking; experienced addiction, and beaten it, have identified as the and more. It’s a long and, we feel justified in saying, impressive single most important element in their recoveries. And what do list of contributions. effective treatment and more humane ap proaches to any life- Sometimes this work has been local; sometimes it has threatening malady offer, if not hope? involved taking our approaches statewide and beyond via our representatives to the CMA and AMA, as well as undertaking advocacy efforts with our elected officials and other authorities. As in other arenas, we have learned that physicians can be the mostwww.sfms.org effective advocates of all. As the evidence base increases June 2010 sAn frAncisco medicine 7 Independent But Not Alone.

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SF Med Society (Dr. Yoss).indd 1 2/3/10 9:22:40 AM edITorIal

David Pating, MD, and David E. Smith, MD the Revolution in Substance Abuse treatment t here is a coming revolution in substance abuse and integratedevidence-based treatmentfor substance abuse within mental health treatment, and it’s called health care HMOs (DP) and free health clinics (DS), we have seen firsthand reform. Building on two decades of brain research, the achievable improvements in health care and quality of life we’ve reached a policy epiphany: The best evidence-based and the reduction in total health care costs when addicts and treatment does little good if people cannot access treatment. alcoholics are properly treated. Healthcarereformmightchangeall that.Inthenewparadigm,31 AtNorthernCalifornia’sKaiserPermanente,wehavedemon - million new patients nationally (3.7 million in California alone) stratedthatmedicalsavingsassociatedwithintegratedsubstance will be newly insured, giving them access to effective substance abuse treatment pays for the cost of treatment within six months abuse treatment. It’s been called a new “culture of coverage,” and by reducing hospitalization and emergency room and medical physicians must be prepared; Here are just a few reasons: office visits. More significantly, simple screening for substance • Nationally, up to 40% of hospital admissions are drug- or abuse in high-risk conditions, such as pregnancy, reduces the alcohol-related. Yet fewer than 20% of physicians routinely odds of preterm delivery by 2:1, placental abruption by 7:1, and ask about alcohol and drug abuse. Many do not know how intrauterinefetaldemiseby16:1. Andwesuspectthat ifindividu - to refer patients once a problem is detected, and, worse, als with addiction are properly treated, not only will their health there is a shortage of programs to treat drug addiction and costs decrease but so will the health costs for their families. alcoholism. In the public sector, for every 1,000 Californians who are un- • Pushed by patient demands for instant cures, many physi- insured or receiving Medicaid, 118 will have an alcohol abuse (or cians prescribe large volumes of opioids for transient pain dependence)disorder,57willabusedrugs,and12willabusepain conditions and as sedatives for anxiety, creating the most medications, totaling 152 persons having any addiction-related rapidly growing drug epidemic: prescription drug abuse. disorder. Annually, this costs the state $1.29 billion in health care OxyContin is everywhere. costsfortheapproximate20%ofCalifornianswhoareuninsured. • Unaware of the developmental risks of substance abuse, If only 10% of this cohort were treated, the estimated health many physicians treat adolescents as “small adults,” miss- savings would be $400 million alone, with additional reductions ing years of opportunity to prevent, delay, defer, or detect in psychiatric problems (greater than 40%), family and social emerging drug, alcohol, or mental health illnesses. Mean- problems (50–60%), other medical problems (15–20%), and while, through well-intentioned “zero-tolerance” policies, employment problems (15–20%)—all stemming from proper marijuana-abusing students are expelled from school, again substance abuse intervention. missing key prevention moments while solidifying their Treatment works! We just need to make it accessible to a academic and social failure. larger population. That’s the beauty of heath care reform. Treat- • As a community, we continue to treat addiction as a moral mentDavid coverage Pating, will MD, expand, is chief costs of willaddiction come down,medicine capacit at Kaisery w ill disorder punishable by jail time, foster care, or stigmatiza- Medicalgrow. We Center, need physicians San Francisco, willing and to assistant lead this clinical revolution! professor in tion rather than seeking opportunities to promote recovery, theDepartmentof Psychiatry atUCSF. Currently,Pating serves as resilience, and community health. anappointedCommissioneronCalifornia’sMentalHealthServices But that was before the revolution. As health care reform OversightandAccountabilityCommission(Proposition63),where unfolds, opportunities will arise to bring the science of sub- he chairs the Services Committee. stance abuse treatment to mainstream medicine, with sig- David E. Smith, MD, is the Chair of Addiction Medicine at nificant economic and public health benefits. We know what Newport Academy and serves as the medical director of Center works in managing the social problem of substance abuse; we Point. He was the founder of the Haight Ashbury Free Medical just need the political will. Fortunately, the Accessible Health Clinic, He is also an adjunct professor at UCSF. Care Act of 2010 declares mental health and substance abuse A full list of references is available online at www.sfms.org. treatment an “essential” benefit. As clinicians who have dedi- catedwww.sfms.org their careers to improving access to comprehensively June 2010 sAn frAncisco medicine 9

addIcTIon and recovery

physician invictus

From Heroin Addict to Addiction Physician

Don Kurth, MD

A pril 5, 1969. The red and white area, the paramedics still trying to pump a chance to turn my life around. ambulance races through the life back into his dying body. The parents On August 12, 1969—three days early morning hours of the dark park to the side and are directed to the before Woodstock—I slammed my last North Jersey night. Sirens are screaming reception clerk to fill out the forms and speedball just before the police sur- and red lights are flashing, casting revolv- paperwork. Then they are asked to take a rounded my parent’s home and a new ing shadows against the trees and houses seat and wait. phase of my life began. Later that year I as the medics race through the darkened Asthey sit, silent intheempty waiting entered drug treatment at Daytop Village suburbanneighborhoods.Therainhasjust area,neitherspeaks;neitherliftstheireyes in New York and started to getmylife back stopped falling and a hazy mist rises from to look at the other; each is lost in private on track. the black pavement. thoughts. Quietly both pray to their own I had already flunked out of college In the back of the ambulance lies a God, isolated in their grief over the loss of twice by the time I overdosed in 1969. In young man, barely out of his teens. His their son, wondering if they should have fact, I had actually achieved a perfect GPA lips are blue and his skin is pale gray, but done something differently, wishing they at my first college—0.00. I had split for the paramedics continue to pump on his could do something more now. California tovisit the Haight and neglected chest and force oxygen in to his lungs Finally, the young ER doctor walks to inform my registrar that I might not be with the plastic face mask and ambu bag. through the swinging double doors from returning to complete my final exams. Bloody vomit drips out of the mask and the treatmentarea,looks around the wait- Apparently, my professors were not lis- down his cheek. There are no signs of ing room, and walks toward the grieving tening as intently as I was to the “Turn on, life, no respirations, no pulse. His dark pair. tune in, and drop out,” call of Dr. Timothy blood is filled with drugs and alcohol and “I am so sorry,” he says slowly, delib- Leary.They failed to recognize thevalue of his lungs are filled with vomit and beer. erately.“I don’t think heis going tomake it. my desire to join in the “Summer of Love” Behind the ambulance the young man’s He was dead by the time he arrived. There and manifested their misunderstanding parents are following, trying to keep just wasn’t any thing more we could do. He by awarding me F’s in every single class. up with the racing van. Neither speaks. didn’t have oxygentohis brain.I am sorry.” But by the summer of 1972, I had They are remembering all the hopes and The doctor feels the grip of both sets completed drug rehab and begged my dreams they had had for their firstborn, of eyes on his own. He feels the sorrow of way back into college. Without drugs in their only son. His mom thinks about their loss in his own heart. Then, after a my bloodstream, my grades improved when she dropped him off for his first day quick moment, he turns on his heel and dramatically and by 1975 I had snagged of kindergarten, when he cried and called hurries back through the double doors an academic scholarship to Columbia for his mother not to leave him. His dad into the treatment area of the emergency University in New York City. I worked as a remembers the first time his boy caught room. An agonizing twenty more minutes gardenertopa y form y livingexpensesand a trout by himself and how proud he was passbeforehereturnswithadifferentlook scrimpedever y penny Icould.Icouldn’taf - of his son and the photos they took of the on his face. fordacar,soIboughtausedSuzukimotor - speckled fish before they slipped him “I think he is going to make it!” he cycletogetaround.Imanagedtosave$200 back into the creek. They both remember exclaims. “We’ve got a pulse and he is over my next month’s rent, so I bought a their dreams of college and a profession starting to breathe on his own. I think he chain saw and a hundred feet of rope and for their son, and maybe grandchildren of might be OK!” became a tree cutter. After each hurricane their own someday. And another round of Thatyoungman wasme,and Idid not or blizzard, I would tie the chain saw and sirenscreamsfillsthenightairastheyrace die of that overdose in 1969. But I was not rope to the back of my motorcycle and tofollowtheambulancethroughthenight. done yet, either. I still had more overdoses ride around looking for fallen trees to cut. Finally they arrive at the hospital and tosurviveandjailstovisit.AndIstill hadto There was always somebody who needed 10 sAn frAncisco medicine April 2010 11 sAn frAncisco medicine June 2010 their son is whisked into the treatment stumble my way into drug rehab and have my help, and eventually www.sfms.orgI found a partner California Has Wrong Rx for Addicted Doctors and bought a pickup truck to expand the believe me, I did not plan it this way. business. It was hard work, but I enjoyed Following my chamber involvement I what I did and made enough money to get was elected to the local water district Timmen Cermak, MD, and James Hay, MD throughschool.Ieventuallygraduated,Phi board. After eight years of elected office, BetaKappaand cumlaude,and wenton to I moved on to the city council in Ran- Nurses, doctors, psychologists, and medical school at Columbia. cho Cucamonga (population 180,000) therapists face the same illnesses as ev- Ihad towork hardtogetgoodgrades. and was then elected mayor in 2006. erybody else. The difference is that health I had a lot of remedial work to do just to Concurrently though, as my skills have professionals must take special care when catchupwiththeotherstudents.AndIhad sharpened in this world of public policy, we’re sick so our illnesses don’t harm our to make the sacrifices that we all have had I have done my best to pull my physician patients. That’s true not only for commu- to make to dedicate our lives to medicine colleaguesalongwithme, and togetherwe nicable diseases, but also for the chronic and patient care. have achieved some degree of success. I disease of addiction. I trained at Hopkins and UCLA and helped create our Addiction Treatment California is developing regulations topunishhealthcareproviderswhosuffer found myself seduced by the California LegislativeDays,firstinCaliforniaandthen sunshine. Iopened an urgent carepractice in Washington, D.C. Working together, we fromthediseaseofaddiction—withoutof - in Rancho Cucamonga, California. But I greatly improved access to care and our fering any help to treat this illness among have always had a soft spot in my heart for AddictionTreatmentParityBillwassigned the same professionals who keep Califor- those who suffer from addictive disease, intolawbythen-PresidentGeorgeBushon nia families healthy. This effort threatens andeventuallyIfoundm y selfonthefaculty October 5,2008. Greateraccessto medical to revoke the professional license of any ofLomaLindaUniversit y,whereIhaverun care for those suffering from addiction health professional who exhibits any sign theaddictiontreatmentprogramsincethe is now the law of the land in the United of substance abuse. mid-nineties. States of America. I was honored by my Decades of research on addiction I got involved with the Rancho Cu- colleagues to be elected president of the treatment—and other chronic diseases— camong a Chamber of Commerce, really California Society of Addiction Medicine showthatthebestwaytoprotectthepublic just to get to know people in my commu- and now serve as president-elect of the from harm is to prevent, intervene, and nity and to build up my own practice. The American Society of Addiction Medicine. treat these diseases at the earliest oppor- more I got involved, though, the more I But my work has really just begun. tunity. This is an evidence-based strategy began to realize the importance of being The greatest frontiers of medicine are not for substance use disorders. There’s no involved on a political level. It became in research or clinical skills, as important evidence that punishment alone will be more and more clear to me that many of as both of these areas are. As physicians, successfulinprotectingpatients.Anoverly the challenges we face, not just in addic- our challenges for the future are the realm restrictive program will drive impaired tion medicine but throughout medicine, of public policy. And we must be a part of health care professionals underground. are challenges that can only be met on a shaping that future, or somebody else will Healthcareconsumerswillbeendangered public policy level. do it for us. If we do not make it our busi- byimpairedprofessionalsdoingeverything Scope of practice, corporate bar, and ness to participate in the process, we may they can to hide their addiction until it MICRAareallissuesthatmustbedefended findthatwedo notlikethefinalresult.And has gotten so out of control that someone onapublicpolicylevel.Butourpoliticalre - remember, whatever happens at the fed- does get hurt. Patients will be at greater, sponsibility as p hy sicians goes far beyond eral level will still have to be implemented not less, risk. that. Who but physicians can better fight in each state. Toward the goal of sensible The American Medical Association the battle to ensure greater access to care health care policy, I am currently running (AMA)recommendsthatallstatesprovide for our patients? Who but physicians can for the California State Assembly from the medical treatment along with monitoring articulatetheimportanceofourphysician - 63rd Assembly District. Come join me on for health care providers with substance use problems. California is one of only a patient relationship remaining unfettered theroadtoabettertomorrowforourselves DonaldJ.Kurth,MD,MBA,MPA,FASAM, handful of states that does not have such by burdensome government interference isanassociateprofessoratLomaLindaUniand for our patients. - a program. and regulations? If we cannot or will not versity and president-elect of the American A well-designed system based on advocate for ourselves, who do we expect Society of Addiction Medicine. He is also assessment, early intervention, treatment, tospeakforus?Thequestionswemustask mayor of the City of Rancho Cucamonga, and monitoring will be the greatest ben- ourselves are these: If not us, then who? California, and a candidate for the 63rd As - efit to all Californians. A simplistic system If not now, then when? As in the poem sembly District in southern California. His based on punishment will create a greater “Invictus,” by William Ernest Henley, we website is at www.DonKurth.com. threattothehealthandsafety ofCalifornia must be the masters of our fates; we must This article first appeared in longer health care consumers. be the captains of our souls. form in . I suppose my career path has been 11 sAn frAncisco medicine June 2010 10 sAn frAncisco medicine April 2010 www.sfms.org www.sfms.org one of unlikely twists and turns. But June 2010 sAn frAncisco medicine 11The Sacramento Bee addIcTIon and recovery

A Time of critical change

Drug Addiction, Addiction Services, and Public Policy

Philip R. lee, MD, and Dorothy lee

t he 2010 Patient Protection and Af- opiates and anaesthetics, or discreetly in Lexington, Kentucky, in 1935 and fordable Care Act has the potential self-medicating with patent medicines in Fort Worth, Texas, in 1938. Federal to facilitate change. Promising to containing low dosages of opium, canna- inmates as well as voluntary patients insure more than 30 million people who bis, or cocaine, was not. Late nineteenth- were treated, and intensive research into are uninsured now, with addiction and century surveys in U.S. cities found that many drugs and aspects of addiction was mental health services included as part more than half of opium and morphine carried out in Lexington at the Addiction of the essential benefits, it provides an users were women. Research Center (later transferred to the excellent opportunity for the medical The 1909 Opium Exclusion Act pro- National Institutes of Health). profession to collaborate with other hibited importation of smoking opium The National Institute of Mental stakeholders to take a leading role in into the U.S., and many addicts switched Health (NIMH), a major advance for the the development of enlightened policies to heroin, morphine, and other yet- Public Health Service, was established related to drug addiction. Attitudes about unregulated drugs. Revenue legislation, in 1949. The Health Amendments Act of drug addiction and treatment have been the Harrison Narcotic Act of 1914, cat- 1956 included funding for the new NIMH slow to change, and public policy even egorized both opiates and cocaine as“nar - Psychopharmacology Service Center, the slower, and the momentum built up by cotics” and was the initial step in federal origin of the NIMH program for research the medical profession in recent decades control (marijuana would not be added to on substance abuse. can ensure that the hope held out for the the category of illegal drugs until 1937). Drug use was on the rise in America well-being of present and future genera- The law’s successful enforcement penal- in the 1960s, and there were new drugs, tions is realized. ized and marginalized drug users and the new trends, and a new “drug culture”— Punitive drug laws have been in place doctors and pharmacists who supplied fueled to some extent by media frenzy. in the United States for about 100 years, maintenance dosages of narcotics. Public The Drug Abuse Control Amendments of at an exceedingly high cost, in dollars health addiction treatment clinics existed 1965 broadened enforcement to include and in human terms. Significant progress for a short time—and only in some major the illegal use of depressants, stimulants, has been made in research; addiction U.S. cities—but afterward there were no and hallucinogens. Heroin addiction was medicine has been established as a spe- options left and addicts were increasingly increasing among U.S. soldiers in Vietnam cialty; and a wide variety of preventions, treated as criminals. Doctors changed and among returning veterans. Mandato- interventions, treatments, and paths to their prescribing habits, legal opiates ry minimum sentencing for drug offenses, recovery exist and are acknowledged to became unavailable, and fewer women which had been introduced by the Boggs be cost-effective in comparison to law than men were now addicts. Act in 1951, included two to ten years for enforcement. Yet the nation keeps its The prohibition of narcotics in con- first-time marijuana possession. Harsh blinders on, stigmatizing, ostracizing, and cert with alcohol’s prohibition in 1919 punishment wasn’t an effective deterrent, imprisoning drug addicts. (deemed unsuccessful and rep ealed in and lucrative incentives for enforcement Production, sales, and use of drugs 1933) created unprecedented op portuni- may have played a role in the swift rise were initially unregulated in the U.S., and ties for organized crime; corruption, ho- in the number of marijuana arrests: in the mid-nineteenth century opium, micides, and violent crime increased. By from 169 in 1960 to more than 15,000 cocaine, ether, and chloral hydrate were the end of the 1920s, the nation’s prisons in 1966. Two decades later, according to not only medical mainstays but were were overcrowded, and drug offenders federal data, marijuana use comprised used for pleasure, even in lieu of alcoholic comprised an estimated one-third of the about 60 percent of illegal drug abuse beverages. To some extent the antialcohol inmates. in the U.S. A 2008 international survey Temperance Movement affected the hab- To relieve some of the burden on the reported lifetime marijuana usage in the its of women: Drinking was considered prisons, Public Health Service “narcotic U.S. at more than 40 percent, more than 12 sAn frAncisco medicine April 2010 immoral; taking commonly prescribed farms” for detoxification were established twice that of the Netherlands, www.sfms.org where it is decriminalized. SA) was established, with Centers for and addiction is now law, and the contro- The Narcotics Addict Rehabilitation Mental Health Services (CMHS), Sub- versial Patient Protection and Affordable Act of 1966 authorized programs and stance Abuse Prevention (CSAP), and Sub- Care Act has passed. Ahead lie ethical grants to private organizations as well as stance Abuse Treatment (CSAT). Federal and practical challenges for the medical individual states for an alternative civil drug, alcohol, and mental health research profession. A few of the many questions process of addiction treatment and for institutes were integrated into NIH and that come to mind: rehabilitation for some federal prison- separate authorization was made for the Will the current relative scarcity of ers. The Office of Economic Opportunity NIDA Medication Development Program specialists affect the inclusion of appro- funded multimodality, community-based and for the establishment of National priate addiction services? drug and alcohol treatment, and metha- Drug Abuse Research Centers. Subse- Is there sufficient commitment to done maintenance for heroin addicts quently, a major program of research medical education in substance abuse? gradually gained acceptance. was expanded at the NIDA Behavioral Will administration and bureaucracy In 1970, federal drug law and police Therapies Development Program. complicate rather than facilitate access power were strengthened by passage From 2001 to 2009 there was a 50 to care? of the Controlled Substance Act, a sub- percent increase in federal funding for Does the removal of barriers to reim- title of the Comprehensive Drug Abuse supply reduction (interdiction of drugs, bursement, created in the 1950s by state Prevention and Control Act. The Act source-country programs, and law en- insurance laws, ensure that appropriate also, in a compromise with moderate forcement). There also was increased screening for substance abuse disorders views, authorized treatment and reha- collaboration between government in emergency departments will no lon- bilitation services, eliminated mandatory and the private sector in the fields of ger be neglected, or are new guidelines minimum sentencing, and raised levels of education, prevention, and treatment; needed? funding for research and for the preven- and significant progress was made in How will resources be prioritized? tion of abuse and dependence. At this translating research into effective prac- Preliminary findings from recent time, treatment of drug abuse received tice. As addiction expert Darryl Inaba studies indicate that adolescence marks more funding than did law enforcement. unequivocally stated in 2008, “Treatment the onset of primary mental health dis- Federal assistance to states with preven- Works! Outcome studies like CALDATA, orders, with substance use disorders tion programs and interventions had a CalTOP, and DATOS document positive occurring some five to ten years later, dur- positive effect: The rate of the increase treatment outcomes for drug and alcohol ing late adolescence and early adulthood. of drug abuse was slowed. The urgency addiction,includingmethamphetamines.” Now there is the opportunity to provide surrounding these issues motivated The recognition that it is important to a full spectrum of health neglectedpopula care for more- Congress to establish the National Insti- engage with the community of addicts to youngtions people. What do health reform and tute on Drug Abuse (NIDA), under the design services that encompass a broad parity regulations offer auspices of the NIMH, in 1972. spectrum (including health, housing, —those suffering the p oorest health, During the 1980s, military spending vocational issues, transportation, and including the homeless, prisoners, and on the “War on Drugs” was substantially legal and social connections) and most war veterans? increased. Mandatory minimum sen- effectively meet their needs has contrib- The opportunity for medical leader- tencing was reinstated, ostensibly to uted to the implementation of integ rated ship is clear. Will the profession rise to punish major drug dealers. The policy services and recovery-oriented programs the occasion,Philip R. Lee, or will MD, the is professor punitive ofpolicies social actually resulted in heavy sentences for that help sustain individual wellness and medicine,of the past senior 100 years advisor, prevail? and chancellor many impoverished addicts and people healthy communities. (emeritus) of the Department of Medicine, in the periphery of the drug trade, and it When the Obama administration Philip R. Lee Institute for Health Policy fostered the rapid growth of a privatized, took office in 2009, it expressed sup- Studies, School of Medicine, U.C. San Fran- for-profit p rison system. Federal support port for giving priority to incorporating cisco;professoremeritusatStanford;anda for social programs diminished; most of public health solutions in federal drug formerUnitedStatesAssistantSecretaryof the responsibility for funding prevention policy, including drug abuse treatment Health.DorothyLeeisafreelanceresearch and treatment programs was transferred services in national health care reform, assistant, editor, and translator based in to the states; and various stakeholders, expanding programs for prevention and Athens, Greece. including university researchers, addic- effective treatment (taking into account tion specialists, treatment providers, the disease model of addiction and state administrators, and community considerations of chronic care), and con- groups, found it vital to intensify their tinuing progress on providing recovery collaboration—with good results. opportunities for addicts in the criminal In 1992 the Substance Abuse Mental justice system. 12 sAn frAncisco medicine April 2010 www.sfms.org www.sfms.org Health Services Administration (SAMH- Insurance parity for mental health June 2010 sAn frAncisco medicine 13 addIcTIon and recovery

san francisco roots

The Evolution of Addiction Medicine

David E. Smith, MD, FASAM, FAACt

O n May 2, 2009, the American Alcoholism as a disease was clearly in 1967 for the “Summer of Love.” The Board of Addiction Medicine described as long ago as the late 1700s Clinic’s experience with this population (ABAM) and Nora Volkow, MD, by Dr. Benjamin Rush, a physician and led to the philosophy that “addiction is director of the National Institute of Drug signer of the Declaration of Independence a disease—the addict has a right to be Abuse, conferred board certification on (Katcher 1993). However, it wasn’t until treated” and prompted the almost imme- nearly 1,500 physicians (myself included) the formation of Alcoholics Anonymous diate expansion of clinic services to drug representing a wide range of specialties. (AA) in the 1930s by Bill Wilson and Dr. crisis intervention and detoxification. The In her address at this ceremony, Bob Smith (no relation) that this concept San Francisco Medical Society and the held during the annual meeting of the of alcoholism as disease spread through- California Medical Society provided early American Society of Addiction Medicine out theBig United Book Statesof AA and subsequently support for these endeavors, despite the (ASAM), Dr. Volkow stated that “years the world. Dr. William Duncan Silkworth, City’s refusal to address a major public of scientific research have proven drug in the , described alcohol- health catastrophe (Heilig 2009). addiction is a brain disease caused by ism as a disease caused by “an allergic re- Dr. David Breithaupt of the Univer- biological, environmental, and develop- action of the body to alcohol” and a com- sity of California, San Francisco, Ambula- ment factors—a disease that can have pulsion of the mind (Silkworth, 1937). tory and Community Medicine program, far-reaching medical consequences. . . . Addiction to other drugs, however, trained medical students at HAFMC. At Identifying drug use early, preventing its was specifically excluded from the scope a recent CSAM-sponsored event in the escalation to abuse and addiction, and of AA. AA emphasized that drug use other Haight, Dr. Breithaupt described battling referring patients in need of treatment than alcohol was not to be disclosed at AA a system that at the time viewed com- are important medical skills” (Kunz and meetings. This prompted the formation munity physicians who treated addiction Gentilello 2009). With the passage of of Narcotics Anonymous in California disease as “outlaws caring for sinners and health care reform and parity in March in the 1950s, which was based on simi- criminals” rather than “physicians treat- 2010, addiction medicine has become a lar twelve-step principles but included ing a chronic disease.” mainstream core benefit. recovery from all drugs of addiction, It was then illegal to detoxify addicts Forty and more years ago, this would particularly opiates such as heroin, using onanoutpatientbasis.Nonetheless, when have been barely imaginable. Addictions the catchphrase “clean and sober.” Dr. Donald Wesson and I determined that were stigmatized as moral failings and/ Initiatives put forth by physicians a phenobarbital withdrawal protocol we or criminal activity. In reality, substance in the New York Society of Alcoholism, had developed at San Francisco General abuse in all its forms, including nicotine/ a forerunner of ASAM, prompted the Hospital could be used to detox addicts, cigarette addiction, alcoholism, and American Medical Association (AMA) to we instituted its use at HAFMC’s out- psychoactive dependence, represents declare in the 1950s that alcoholism was patient Drug Detoxification, Rehabilita- our country’s number-one public health a disease and to reaffirm this position in tion, and Aftercare program, combining problem. 1966. medical intervention with psychological Complementing this is the rise in In the late 1960s, the movement to counseling and recovery groups. After the prescription opioid abuse, particularly recognize addiction as a disease escalated Detox program received a substantial fed- in adolescents, where prescription drug in California, particularly in San Francisco. eral grant initiated in 1971 by Dr. George overdose deaths in 2008 exceeded all the Based on the principle that “health care “Skip” Gay of HAFMC—a grant that came overdose deaths for heroin, methamphet- is a right, not a privilege,” the Haight from the White House Office of Drug amine, and cocaine combined. Substance Ashbury Free Medical Clinic (HAFMC) Abuse Policy (SAODAP, predecessor of abuse is now the leading cause of death was founded in response to the large the ONDCP), then headed by methadone in young people, exceeding even traffic number of drug-using youth who flocked maintenance pioneer Dr. Jerry Jaffe—the 14 sAn frAncisco medicine April 2010 15 sAn frAncisco medicine June 2010 fatalities (Knudsen 2009). to San Francisco’s Haight Ashbury district concept of addiction as www.sfms.org www.sfms.org a disease was further acknowledged. Supported by the Bromley as the ASAM delegate and me as is not even dead.” Addiction medicine’s new Nixon White House philosophy that alternate delegate (ASAM, 2006). history demonstrates to the next medi- “no addict should have to commit a crime The AMA accepted the motion intro- cal generation that it can both continue because he can’t get treatment,” due to duced by ASAM that all drug dependen- the battle to help the suffering alcoholic the increase in the numbers of addicted cies, including alcoholism, are diseases and addict and further the integration Vietnam veterans returning to the United and that medical practitioners should of addictionDavid E. medicineSmith, MD, with currently mainstream serves States, addiction treatment services in base their medical practice on the dis- medicine.as chair of addiction medicine at the New- San Francisco increased significantly. ease model of addiction. When ASAM port Academy and as medical director of Despite these philosophical trends, expanded its focus to include cigarette/ Center Point. He is an adjunct professor at physicians were still the targets of puni- nicotine addiction, with its associated UCSFandapastpresident of theAmerican tive action. After the arrest of two South- morbidityand mortality, the AMAgranted Society of Addiction Medicine and the ern California physicians for detoxifying specialty status with the code of “ADM” California Society of Addiction Medicine. heroin addicts with Valium in an outpa- after introduction of a resolution by the He is the founder of the Haight Ashbury tient medical setting, Dr. Jess Bromley California Medical Association in 1990 Free Medical Clinic. recommended that we start a California (ASAM 2006). professional society. By aligning with the We had hoped primarily to gain ac- references California Medical Association (CMA), we ceptance by organized medicine in the could associate nationally with the AMA, U.S. for addiction medicine (the study an essential step toward overcoming and treatment of addictive disease). The ASAM. 2006. Turning points in the organized medical establishment’s specialty now is recognized throughout establishing the medical specialty of resistance to efforts to get nonalcohol the world; the International Society of addiction medicine. http://www.asam. addictions accepted as diseases. Addiction Medicine (ISAM) has been org/CMS/images/PDF/Certification/CSAM News One of the key organizers of the meeting reg ularly since its formation in TurningPoints.pdf. California Society of Addiction Medicine Palm Springs in 1999. The significance of CalData study. . 2000.San (CSAM) was Dr. Max Schneider, a South- the disease model of addiction is nowfully FranciscoHeilig Medicine. S. 2009. David Smith: Pioneer- ern California gastroenterologist. Treat- acknowledged by mainstream medicine, ing community-based health care. ing cirrhosis of the liver with associated to the extent of gaining parity with other 2009; 15. GI bleeds, he became concerned that the medical issues in health care reform. AmerKatcher J Public BS. 1993. Health. Benjamin Rush’s existing medical system offered little to A 2000 CalData study showed that educational campaign against hard drink- treat the causative disease of alcoholism. every dollar spent on treatmentCSAM savedNews ing. 83(2):273-281. In fact, all of the founders of CSAM were an estimated seven dollars in health and Knudsen HK. 2009. Barriers to treat- motivated by the principle that it makes social costs (CalData study, ing alcohol and drug problems among no medical sense to treat the complica- 2000). Kaiser Permanente researchers adolescents. Robert Wood Johnson Foun- tions of a disease and not treat the under- have also found strong evidence of cost dation/Substance Abuse Policy Research lying chronic medical illness, whether it is savings (Parthasarathy et al 2001). Mean- Program. www.saprp.org/KnowledgeAs- a disease of the brain—like addiction—or while, the criminal justice system and sets/Knowledge_Detail.cfm?KAID=20. a disease of the pancreas—like diabetes. community and school-based prevention Kunz KBAddiction and Gentilello Professional. LM. 2009. As an appointee to the AMA com- programs have not proved sufficient to Landmark recognition for addiction mittee on alcoholism, I introduced the turn the tide of substance abuse. Addic- medicine. TheAudacityofHope. 2009; disease model of addiction to the AMA tion medicine has encouraged medicine 12-17. committee in 1976. I coined the term to become a major force in dealing with Obama B.2006. “addiction medicine,” and after much this public health issue: 100 percent of New York: Crown Publishers debate it was accepted. Also at that time, alcoholics and addicts will at some time Parthasarathy S, Weisner C, Hu TW, Dr. Douglas Talbott, who pioneered the interface with the medical system. and Moore C. 2001. Association of out- treatment of addicted physicians, intro- However, despite compelling evi- patient alcohol and drugJournalofStudieson treatment with duced the term “addictionology.” dence for a decade demonstrating excel- healthAlcohol. care utilization and cost: Revisiting In 1983, individuals in the addiction lent cost-benefit outcomes for addiction the offset hypothesis. field met at the Kroc Ranch in California as a brain disease emphasizing preven- 2001; 62(1):89-97.Medical Record. and agreed that a single organization, tion, intervention, and treatment, the Silkworth W. 1937. Alcoholism as a what has evolved into the American battle to imp lement parity by the socio- manifestation of allergy. Society of Addiction Medicine, would logical and politicalThe structure Audacity of ofthe Hope U.S. 1937; 145:249-251. represent the field. Five years later, ASAM remains to be won. As President Obama gained acceptance in the AMA House of stated in his book, , 15 sAn frAncisco medicine June 2010 www.sfms.org Delegateswww.sfms.org as a specialty society with Dr. “past history is not dead and buried, it June 2010 sAn frAncisco medicine 15 addIcTIon and recovery

mainstreaming mental Health

Integrating Substance Abuse and Mental Health Treatment into Primary Care

Robert M. McCarron, DO; Sergio Aguilar-Gaxiola, MD; and Caitlyn Meltvedt

t he primary care setting has been cancers, and sequelae3 relatedto substance expandintegrativecaremodels.Duringthe the de facto mental health care sys- dependence. eighteen-monthproject,variousoutcomes tem in the United States for several Intheeveofhealthcarereformimple - willbemeasured,includinganassessment decades. Up to 60% of all mental health mentation,therehasrecentlybeenastrong of how often standard-of-care primary care services, including substance abuse push by policy makers and clinic directors preventive strategies are used (such as treatment, are delivered by primary care to redesign the primary care setting and screeningfordiabetesandlipidabnormali - practitioners (PCPs). Nonpsychiatrists— moreeffectivelyintegrateprimarycareand ties). In mid-2011, each CPCI pilot site will mostly PCPs—prescribe more than 80% mental health care. This is a logical move, share its findings and achievements at a

of antidepressants, now the most1 widely given the extraordinarily high prevalence CalMEND Learning Forum, with the goal prescribed class of medications. Primary of mental and substance abuse disor- of improving medical and psychiatric care care settings are also the first point of ders and physical-mental comorbidities uc davis: integrated medicine/for those who have SMI. contact and the treatment site of choice encountered in the primary care setting. psychiatry Ambulatory residency forminority,low-incomepatients.Primary The following is a brief summary of some Training (impArT) care is more available and easier to access statewide initiatives designed to improve than specialty care, and many patients the health of individuals with SMI and view substance abuse and mental health co-occurring chronic medical disorders Recent research has shown that treatment in primary care settings as less through more effective partnerships chronicphysicalconditions,includingboth stigmatizingthancarereceivedinspecialty between mental health and primary care common chronic physical diseases (diabe- behavioral health settings. providers.calmend pilot-collaborative tes, asthma, hypertension, heart disease, Althoughthisisthecase,PCPsoftendo to integrate primary care and and so on) and chronic pain conditions not have time to address complex mental mental Health services (cpci) (arthritis, back pain, headaches) are often healthandsubstanceabuse-relatedissues. accompanied by common psychiatric dis- Moreover,eventhoughdepression,bipolar, orders such as major depression, anxiety anxiety,andsubstanceabusedisordersare This county-based program is spon- disorders, and substance abuse. The fact so prevalent in the primary care setting, sored by the State of California Depart- that these psychiatric disorders often oc- PCPs generally have disproportionate and ments of Health Care Services (DHCS) and curwithinthecontextofcomorbidchronic suboptimal residency and postresidency Mental Health (DMH), and it is structured physicalconditionsemphasizesthecentral psychiatrictraining.Unfortunately,theend around the Institute for Health Care role that providers of primary health care result for many who suffer from mental Improvement Breakthrough Series Col- play in efforts to improve overall health illness is either ineffective treatment or, in laborative model. The primary goal is to outcomes ofnot both physical and psychiatric many cases, no treatment at all. effectivelybringtogethermentalhealthand disorders.Muchofthisco-occurringillness, Meanwhile, the delivery of preven- primary care practitioners and organiza- however, is diagnosed or treated. With tive and primary care medicine to those tions that share a commitment to making Mental Health Services Act (MHSA) fund- who have severe mental illness (SMI) is majorchangesthatproducesignificantand ing, the University of California, Davis, has also sorely lacking. In fact, those with SMI sustainable breakthrough results. developed and expanded two residency

live, on average, twenty-five2 years less CPCI will involve four to six county programs—internal medicine/p sy chiatry than those without SMI. Although the behavioral health authorities and their (IMP) and family medicine and p sy chiatry main cause for this dramatic disparity is partner primary care organizations. (FMP) —that specifically train physicians cardiovasculardisease,peoplewithmental Each pilot site will have direct access to to better understand the mind-body con- illness are much more likely to suffer from faculty support and regularly scheduled nectionandphysical-mentalcomorbidities chronicpulmonarydisease,diabetes,sexu - CPCI sponsored “learning sessions” that and to address4,5 this important health care 16 sAn frAncisco medicine April 2010 17 sAn frAncisco medicine June 2010 allytransmittedinfections,certaincommon are specifically designed to develop and disparity. www.sfms.org www.sfms.org RobertM.McCarron,DO,ispresidentof the Association of Medicine and Psychiatry In November 2004, Proposition 63 CareServices(DHCS)isnowintheprocess and training director for the Internal Medi- (the Mental Health Services Act, or MHSA) of significantly revising its 1115 waiver for cine and Psychiatry Residency program at passed in the state of California, allow- hospital financing and uninsured care to the University of California Davis School of ing the California Department of Mental changethemannerinwhichMedi-Calpro - Medicine. Healththeopportunitytoprovidefunding, videsservicestosomeofitsmostmedically SergioAguilar-Gaxiola,MD, isaprofes - personnel, and other resources to public vulnerablebeneficiaries.Thisrestructuring sor of clinical internal medicine at the Uni- mental health programs. MHSA funds are includes the development or realignment versityofCaliforniaDavisSchoolofMedicine. also used to reduce barriers to access and of organized delivery systems of care for He is the founding director of the UC Davis address stigma associated with mental specific high-risk populations, including Center for Reducing Health Disparities and illness, while promoting prevention, early those with SMI. Various technical work thedirectoroftheCommunityEngagement intervention, and the development of inte- groups have been established to focus on Program of the UCD Clinical Translational grated educational programs that support specific populations that have been identi- Science Center (CTSC). He is also cochair wellness and recovery. fiedasathighriskforpoorhealthoutcomes of the NIH’s Community Engagement Key In 2008, with MHSA grant funding, in the currentservice delivery system.One Function Committee for the CTSA awards the U.C. Davis Center for Reducing Health suchgroupiscomprisedofadultswithSMI and the Immediate Past Chair of the Board Disparities partnered with the U.C. Davis and/or substance abuse disorders. of Directors of Mental Health America. DepartmentsofPsychiatryandBehavioral Asoutlinedpreviously,thosewithSMI CaitlynMeltvedtisaResearchSpecialist Sciences, Internal Medicine, and Family have a much shorter life span when com- forthedepartmentsofInternalMedicineand and Community Medicine to develop the pared to those without SMI. There is clear Psychiatry at UC Davis Medical Center. Her Integrated Medicine Psychiatry and Resi- evidence that improving the integration of research focuses on quality improvement dency Training (IMPART) initiative. The primarycare,mentalhealth,andsubstance projects for medically underserved patients primaryobjectiveforIMPARTistoprovide abuse services also improves the overall in Sacramento county. IMP and FMP residents with sixty months health6 status for this vulnerable popula- of integrated, culturally and linguistically tion. Before the end of August 2010, the references competenttraininginpsychiatryandeither collective input from several work-group family medicine or internal medicine. The sessionswillbeusedtodevelopclinicaland 1 N Engl core principles of MHSA (which include educational strategies that will advance J Med. Whooley MA, Simon GE. Managing reducing health disparities with a focus on medical and psychiatric care for Medi-Cal depression in medical outpatients.

patient-andfamily-centered,culturallytai - recipients with SMI. 2 2000; 343(26):1942-1950. lored,andtargetedtreatmentthatislargely The CPCI, IMPART, and Waiver 1115 Colton CW, Manderscheid RW. Con- dependant on one’s sense of personal re- programs are just a few examples of how gruencies in increased mortality rates, covery) are incorporated into the IMPART models of integration and statewide in- years of potentialPrev life Chroniclost, and Dis. causes of curriculum and recruitment process. Each novation can affect positive change in indi- death among public mental health clients graduate from these five-year programs vidualsandfamilies.Whiletheissueofbet - in eight states. 2006.

willbeboardeligibleineitherfamilymedi - ter coordination and integration of mental 3(2):A42.3 cine or internal medicine and psychiatry. health and physical health care in persons Jones DR, Macias C, Barreira PJ, Manyoftheresidentshaveastronginterest withmentalandsubstanceabusedisorders Fisher WH, Hargreaves WA, Harding CM. in working with underserved populations is relevant to the overall redesign of health Prevalence, severity, and co-occurrencePsychiatric of and in teaching students the importance care systems, the integ ration of effort on Serv.chronic physical health problems of per- integrating medicine and psychiatry, par- the part of the public agencies responsible sonswithseriousmentalillness. waiver 1115ticularly in the primary care setting. for child, family, adult, and elderly mental 4 2004. 55(11):1250-1257. health—child welfare, special education, Servis M. CombinedAcad Psychiatry. family practice primaryhealthcare,mentalhealth,juvenile and psychiatry residency training: A 10- Section1115oftheSocialSecurityAct or criminal justice, and substance abuse— year appraisal. 2005.

allows the Secretary of Health and Human is of particular relevance to vulnerable 29(5):416-418.5 Services to authorize pilot or demonstra- populations,includingthepoor,uninsured, Harv RevServis Psychiatry. ME, Hilty DM. Psychiatry and tion projects that can help promote the children and the elderly, and immigrants. primarycare:Newdirectionsineducation.

existing objectives of statewide Medicaid Although we are still in the early stages of 6 2000. 8(4):206-209. programs.Section1115waiversaregener - developing, implementing, and evaluating GlobalPerspectivesonMentalDisordersand Aguilar-GaxiolaS.Policyimplications. ally used to allow states to institute dem- widespread primary care, mental health PhysicalInM.VonKorff,K.Scott,andO.Gureje(eds.), Illness in the WHO World Mental onstration projects and provide federal collaborativecare,andeducationalmodels, HealthSurveys fundingthatwouldnotnormallybeeligible we are on the right path to building better under federal law. care models that are responsive to the .2009.NewYork:Cambridge 17 sAn frAncisco medicine June 2010 www.sfms.org www.sfms.org The California Department of Health needs of diverse populations. June 2010 sAn frAncisco medicine 17University Press.

addIcTIon and recovery

Treating a disease as a disease

Health Care Reform and Substance-Use Disorder Parity

thomas J. Brady, MD, MBA

F oryears,publichealthexperts,ama - abuse (e.g., alcohol-related pancreatitis, emergency department costs declined jority of the public, and even many substance-relatedmotorvehicleaccidents , by 39%. In another study, total medical politicians have understood the etc.). To these expenses we should add costs decreased by more than one-half, importance of expanding treatment for al- nonmedicaleconomiccosts—schooldrop - from $431.12 to $200.03 per patient per coholicsanddrugaddicts.Theproblemhas out rates, poverty and lowered earnings, month. Thus, while parity may lead to beenhowtopayforit.Governmentsupport absenteeism and presenteeism (showing greater useofsubstance abuse and mental for treatment is continually cut whenever up but not producing), domestic violence healthservices,thattreatmentremainsour budgets get tight, as they are presently. and child abuse, and crime. And yet only best strategy to increase recovery from Funding for treatment in California has about 1% of the U.S. health care dollar is addiction and improvements in mental been slashed in recent years, and waiting spentondirectsubstanceabusetreatment. health, leading to greater productivity, in- lists for treatment slots are expanding as Consider the 80/20 rule regarding creasedqualityoflife,andimprovedoverall a result. health care reimbursements; that is, that health—precisely what we physicians U.S. health care reform promises criti- medical/surgical treatment in the U.S. is would like to see—and to lower costs cally important change for the millions of funded 80% by private third-party payers for insurers, employers, and government Americans who suffer from the disease of and 20% by the government. Why is the health programs. addiction. The Patient Protection and Af- opposite true for substance abuse treat- A study of parity in the Federal Em- fordable Care Act of 2010 (HR 3590) will ment, where 20% is funded by private ployee Health Benefit Program found that require all health plans to cover substance health insurance and 80% by government two-thirds of the plans incurred no added usedisorderservices,andnearlyallAmeri - sources? The reasons are many: a cultural administrative costs, and none reported cans, including many of the uninsured in viewthatsubstanceabuseisamoralfailing majorproblemswithimplementation.An - most need of addiction treatment, will andshouldthusbeacriminalmatter,treat - other study of a comprehensive substance finally have coverage. Substance abuse ment is ineffective, and treatment is not abuse and mental health parity law in Ver- andmentalhealthtreatmentaretoachieve cost-effective,amongothers.Noneofthese montfoundthat,relativetospendingforall true parity. rationalizations is true, and yet mistaken services, the amount spent by Blue Cross/ Substance use disorder parity means ideas, biases, and discrimination continue. BlueShieldofVermontonsubstanceabuse that health insurance coverage for sub- Critics opposing parity for substance and mental health treatment increased stance use disorders is equal to coverage abuse and mental health treatment most only from 2.30 percent to 2.47 percent. for other medical disorders. Why is parity often argue that it would be too costly. But According to an analysis by the Legal important? The answer is both economic analysishasconsistentlyshownotherwise. Action Center, a Washington, D.C., non- and medical. U.S. health care expenditures While substance abuse and mental health profit public interest law firm and policy in 2009 accounted for almost 16% of the disorders are among leading causes of dis- organization that specializes in fighting total gross domestic product (GDP, or all ability, numerous studies have indicated discrimination against, and protecting dollars spent) and by 2020 will account that substance abuse treatment is as ef- the rights of, people with alcohol or drug for 20% of GDP. Disparities are great, and fectiveormoresothantreatmentforother problems, HIV/AIDS, or criminal records, overall U.S. healthcare is suffering—infant chronic medical diseases such as asthma, HR 3590 includes many particular and mortality ranks twenty-ninth and life diabetes, and hypertension. Substance general provisions that support treatment expectancy ranks forty-second among abusetreatmentalsoreducesoverallhealth forsubstanceusedisorders.Specifically,HR countries of the world. Substance abuse care costs. A California study reported that 3590 requires: and addiction account for approximately after an outpatient chemical dependency 1. Abasicbenefitpackageforallhealth one quarter of total U.S. health care costs, recovery program, medical costs for the plans in the individual market and small- includingindirectcostsofmedical,surgical, study group declined by 26%, inpatient group markets, such plans being required 18 sAn frAncisco medicine April 2010 19 sAn frAncisco medicine June 2010 andpsychiatriccomplicationsofsubstance health care costs declined by 35%, and to cover mental health and www.sfms.org www.sfms.org substance use disorder treatments. must still be developed. And, as trite as it 1600 is that the timetable for basic stan- 2. All plans in the health insurance sounds,thedevilisinthedetails.Evenwith dards to be in place under national health exchangetoadheretotheprovisionsofthe federal health care reform, there are many care reform is 2014. The passage of AB Wellstone/Domenici Parity Act. ways that parity could still be thwarted. 1600 would mandate parity in California 3. Medicaid (California’s MediCal) People with substance use disorders have by January 1, 2011. California’s legislation enrollees,includingnewlyeligiblechildless never been treated like other medical pa- could help define what parity will really adults,toreceiveadequatehealthcoverage, tients. Consistent treatment until recovery mean for millions of people with mental including mental health and substance is achieved has never been considered a health and substance use disorders. AB use disorder benefits. MediCal eligibility medical necessity. Instead, arbitrary limits 1600 and subsequent legislation and expands to 133% of federal poverty (2009 ontreatmenthavebeentherule,reinforced regulationwouldsetthebasicstandardsfor figures: $14,404 for an adult and $29,327 by string ent medical necessity utilization mentalhealthandsubstanceusetreatment for a family of four). review guidelines. Will these guidelines under national health care. 4. No denials for preexisting condi- become even tighter? Federalsubstanceabuseparitylegisla - tions, charging higher premiums based on California is getting the jump on the tion,thePaulWellstoneandPeteDomenici gender or health status, or placing annual rest of the country by offering its own Mental Health Parity and Addiction Equity or lifetime caps on insurance coverage. parity legislation, AB 1600, introduced by Act of 2008, and HR 3590, along with the 5. Allowing adult children to remain Assembly Member Jim Beall, Jr. AB 1600 doggedeffortsofCalifornialegislatorssuch on their parents’ insurance until their would mandate that all health plans and as Assembly Member Jim Beall, Jr., should twenty-seventh birthday. insurers cover all mental health benefits give substance abuse patients and provid- 6. Providing sliding scale subsidies at parity for patients with any disorder erscautiousoptimismregardingincreased for individuals and families up to 400% of defined in the Diagnostic and Statistical access to substance abuse treatment. The thefederalpovertyleveltopurchasehealth Manual of Mental Disorders, Fourth Edi- next few years will likely be both a realiza- coverage. tion (DSM-IV-TR), excluding V codes. That tion of hope and promise in that regard, 7. Individuals to carry health insur- includes the diagnosis and treatment of mixed with increased need for scrutiny ance or pay a financial penalty. substance use disorders. Coverage would to ensureThomas that J. Brady,needed MD, changes MBA, occuris board as 8. $15billionovertenyearstosupport be mandated for all disorders included in planned.certifiedingeneral,childandadolescent,and home, school, and workplace prevention subsequentupdatesoftheDSM;anupdate forensic psychiatry and addiction medicine. services, including substance abuse pre- to DSM-5 is underway. He is a behavioral health consultant, a staff vention.* Why do we need a California law psychiatristatFamilyServiceAgencyinSan What can we expect from HR 3590 on mandatingparitywhenamandatealready Francisco, and a member of the SFMS. thestateofCalifornialevel?Healthcoverage appearsinHR3590,aswellasintheMental Afulllistofreferencesisavailableonline will be extended to 3.8 million uninsured Health Parity and Addiction Equity Act of at www.sfms.org. Californians and improve coverage for 21 2008?Aswithmostfederallegislationthat million Californians with employer-based mandates state administration and imple- or individual health insurance, together mentation, the states serve as laboratories covering 94% of legal state residents, for best practices. Parity will be no excep- * The legislation also creates new while 3.2 million young adult Californians tion.WiththerequirementinAB1600that initiatives specifically designed for treat- and 800,000 Californians with preexisting parity include all disorders in the DSM, ment and prevention of substance use dis- conditions can obtain coverage. Over the California would begin providing specific orders. A national prevention council will next ten years, the state and its residents guidelines for parity in practice. be established with the Office of National will receive new federal support for health Furtherlegislationandregulationwill Drug Control Policy Director (ONDCP) as care worth approximately $124 billion, of likely be needed as new problems crop up a member and the Substance Abuse and which $106 billion will be in the form of in this immense change in how substance Mental Health Services Administration tax credits. More important here is that abuse and mental health treatment is (SAMHSA) one of the main support- all health plans must cover substance use funded. Behavioral health carve-outs may ing agencies. The legislation’s National disordersthesamewayasallothermedical becomeobsoleteasweintegratesubstance Workforce Strategy section includes the andsurgicalbenefitsareprovided.Andbe - abuse treatment into primary health care. capacity of the treatment workforce as a causethelegislationprohibitshealthplans Requirements for increased quality assur- high-prioritytopic.Substanceusedisorder from denying coverage based on preexist- ance may lead to improved standards and treatmentproviderswillbeeligiblefornew ing conditions, people with substance use trainingforthesubstanceabusetreatment community health team grants aimed at disorders must be accepted for care. workforce. Such standards will have to be supporting various types of residential While the addiction treatment com- developed,anddevelopmentwilllikely fall treatment centers. munity is universally excited about this to the states. 18 sAn frAncisco medicine April 2010 19 sAn frAncisco medicine June 2010 www.sfms.org www.sfms.org www.sfms.org prospect, the details of implementation Another important reason for AB June 2010 sAn frAncisco medicine 19 addIcTIon and recovery

Adolescent substance Abuse

A Blueprint for California

timmen l. Cermak, MD

A ddiction medicine has long of those receive adequate treatment. while more than 16% of 15-year-olds labored with a flaw at its very The juvenile justice system provides the who started smoking in the past two core—a flaw that arose from greatest access to treatment, and except years satisfy the diagnostic criteria for the fact that adult professionals treating for twelve-step meetings (such as AA and dependence. adult patients originally developed the NA), there is virtually no aftercare for Why are adolescents at higher risk field decades ago. As a result, substance adolescents in California. of substance dependence than any other abuse has been seen as an adult disease.Jour- CSAM views substance abuse (SA) as age group? The answer is clearly multi- nal ofIn the his Americanseminal paper, Medical “Drug Association Depen- a disorder of the brain, with hereditary factorial, but heading the list is the fact dence, a Chronic Medical Illness” ( and social/experiential components plac- that the human brain experiences a burst , ing a subset of the population at increased of dendritic growth and an explosion of 2000), Thomas McLellan (current deputy risk. With sufficient exposure to drugs of new synapses at puberty with a gradual director of the Office of National Drug addiction, however, brain changes that pruning process that lasts until at least Control Policy) presented a coherent promote dependenceoccurinsusceptible 24 years of age. The last areas of the rationale for comparing treatment strate- individuals. Of all age groups throughout brain to fully mature are the frontal and gies and outcomes for addiction to those the life cycle, adolescents are at highest prefrontal areas, regions that underlie used for other chronic medical illnesses risk of experiencing brain alterations our higher-order mental capacities— such as hypertension and diabetes. Addic- as a result of alcohol and drug use. For the executive functions and conceptual tion medicine primarily resonated with example, the percentage of an alcohol frameworks that modulate and inhibit McLellan’s conclusion that, “like other use disorder (AUD) within the first two impulses arising primarily in the limbic chronic illnesses, the effects of drug de- years of initiating drinking is 3.7% in system. Without these higher-order func- pendence treatment are optimized when ages twenty-two through twenty-six; but tions, adolescents have fewer resources managedpatients remain in continuing care. . . .” In 9.5% of 16 year-olds will demonstrate with which to respond to the ultimately other words, substance abuse must be an AUD if they have initiated drinking in destructive demands of a reward system for the long term, not treated the previous two years. Of those adults that has been hijacked by psychoactive once like an acute illness. who started drinking at 21 or older, drugs. There is, however, another conclu- only 2.6% demonstrated an AUD in the The data show that at least 50% of sion embedded in the concept of drug previous years, while 15% of those who the cases of addiction we treat in adults dependence as a chronic medical illness began drinking between 12 and 14 years had their onset during adolescence— that has not yet received adequate atten- of age will demonstrated an AUD in the when individuals’ primary care physi- tion. As with any chronic disease process, past year. cian was a pediatrician! Addiction is a the treatment of drug dependence would Greater than 47% of adults with chronic medical illness of pediatric onset, likely be improvedwith early diagnosis. In alcohol use before age 14 later meet and this fundamental fact still needs to fact,with substance abuse, earlydiagnosis criteria for alcohol dependence, versus be integrated into the core of addiction may eventually be one of the essential 9% for those who first used at age 21 or medicine. The fundamental fact of addic- keys to better outcomes. older. And more than 90% of adults with tion being a childhood disease needs to A review of the data relevant to the current substance use disorders started become central to the thinking of every onset of substance abuse today is en- using before18;half ofthose began before physician who comes in contact with our lightening. There are currently at least 15. But the high susceptibility toaddiction youth. As with all chronic medical condi- 250,000 adolescents (twelve to seventeen is not restricted to alcohol in adolescents. tions, early diagnosis is the key to more years of age) in need of substance abuse Among 22 to 26-year-olds who initiated effective treatment. treatment in California. Only one in ten marijuana smoking in the past two years, And we already know that early 20 sAn frAncisco medicine April 2010 21 sAn frAncisco medicine June 2010 receives any treatment, and only 25% only 3% exhibit cannabis dependence; intervention and treatment www.sfms.org saves lives. Adolescent treatment produces a 48% substance abuse before legal difficulties Peggy Hora of Alameda County enunci- reduction in primary drug use, a 53% become too severe. CSAM believes that ated the direction CSAM believes should reduction in alcohol and drug-related we should strive to keep youth in school be taken in California when she wrote medical visits, and an 80% reduction in and out of jail. Substance abuse is an ill- the following: criminal activity. While increasing the ness, not a crime. School achievement “Once an adolescent finds he or she availability of treatment for substance lowers risk of substance abuse. Bringing is unable to stop using without help, then abuse for adolescents would require an treatment to where youth are—in the treatment should be provided on demand economic investment, the Little Hoover schools—rather than waiting until they and in a safe environment. The stigma on Commission estimates that treatment have to be removed and incarcerated seeking help must be erased so that teen- saves $7 for every dollar spent. Thisfigure would facilitate early intervention and agers can get the treatment they need. We does not take into consideration the sav- normalize recovery. need to identify children who are at risk ing s beyond direct medical costs (i.e., sav- The bottom line is that parity is es- for addiction at a much earlier age and ings to the juvenile justice system, social sential for effective treatment. Health provideTimmen the interventions Cermak, MD, theyis president will need of welfare programs, reduced crime, etc.). insurance is a strong predictor of whether tothe avoid California alcohol Society and other of Addiction drugs.” Medi- Neither doesit take intoconsideration the or not an adolescent will receive needed cine. He is currently in private practice in increased productivity that accrues to so- health care services. Currently 64% of psychiatry in Mill Valley. ciety when fewer youth drop outof school adolescents 12 to 17 are covered by and fail to contribute to an educated and private health insurance; mandated par- skilled workforce. The investment in ity would provide substanceif abuse and develop ing a treatment system for youth mental health treatment to all of them. would pay dividends both financially and Federal law only states that a medical in terms of reducing human suffering for insurance plan provides coverage for sub- countless families. stanceabuseandmental health problems, Secondhand Smoke Treatment for youth will be more it must provide benefits that are on a par Ordinance Victory in costly than for adults for two primary rea- with other medical benefits. Offering full San Francisco sons: (1) The level of professional training parity to all ages for substance abuse and required of workers in adolescent treat- mental health treatment would increase ment is higher than in adult treatment, insurance premiums by only 0.2%, about and (2) the intensive phase of treatment $5 per year. Mandating parity only for The San Francisco Board of Sup er- must often last longer with adolescents adolescents, at a minimum, would be a visors adopted San Francisco’s compre- than with adults. Youth treatment must relatively inexpensive method for provid- hensive secondhand smoke ordinance address both mental health and sub- ingaconsistent sourceof revenueto begin on its second reading. stance abuse issues. Co-morbidity is the building a treatment system in California The new policy, introduced by norm for adolescent substance abusers. designed to meet adolescents’ needs. Supervisor Eric Mar and approved Psychiatric conditions complicating the A statewide treatment network for unanimously, tightens up existing rules substance abuse frequently include de- adolescents is required. Treating youth and helps San Francisco catch up with pression, anxiety, ADHD, and conduct dis- and their families within their envi- some other municipalities. It will re- orders. Family dysfunction is very com- ronment is preferable; but sometimes strict smoking in many public places, mon and must also be addressed. Normal individuals need to be removed from including dining areas where food is developmental issues, often delayed and their immediate environment in order served outdoors, waiting lines, building distorted by the substance abuse, need to interrupt destructive patterns of sub- entrances, hotels, most bars, farmer’s to be addressed during treatment. As a stance use and/or ongoing traumatiza- markets, taxicabs, and common areas result, the level of professional training tion. Currently, only the wealthy can in multiunit buildings. The policy is the required of workers in adolescent treat- afford expensive out of state wilderness result of great effort by a broadcoalition ment is higher than in adult treatment. programs designed to remove youth from of health advocates, including the San However, while youth treatment is more toxic environments, circumstances, and Francisco Medical Society. costly, the benefits (both psychologically behaviors. With a statewide treatment SFMS Past-President Steve Fugaro, and economically) last far longer when system, similar opportunities could exist MD, who testified in favor of the policy, sobriety is established early in life. for individuals to receive residential care reports, “This is a big victory for the an- Currently in California, the juvenile within California, at some safe remove titobacco forces, and Iamvery pleased!” justice system is the main portal for from their dysfunctional environment A one-page summary of the policy entry into treatment. This is inefficient. but still close enough that family work is available from the SFMS’s Steve Heilig Student Assistance Programs are a far could proceed. at [email protected]. 20 sAn frAncisco medicine April 2010 21 sAn frAncisco medicine June 2010 www.sfms.org www.sfms.org more effective way to intervene in youth In summary, the Honorable Judge June 2010 sAn frAncisco medicine 21 addIcTIon and recovery

marijuana facts

The Risk of Addiction

timmen l. Cermak, MD

M arijuana is aneuro marvelous story. I For researchers, the “cannabinoid cally engineered to have no CB1 receptors, mean that scientifically; more story”hasshiftedradicallyfrommarijuana and thus no functioning endocannabinoid specifically, scientifically. tothebrain,fromthequestionofwhymari - system in the CNS. A variety of interesting It was not until 1960 that Raphael juana makes people “high” to the question differences exist between CB1 knockouts Mechoulam,anIsraeliresearcher,wasable ofwhatfunctionsthismassiveneurochemi - and their normal brethren.CB1knockouts toworkoutthemolecularstructureofTHC, cal system underlies. displayhypomotilitywhenputintoamaze. delta-9-tetrahydrocannabinol—the main To begin, our endocannabinoids (at They explore their environment less. They psychoactive ingredient extracted from least four different endogenous ligands havebettermemories.Anyonewhohasrun the oily resin produced by the cannabis have been identified) are neuromodula- apersonalexperimentwithincreasingcan - plant.However,foralmostmorethanthree tors, not neurotransmitters. Rather than nabinoidstimulation might remember the decades, the mechanism by which THC in- transmit detailed information, endocan- declineinshort-termmemorythatensued. teractedwiththebrainremainedamystery. nabinoids act in a retrograde fashion at One downside of better memories is that Dr.AllynHowlettpaved thewayoutof synapses, reaching back to enhance or CB1 knockouts also show decreased for- thismysteryin1988whenshefirstdemon - dampen input from incoming neurons. gettingofaversivememories.Forexample, stratedtheexistenceofcannabinoidrecep - Rather than being stored in vesicles, like classical conditioning using punishment tors in the brain. After that, the new field most neurotransmitters, the endocan- is highly resistant to extinction. One might of cannabinoid neuroscience took flight. nabinoids reside within the neuronal speculatethatveteranswithposttraumatic Twoyearslater,Dr. Miles Herkenham used membrane itself (remember, THC is fat stress disorder who have an inclination a labeled cannabinoid agonist to map the soluble) and become available as needed to use marijuana might be reacting to the concentrationofwhatwassoontobecalled to modulate efferent input. temporary balm it provides for their aver- CB1 receptors (CB2 receptors, discovered The endocannabinoid system is toni- sivememories.Animalstudiesindicatethat in 1993, are located primarily outside the cally active, meaning that it exhibits a AM404 (an inhibitor of eCB breakdown CNS) in several species. Then Dr. William constant level of ongoing activity that can and reuptake) may be a more effective Devane, working in Mechoulam’s lab after be either increased or decreased in order enhancer of extinction. leaving Howlett’s, announced discovery to modulate a function—appetite, for ex- Perhaps most significant is the in- in 1992 of the first endogenous cannabi- ample.Anyonewhohasbeeninthethrallof creased mortality that CB1 knockouts noid—anandamide. increased cannabinoid stimulation knows show, not from any single cause but from a Thebasicresearchblueprint—extract what the “munchies” are—an increased widevarietyofnormalillnesses.Thespecu - the psychoactive substance from a plant’s appetite for comfort food. On the other lation is that the endocannabinoid system oily residue, label it, discover and map hand,decreasingendocannabinoidactivity continuously modulates a wide array of receptor sites within the brain, and then belowitsusualtoniclevelbyadministering physiologic functions, thereby increasing findtheendogenousligandforthoserecep - a cannabinoid antagonist (for example, the flexibility an organism’s responses to tors—replicates the path earlier paved by SR141716A,orRimonabant)leadstoaloss the changing environment. Without this opiate researchers. Except the endocan- of appetite. More strikingly, administering ongoing capacity to modulate such func- nabinoid system is at least tenfold the size SR141716A to newborn rat pups in the tionsasmemory,painthreshold,appetites, of the endorphin system. In fact, according first twenty-four hours of life (when the attention, motor activity, fear/anxiety, and toMechoulam,“Thecannabinoidreceptors concentration of endocannabinoids in the novelty/familiarity (to name a few), an are found in higher concentrations than brain is at the highest) leads to a failure to animalisrestrictedtoamorenarrowrange any other receptor in the brain . . . and the suckle, and death. of physiological and behavioral responses. endocannabinoidsystemactsessentiallyin An intriguing window into the overall Suchrigidityleadstoawearingdownofthe just about every physiological system that value of our endocannabinoid system is various organ systems more quickly, and 22 sAn frAncisco medicine April 2010 23 sAn frAncisco medicine June 2010 people have looked into. . . .” providedbyCB1knockouts—micegeneti - hence to early mortality. www.sfms.org www.sfms.org To summarize up to this point: Every timelessness, and so on. While marijuana treating an underlying medical condition cell in our body contains the DNA to p ro- stimulates these experiences, it also can with “medical” marijuana from when they duce cannabinoid molecules and complex leave the brain altered when used too have smoked heavily enough to down- protein receptors. The CNS produces large consistently, because it can so excessively regulate cannabinoid receptors (thus quantities of both, relative to other neuro- stimulate cannabinoid receptors that they requiringexogenouscannabinoidstimula - chemicals,tocreateapervasivemodulator y begintodown-regulate,byasmuchas60% tion in order to feel “normal”) is complex. system that enhances the brain’s flexibility in some areas of the brain. As a result, any It is also imprecise. This discernment can and adaptability to a changing environ- cessation of exogenous stimulation (stop- beaccomplishedonlywithinthecontextof ment. Maintaining the endocannabinoid ping smoking marijuana, for instance) a good therapeutic alliance with a patient systemingoodtonicbalanceispresumably leads to a relative cannabinoid deficiency who is willing to explore the conundrum a good strategy for staving off mortality. state,Wanting generally considered to be unpleas- honestly. Thisbringsustothetopicofaddiction. ant. Patients need to be viewed in a Is there evidence for marijuana (i.e., THC) , on the other hand, is a similar manner whether they are using addiction? And, if so, what is the clinical motivational force rather than a hedonic marijuana or Vicodin. While either might significance of marijuana addiction? experience.Wantingisrelatedtodopamine be a useful medication, getting high every There are four lines of evidence of manipulationintheventraltegmentalarea day through excessive use is still getting physical addiction and withdrawal caused (VTA)andlargepartsofthenucleusaccum - high every day. And relying solely on a by THC. First,administeringTHC forseven bens. While the mechanisms underlying patient’s judgment of what is the best days, followed by SR141716A (a canna- liking develop tolerance (through recep- medication for a given symptom is to binoid antagonist that leads to sudden tor down-regulation), the mechanisms abandonTimmenCermak,MD,ispresidentofthe the scientific princi ples at the displacement of THC from cannabinoid underlying wanting become sensitized by CaliforniaSocietyofAddictionMedicine.Hecore of our medical training. receptors), produces similar symptoms continuous or large uses of a drug of ad- iscurrently inprivate practice inpsychiatry across several species—snout rubbing, diction. Over time it takes less exposure to in Mill Valley. difficulty sleeping with characteristic EEG thedrug,andfewer cues from theenviron - Afulllistofreferencesisavailableonline disturbances, “wet-dog shakes,” and so on. ment, to stimulate wanting and the deep at www.sfms.org. Second, clinical reports by humans seek- motivation to obtain and use a drug, even ing treatment for marijuana dependence when the pleasure value of the drug may include similar symptoms of irritability, have wanedlike considerably. Health Care Reform law anxiety, insomnia with characteristic EEG There is no doubt that manywant Califor- GivesBigBoosttoAddiction disturbances, restlessness, etc. Third, nians marijuana.Themorepenetrating treatment and Prevention epidemiologic studies reveal that approxi- question lies in why so many it with mately 9% of people who begin smoking such passion. Is this simply a matter of marijuanaattwenty-oneyearsoldorolder libertarian fervor? In some cases, yes. But Bob Curley, www.jointogether.org eventually satisfy the criteria for cannabissine why would such fervor be attached to the Don’t count addiction recovery ad- quadependence. non issue of access to marijuana? Many would The fourth line of evidence is the argue that devotion to the issue stems vocates among those who see health care for any addictive substance: THC from the need to protect vital supplies of reform as the next Armageddon: The bill causes a rise in dopamine levels in the a medicine that has become essential to signed into law by President Obama in- nucleus accumbens (often called the re- their well-being. Perhaps. But addiction cludesaddictionandmentalhealthservices wardcenter).Whilethisisoftenequatedto medicinepractionersconfrontsuchfervent in its basic benefits package and is being producing pleasure, complicated research attachment to a variety of psychoactive broadly praised by treatment, prevention, on the distinction between “liking” and drugs on a daily basis. andrecoveryleaders.Thenewlawrequires “wanting” is forcing addiction medicine While no one writhes in uncontrol- that addiction and mental health benefits to generate a more sophisticated picture lable agony from marijuana withdrawal, be provided in the same way as all other covered medical and surgical benefits. of theLiking neural mechanisms involved in the assomeopiateaddictsdo inthe absenceof development of dependence. theirdrug,researchersdofindasignificant “Includingaddiction treatmentinthe is related to opioid, cannabi- connectionbetweenpot’ssubtlesymptoms basic benefit for all medical insurance is noid, and GABA manipulation in parts of of abstinence and relapse behavior. Many a major public health achievement,” said the palladium, and in only a small portion people“prove”thattheyarenotdependent DavidRosenbloom,PhD,ofJoinTogetherat ofthenucleusaccumbens.Thereareplenty onmarijuanabyabstainingforweeks,then Boston University School of Public Health. of experiences stimulated by THC that findthemselves“wanting”tosmokeitagain “Nowwemustturnourattentionandadvo - people like: relaxation, a sense of novelty tocalmtheirritabilitytheyattributetolife’s cacy to ensure that the promise is actually (especially as concerns sensory stimuli), stressesratherthantoongoingwithdrawal. delivered in every community.” 22 sAn frAncisco medicine April 2010 23 sAn frAncisco medicine June 2010 www.sfms.org www.sfms.org anwww.sfms.org altered attentional focus, reduced pain, Discerning when patients are truly June 2010 sAn frAncisco medicine 23 addIcTIon and recovery

not the right prescription

“Medical” Cannabis and Adolescents

lynn Ponton, MD, and Sam Judice, MD

guidelines for Teenagers and parents P hysicians who work with young lege semester. Upon first interview, David people need to understand the denied any marijuana or drug use. When multiple and often insidious roles asked, his parents, both professionals, • All teenagers take risks as a normal that marijuana may be playing in the lives were certain that David did not use drugs part of growing up as a way to define and of their young patients. The following but that he had inherited the family curse develop their identities. two cases represent p atients treated by of severe mood disorder. The psychiatrist • Most adolescents try marijuana with the authors, who are practicing child and was hesitant to order a urine toxicology their friends (over 40%). They are often adolescent psychiatrists. These cases il- screenbecauseallpartiesinvolvedseemed unawareofthedangersthatthisdrugposes. lustrate current challenges faced by physi- highlycredibleandDavid’sinitialsymptom • Brain growth and development cians working with adolescents in the Bay picture suggested the proposed severe continues throughout life, but there is a Area—currently a unique culture with its mood and anxiety disorder. period of rapid growth in adolescence that owncase 1 challenges. However, his eventual urine toxicol- continues through the mid-twenties. Many ogy screen revealed a different story and substances,includingmarijuana,negativel y measured a level of THC over 350 ng/ affect brain development. Eighteen-year-old Jonathan had been ml. When asked if he was surprised that • Serious negative side effects of in psychiatric treatment for depression, his urine toxicology screen indicated that marijuana use affecting adolescents are anxiety, and lack of initiative in high school he was a heavy, chronic marijuana user, diminished passion and motivation for life. for approximately one-and-a-half years David snickered, “No,” and then asked the Outgoing teens can become withdrawn. whenhefinallysharedwithhispsychiatrist psychiatrist if he would be willing to help Grades inschoolcan fall.Teenagerscan lose thathewastakingprescribedmarijuanain him get a medical marijuana card, adding interest in most activities. additiontotheantidepressantthatshewas that marijuana was the only thing that • Adolescents who have serious psy- prescribing. With Jonathan’s permission, helped him sleep. chological problems, such as depression, andbecause hewasexperiencingmore se- Since David was nineteen years old, anxiety, bipolar disorder, or other mental vere difficulties, the psychiatrist called the the psychiatrist needed David’s consent to health issues, are extremely vulnerable to physician who had prescribed Jonathan’s speak to his parents about these difficul- marijuana use, which frequently results in marijuana,lettingherknowthatJonathan’s ties. At this point in the treatment David a worsening of their symptoms. lack of initiative and impaired school per- adamantlyrefusedtogivewrittenconsent, • Marijuana is psychologically addic- formance worsened after Jonathan began not allowing the psychiatrist to speak with tive. Marijuana symptoms include with- using medical marijuana. The prescribing hisparents.Severalmonthslater,whenthe drawal and a compulsive craving for the doctor did not know this information psychiatristfinallybegan to confront these drug. Both psychological and substance because she had planned no follow-up issues with permission, he discovered that abuse treatments aid in stopping it. visits to check on her young patient. Fol- David’sfatherwasalsosmokingmarijuana. • Teenagers and their parents can lowingthisexchange,thepsychiatristspent At this point David’s father pulled his son contacttheNationalInstituteofDrugAbuse months working with Jonathan and his out of treatment. Father and son both left, (NIDA) for information about marijuana family, gradually helping him understand saying that marijuana smoking was harm- abuse and treatment. that marijuana was not the right medicine lessandthatanytreatmentthatfocusedon • Duringthelasttwo decades,marijua - case 2for him and to address the initial problem. abstaining from marijuana was “bad treat- na grown in the UnitedStates has increased ment.” They felt supported by the culture itspercentageof THC—tetrahydrocannabi- and beliefs in the Bay Area and were sure nol—more than tenfold. • Marijuana use is frequently found Davidisanineteen-year-oldmalewho thattheycouldfindanotherphysicianwho Continued on page 26 . . . was referred for treatment of depression, would give them what they wanted. clustered with other unhealthy risks and 24 sAn frAncisco medicine April 2010 anxiety, and failing grades in his first col- other symptoms. www.sfms.org addIcTIon and recovery

new frontiers

Treatment for Homeless Substance Abusers under the Mental Health Services Act

Barry Zevin, MD, and David Pating, MD

“D octor, Ithink I’mlosingmy mind.” maintained but he clearly does have defi- substance abuse and mental illness who This has become a famil- cits affecting his memory and judgment. arehomelessoratriskforhomelessness— iar declaration from Alan M, a However,heisalsonowstronglymoti - MHSA dedicated 51% of Community sixty-three-year-old man I have treated vatedto stop andfeels morehopefulabout Support and Services funds to provide for the past four years. When he initially his future. When Mr. M. first presented, comprehensive “wrap-around” services presented with this exact complaint, he he was isolated and had only emergency through full-service partnership (FSP) had been homeless for several years, had services available to him, and he was at programs. Individuals with co-occurring been drinking heavily, and had several very high risk of death. With our current substance abuse and mental illness are admissions at our sobering center after multidisciplinary approach, he has strong common.Communitysurveysindicatethat numerous emergency room visits. Over community support and knows how to at least 50% of individuals with substance several months of visits in our open- access it. His health, both physical and abuseormental illnessalso havetheother. access, multidisciplinary primary care mental, has improved and he is at lower These individuals are two to four times Tenderloin-based satellite clinic, we were risk of death. There is no Hollywood end- more likely to use emergency services able to piece together that Mr. M had had ing tothis case, but infactthisis the kindof and have greater medical needs, greater a history of severe depression alternating everyday success thatweaccomplishwith hospitalization rates, higher suicide po- with periods of grandiosity, paranoia, and resourcesfromtheMentalHealthServices tential, and poorer treatment response poorjudgment since hisearlytwenties.He Act funding full-service partnerships. (cite, Drake). had been diagnosed with bipolar disorder In November 2004, landmark legisla- Due of the paucity of integrated sub- but had never stayed on medications. He tion rocked mental health care with the stance abuse andmental health treatment hadsucceededingettingamaster’sdegree passage of the Mental Health Services Act services, individuals with co-occurring in chemical engineering but used his skills (MHSA or Proposition 63) by 53.4% of disorders are among our most under- in the illicit drug trade and had extensive votersand reaffirmed by atwo-thirdsvote served. Often these individuals end up criminal justice trouble. For the past ten in May of 2009. MHSA placed a 1% tax on arrested and jailed for drug possession years he had been living marginally in San the adjusted gross income of Californians charges, rather than enrolled in treatment Francisco. earning$1millionormoreandcommitted programsdesignedtomeettheirneeds.By Withextensiveengagement andtrust theserevenuestotransformmentalhealth current(national)estimates,17%ofthose building, we were able to engage him in careforCalifornianswhoareunservedand incarcerated have a mental disorder, most care with an intensive case management underservedbyourcounty-operatedmen - of which are co-occurring with substance team focused on older adults. The team tal health system. To date, $7.3 billion has abuse (cite). was able to get him permanent housing, been collected with more than $1 billion MHSA’s full-service programs, mod- albeit in an SRO with minimal amenities allocated to counties for approximately eled after California’s AB2034 programs, and no onsite services. Initially his use 378,000 individuals (unduplicated count are designed to provide the compre- of health services increased with several FY07/08)toreceivecommunit y supports hensively integrated mental health care, psychiatric and medical hospitalizations, and services and approximately 542,000 substance abuse treatment, housing, but after about one year in this model of individuals estimated to receive preven- education, and employment trainingtodo care his use of services has decreased. tion and early intervention services in FY “whatever it takes” to meet needs of these His alcohol use has perhaps moderated 08/09.OtherMHSAcomponentprograms clients. According to Rusty Selix, director but he still drinks heavily daily. He has not include capital facilities and technology, of Mental Health America and coauthor beenabletoconsistentlytakemedications, workforce education, and training and of the MHSA, doing “‘whatever it takes’” primarily due to paranoid ideas about the innovation. meansContinued thatcountiesprovide on the following flexiblefund page . . -. effects they may have on him. His verbal For California’s most burdened co- ing and flexible services” to keep people andwww.sfms.org interpersonal cognitive skills are hort—thoseindividualswithco-occurring June 2010 sAn frAncisco medicine 25 New Frontiers Not the Right Prescription Continued from the previous page . . . Continued from page 24 . . . based model of care. This system is complex, involves off the street, out of the hospital, out of numerous public and nonprofit organiza- California and Colorado are both con- jail, and on the job. And we know these tions, and operates under difficult and sidering further legalization of marijuana programs work. politicized budget conditions. The inten- use. Cases like those of Jonathan and Da- From previous experience of the sity and extent of the needs in the most vid are frequently seen in the practices of 4,763 individuals enrolled in California’s severely affected populations continues physicians working with adolescents and comprehensive AB2034 programs from to surprise and confound us. The most young adults in the Bay Area. Physicians November 1999 through January 2004, recent challenge is how to truly bring working with adolescents in this culture “whatever it takes” programming re- primary medical care to those severely need to develop an educated awareness sulted in 60.8% reduced hospitalization affected with co-occurring disorders and that marijuana use is an accepted part of days, 75.4% reduced incarceration days, how to bring behavioral health services the Northern California milieu for many and 71.5% less homeless days, and an intoprimarycare,bothto servethosewith adolescents and their parents. Marijuana increase of 55.9% days fully employed or less complex behavioral health conditions usemaynotbeadmitted,however,sotreat - 91.8% more days employed part-time in and to prevent at-risk individuals from ing physicians should be prepared to con- the twelve months following enrollment progressinBarry gZevin, to severe MD, disabilitypractices andinternal risk front it as a hidden issue and to conduct a compared to the twelve months prior. ofmedicineinSanFrancisco.HeistheMedical death. fullhistory,oftenrepeatingquestionsabout Preliminary data (forthcoming) collected Director of the Tom Waddell Health Center. substance use. In addition, they should by U.C. Berkeley’s Department of Public David Pating, MD, is chief of addiction considerorderingurinetoxicolog y screens. Health-Nicholas C. Petris Center demon- medicine at Kaiser Medical Center, San Written consents to talk with parents strates successes of MHSA full-service Francisco,andassistantclinicalprofessorin and other treating physicians should be partnerships that are equally amazing. the Department of Psychiatry at UCSF. Cur- obtained atthe onset of treatment.Inmost The point is this, when public policy rently, Pating serves as an appointed Com- cases, they are difficult to obtain later in follows evidence—directing funds where missioner on California’s Mental Health treatment.Itisalsoessentialtobeprepared it matters most—human suffering is ServicesOversightandAccountabilityCom - to confront angry maneuvers, including reduced at reduced costs. As an example, mission (Proposition 63), where he chairs labeling marijuana as good and the psy- under MHSA, as of August 2009, $159.7 the Services Committee. chiatrist’s treatment as bad. million MHSA dollars have been lever- Prescribing physicians must also be aged nearly $1.1 billion additional dollars references questioned. They have responsibility for for affordable housing units in California the treatment they are recommending throughhousingbonds.Providinghousing even if they plan no follow-up. It is key to as a first step toward reducing homeless- AlcoholDrake, Research R., Mueser, & Health K., “Co-occurring understandthatthecultureintheBayArea , ness reduces annual costs from $61,000 AlcoholUseDisordersandSchizophrenia,” which includes many parents, teenagers, annually to $16,000 and greatly improves , Vol 26, No. 2, andasmallgrou p ofprescribingphysicians , acceptance and retention in services 2002 arenaively acceptingandpromotingmari - San Francisco has been a state and BureauofJusticeStatisticsSpecialRe - juanauseamongyoungpeop lewithoutthe national leader in developing successful port, Mental Health Treatment of Inmates medicallyLynn Ponton,necessary MD, evaluation is a professor and the of services and programs to serve homeless and Probationsers (NCJ174463). psychiatryall-important at UCSFfollow-up. and the author of clients with co-occurring substance abuse Gleghorn, A., Deputy Director Com- and mental illness. Based upon a truly munity Behavioral Health Services, San . Sam Judice, MD, alsoThe inclusive community planning process, Francisco County, MHSOAC testimony teachesatUCSFandisapracticingchildandRomance of Risk: Why Teenagers Do San Francisco has developed a system (2009) on MHSA Housing. adolescentthe Things psychiatristThey Do with an expertise in of programs that identify and link the AlcoholDrake, Research R., Mueser, & Health K., “Co-occurring substance abuse. highest risk (and most expensive to care AlcoholUseDisordersandSchizophrenia,” for) individuals to multidisciplinary case , Vol 26, No. 2, management programs, supportive hous- 2002 ing, residential treatment, and vocational BureauofJusticeStatisticsSpecialRe - rehabilitation. All the programs funded port, Mental Health Treatment of Inmates by the Community Programs division of and Probationsers (NCJ174463). the San Francisco Department of Public Gleghorn, A., Deputy Director Com- Health have received extensive training to munity Behavioral Health Services, San increase the capacity to care for patients Francisco County, MHSOAC testimony with co-occurring disorders, and all work (2009) on MHSA Housing. 26 sAn frAncisco medicine June 2010 under a harm reduction and recovery- www.sfms.org addIcTIon and recovery

opioid Analgesics: optimal use

Addressing Risks and Benefits in Clinical Practice for Treatment of Chronic, Nonmalignant Pain

Elinore F. McCance-Katz, MD, PhD

A s noted elsewhere in this issue, ment of hyperalgesic states induced by can be accessed. This can be a valuable there is an ongoing and grow- the opioids, which can also be associated tool in determining what controlled sub- ing epidemic of prescription with rebound pain or opioid withdrawal stances a patient requesting treatment opioid addiction in the United States, in symptoms masquerading as unrelieved is receiving concomitantly from others, large part related to the rapid increases chronic pain. Consideration of the insti- and it becomes increasingly important in prescribing of opioid analgesics for tution of a few practices are suggested as we learn more about toxicities and treatment of chronic, nonmalignant pain. to help to avoid misuse of prescribed deaths associated with opioid therapies Until the mid-1990s, there had been, his- opioids: and drug-drug interactions (Maxwell torically, underprescribing of opioid pain • Evaluation of the medical condi- and McCance-Katz 2009). Of particular medicines based on fear, in many cases, of tion—If chronic opioid therapy is being importance are drug-drug interactions creating addiction. More recently, there considered, there should be a complete between opioids and benzodiazepines. has been increased emphasis on relief evaluation of the patient’s condition to • Use of treatment agreements— of painful conditions with medication include physical examination, diagnos- Treatment agreements specifying the management and, with it, an explosion in tic testing, and releases of information expectations of the patient who is to be the prescribing of opioid analgesics even obtained so that family members and prescribed opioids chronically as well as for what some might consider to be mild- previous providers can be contacted for delineating what the patient can expect to-moderate pain conditions. What needs additional information. There should be from the clinician and staff provide a to occur is a balance in which those in written documentation of these find- concrete set of parameters that define the real need of opioid analgesics for painful ings as well as discussion of alternative treatment, goals, and a means of making conditions are not denied access, but mis- treatments and risks/benefits of opioid clinical decisions in an expeditious man- use, abuse, addiction, and diversion are therapy. ner. Treatment agreements should define minimized. The best way to meet these • Urine toxicology screen—A urine the limits of opioid therapy. Suggested goals is for physicians to become familiar toxicology screen should be obtained on content of treatment agreements: with the many interventions available every patient prior to prescribing opioids. • The patient is required to use only for pain management other than opioid The use of illicit substances by patients one physician/one pharmacy. medications and when to appropriately can be a predictor of misuse of opioid • Urine drug screens will be given use these alternative therapies. It is also medications. Chronic alcohol use can also when requested. important, if opioid therapy is to be used be arisk forthose prescribed opioid medi- • The patient agrees to return for pill for chronic pain, that physicians and clini- cations and it is now possible to test urine count when asked to do so. cians institute practices and procedures for the presence of ethyl glucuronide, an • The patient agrees to have body to minimize abuse and diversion of these alcohol metabolite that is present in the fluid testing for medication levels, if medications. This brief article will focus urine for several days. Endorsement of al- requested by the physician. on practices that can be easily put in p lace cohol use or presenceof ethyl glucuronide • The number/frequency of all refills in office-based practices to avoid opioid should prompt obtaining more detailed that will be allowed is stated, includ- misuse by patients. history of alcohol use. ing language stating that lost/stolen It bears mentioning that there is • Register with the CURES system— prescriptions will not be replaced limited evidence of the efficacy of chronic CURES is California’s prescription moni- (if this is to be your practice; an- opioid therapy in chronic, nonmalignant toring program. By registration online other op tion is to specify that stolen pain, particularly with use of high doses at http://ag.ca.gov/bne/cures.php, fol- prescriptions will not be replaced of opioid medications (Ballantyne 2003). lowed by submission of documentation withoutContinued a police on the report following documenting page . . . Further, lack of a satisfactory response to of medical license and DEA registration, the theft). 26 sAn frAncisco medicine June 2010 www.sfms.org opioidwww.sfms.org therapy may bedueto the develop- the prescription history of any patient June 2010 sAn frAncisco medicine 27 Continued from the previous page . . . Table 1: identification of prescription opioid Abusers

Reasons must be g iven for discon- tinuation (violation of agreement, misuse of medication, abuse of other substances). Deterioration in home/work performance Prescription forgery Patients who violate treatment agree- ments can have an opioid taper initiated Resistance to changes in therapy Abuse of other substances and can be given a referral to another provider. Use of drug by injection or nasal route Frequent emergency department visits Once chronic opioid therapy is initi- ated, there should be ongoing, regular Early refills Unauthorized dose increases medical assessment. These assessments should include urine drug screening to Lost/stolen prescriptions Nonmedical use determine that the drug being prescribed is present in the patient. There should Doctor shopping Refusal to provide urine drug screen or see also be the determination that illicit a specialist substances are not being used, because state medicaldirectorofthe California De- such use predicts a poor outcome for the partment of Alcohol and Drug Programs. opioid therapy. If there is regular illicit If a patient being treated with opioid References drug use (or chronic alcohol use), patients therapy for chronic pain does become ad- often need referrals to drug abuse treat- dictedtothe opioid medications, there are N Engl J Med ment programs, since they may have co- several treatment options available. The Balantyne JC, Mao J. Opioid therapy occurring substance use disorders. treating physician should have a discus- for chronic pain. . 2003; Random callbacks for pill counts sion with the patient about the concerns 349:1943-53. should and can be done by office staff. and treatment options for opioid addic- McCance-KatzHarvard EF. Office-basedReview of Psychia treat- Urine drug screening can be done by tion treatment. Options include referral tryment of opioid dependence with bu- point-of-service testing in the office or it to a substance abuse program that can prenorphine. may be done by sending the specimen to provide medical withdrawal, referral to . 2004; 12:321-338. a clinical laboratory. Every provider will methadone maintenance (this could be Maxwell J, McCance-Katz EF. IndicaAm -J need to decide how this can best be done especially helpful if the individual is ex- torsAddict of methadone and buprenorphine given the practice in which they work. If pected to need opioid pain medications use and abuse: What do we know? point-of-service testing is the option, a in the future) or a trial of buprenorphine . 2009; 19:73-88. urine specimen with a disputed result treatment. Buprenorphine is an FDA- need Assistance with Alco- can always be sent to a clinical laboratory, approved treatment for opioid addiction holism, drug dependence, or where the results will be confirmed using that can be offered through office-based mental illness? call the cmA accepted standards. practice by physicians who have met cer- confidential Assistance line at There should also be frequent review tain requirements that, for most, includes (650)756-7787 of whether there is evidence of analgesia eight hours of specialized training that with the prescribed regimen, whether can be obtained in a variety of learning side effects should be treated, whether settings (office-based treatment of opioid California Medical Association Phy- there is enhanced social/employment dependence is reviewed in McCance-Katz sicians’ and Dentists’ Confidential As- functioning, whether the treatment has 2004). Additional information about sistance Line is a service for physicians, improved overall quality of life, whether this practice is available at http://www. dentists, and their family members who family members agree that the treatment buprenorphine.samhsa.gov. request help with problems of alcohol- is beneficial (through a family assess- There are many aspects to consider ism, drug dependence, or mental illness ment), whether results are unsatisfactory in the treatment of chronic, nonmalignant within their families. When you call the and other options must be reviewed, and pain with opioid therapies. This article Confidential Assistance Line, you reach whether consults can be obtained when is meant to provide a brief overview of an answering service that relays the needed (are pain specialists, addiction these considerations that may be helpful message to the on-call physician, who medicine specialists, and/or psychiatrists to office-based physicians and clinicians thenreturns thecall.Physiciansandden - tistsstaffing thelineareselectedbecause available). who E worklinore on F. McCance-Katz,a daily basis with MD, patients PhD, is oftheirexperiencewithalcoholism,drug In overseeing the treatment of pa- professorhaving these of psychiatry issues. at the University dependence,andmentalhealthandtheir tients receiving chronic opioid therapy, of California, San Francisco. She is also the there are some warning signs of possible ability to work with doctors as patients. 28 sAn frAncisco medicine June 2010 prescription opioid abuse (see Table 1). www.sfms.org addIcTIon and recovery

proposition 36, Ten Years later

Can We Learn from Experience?

Margaret Dooley-Sammuli and Peter Banys, MD, MSc

It has been ten years since Cali- 4 forniarecognizedthatincarceration W hen 61% of California voters more than 27%. An estimated $2,861 wasn’t the answer to our families’ approved Proposition 36 in was saved perno participant, or $2.505 for and communities’ drug problems. 2000, California led the na- every dollar invested in Prop 36, and In 2000, 61% of voters approved tion, indeed most of the world, in criminal there was adverse effect on crime Proposition 36, which permanently justice interventions for people arrested trends (despite catastrophic predictions6 changed state law to allow people for low-level dru g violations. Prop 36 from law enforcement lobbies). convicted of a first- or second-time permanently changed state law to require As elimination of Prop 36 funding nonviolent, low-level drug posses- probation and treatment rather than in- threatens to wipe out a significant portion sion offense to opt for probation carceration for most people convicted of of the state’s public treatment capacity, and drug treatment instead of a first or second low-level drug offense. Prop 36 will become another unfunded incarceration. Decades of research California became the first state to offer mandate. Tens of thousands of people will show that addiction treatment is treatment instead of incarceration in find themselves in legal limbo each year, successful—at reducing drug use every courtroom, not just in special drug entitled to treatment but unable to access andarrestsandatincreasingfamily courts. This heralded a major shift from it. We are likely to see “indefinite waiting stability and employment. three decades of a punishment model to lists” in courts and renewed enforcement a public health model. opportunities for rearrest or probation Ten years later, even as the state violations. defunds Prop 36 drug treatment to cope Now some promising news: Despitemight and punishes it as such. with a budget crisis, new federal health the real and immediate pain that a 90% A true public health approach will care legislation gives California an oppor- funding cut has already wrought, it look very different—and it’s closer than tunity to move to a more comprehensive also represent a step in the right direc- ever. The federal health care legislation public health-oriented drug policy. tion. Proponents of a public health ap- that President Obama signed in late First, the bad news: Funding for drug proach cannot be satisfied with diversion, March represents an unprecedented treatment both in the community and in which, by its very nature, depends on the political acknowledgment that drug use the criminal justice system has plummet- criminalization of drug use. Admission to is fundamentally a health issue. (The ed. When Prop 36 passed, it doubled state Prop 36, as in drug courts, follows convic- ex p ansive parity requirement did not funding for drug treatment (and helped tion, and failure to maintain abstinence appear in a vacuum but builds on the establish nearly 700 new program sites). guarantees eventual imprisonment and passage of the federal Paul Wellstone and But in just three years, state funding for a criminal record. Prop 36 included Pete Domenici Mental Health Parity and Prop 36 drug treatment has been slashed important protections for participants: Addiction Equity Act of 2008 and on the by a whopping 90%—from $145 million it universalized access; prohibited incar- passage of similar bills at the state level.) in 2007/2008 to just $18 million this ceration (including jail sanctions); funded The health care legislation holds year—and the governor has proposed drug testing for treatment p urposes only; the potential to broadly expand access

eliminating funding entirely in 2011. and empowered health providers, not7 to alcohol and drug treatment here in Prop 36 was initially funded at $120 judges, to make treatment decisions. California and across the country. Not

million a year, and1 36,000 people were Despite its protections, Prop 36 still only will more people (be required to) enrolled annually (nearly ten times the reflects the prevailing ideologies of the have insurance or be eligible for Medi-Cal;

2number in all of California’s drug courts criminal justice system, which are rooted insurers will be required to cover alcohol

), completion rates were comparable to3 in principles of deterrence,8 incapacita- and drug treatment as they do any other those of other criminal justice programs, tion, and retribution, bound to the single chronicContinued health condition.on the following Drug page treat . . -. and the number of people in California benchmark of abstinence, which equates ment—which now exists largely outside 28 sAn frAncisco medicine June 2010 www.sfms.org prisonswww.sfms.org for drug possession dropped by any drug relapse with criminal recidivism June 2010 sAn frAncisco medicine 29 starving system since its passage, proposition 36 has After guaranteed funding for the prog ram sunsetted in 2006, the legislature has • Providedtreatmentto30,000+ set annual funding levels—first increasing, then slashing them. people a year.

Almost 300,000 people 2001/ 2002– $120 million per year, as guaranteed by statute have entered community-based treat- 2005/2006 ment under Prop 36, half of whom had never receivedtreatmentbefore.About 2006/2007 $145 million ($120 million in the Prop 36 trust fund and $25 million in new one-third of participants complete Offender Treatment Program, a program for Prop 36 participants) treatment and probation; about half stay for• Sharply at least 90reduced days, “the the minimum number13 ofthreshold people forin statebeneficial prison treatment.” for simple 2007/2008 $120 million ($100 million in Prop 36 fund; $20 million in OTP) drug possession.

In the twelve years 2008/2009 $108 million ($90 million in Prop 36 trust fund; $18 million in OTP) prior to Prop 36, the number of people in state prison for drug possession quadrupled, peaking at 20,116 in June 2009/2010 $63 million ($0 in Prop 36 fund; $18 million for OTP from General Fund and 2000. That number dropped by one- $45 million in OTP from federal stimulus funds to OTP) third shortly after Prop 36 took effect and •remained Reduced lower state by 14costs 8,000 by (40%) more thanas of December$2 billion. 2008. 2010/2011 The Governor has proposed $0 for both Prop 36 and OTP. For every $1 invested Source: California Department of Finance Continued from the previous page . . . in Prop15 36, the state saves a net $2.50– 4.00 Average per-person treatment may 11 costs are about $3,300 per year, while themainstreamhealthcareandinsurance (or $49,000 each ). A shocking 28.4% incarceration costs $49,000 per year. systems— finally be allowed to come of new felony admissions to prison and UCLA calculated that the program cut in from the cold. 32.7% of parolees returning to prison costs by $173 million its first year;

The California Legislature has al- with a new12 term were for drug offenses the Legislative Analyst’s Office calcu- ready formally acknowledged that drug in 2008. This does not include drug- lated• annualAchieved savings expected for later rates years ofat use is a health issue, having passed parity related technicalpossession parole revocations. The “progress”$200–300 million. and “completion.” legislation (vetoed by the governor). Simi- vast majority of these commitments are larly, the California electorate is on record for drug , not sale, manufacture, Ac- as supporting expanded access to treat- or transport. cording to UCLA, Prop 36 completion ment—and reduced incarceration—for MostEuropeancountriesandCanada rates are “fairly typical” of drug users

both alcohol and drugs problems (Prop have long ago embraced a public health referred to treatment16 by the crimi- 36 in 2000) and mental health issues posture about drug use and simple pos- nal justice system. The statewide (Prop 63 in 2004). session. The combination of a California completion rate reached 40% in 2007. On the public and personal levels, budgetdisasterandthemanifestfailureof At the county level, Prop 36 comple- Californians understand that drug use is three decadesofthewaron drugsmayyet tion rates range from 26% to more fundamentally a health matter. And yet turn out to be a crisis too good to waste. Hethan is the 50%. director of the Substance Abuse our criminal code continues to require ar- We can thinkafresh about addictions and Programs and the Substance Abuse Phy- rest, prosecution, and punishment. More theirMargaret treatment Dooley-Sammuli in the context ofis deputy health sician Fellowship Program at the V.A. than 270,000 people were arrested for a carestate reform. director in Southern California for Medical Center, San Francisco. He is past drug offense in California in 2008 (more the Drug Policy Alliance, the nation’s lead - president of the California Society of Ad- than 78,500 for marijuana), accounting ing organization working to end the war diction Medicine. for one-quarter of9 all felony arrests in on drugs and a proponent of Proposition A full list of references is available the state that year. About 30,000 people 36 in 2000. online at www.sfms.org. were in prison for10 a nonviolent drug Peter Banys, MD, is health sciences offense that year; they made up more clinical professor of psychiatry at UCSF. than 15% of the prison population and 30 sAn frAncisco medicine June 2010 cost $1.5 billion per year to incarcerate www.sfms.org addIcTIon and recovery

Big Alcohol’s new products

New Media for Youth

Sarah Mart, MS, MPH

B ig Alcohol (the global beer, wine, advertising and promotion (Center on Al- alcoholic beverages” (Marin Institute and spirits conglomerates that cohol Marketing and Youth 2007). In ad- 2009). They are a go-to alcoholic bever- own most of the alcohol industry) dition to traditional media channels such age choicemarketed to youth, particularly uses several tactics to achieve its goals as television, print, and outdoor ads, Big young girls. of ever-increasing profits. It targets vul- Alcohol also offerstext messages, cell-and An American Medical Association nerable populations such as youth with smart-phone applications, downloadable survey conducted in 2004 found that products specifically geared to their ringtones, and wallpaper backgrounds about one-third of teenage girls respond- demographic. It spends billions on adver- from their product websites. edthat they had tried alcopops. More than tising campaigns with celebrity icons and Social networking platforms have 60% of teen girls who saw TV, print, or trendy media. It spends millions more to emerged in the last five years as major in-store ads for alcopops had tried the block efforts to enact effective, evidence- players in alcohol marketing campaigns. beverages (American Medical Association based public health policies such as re- The frontrunner, Facebook, has more 2004). Alcopop ads tended to be the only stricting alcohol advertising and limiting than 400 million active user accounts way that teen girls became aware of the access to youth-friendly drinks through (Facebook 2010). Facebook offers both products, as more than 50% of the teens increased prices and product bans. Now paid and free advertising functions for who saw the ads did not report seeing more than ever, physicians need to shine companies to promote their alcohol alcopop products anywhere else, such as a spotlight on the harm caused by Big products, sponsored events, and brand- at parties or with friends. Alcohol in our communities. related content. Many of the thousands Leading alcopops brands and their It is not surprising that alcohol re- ofalcohol-related Facebook pages, events, producers include Mike’s Hard Lemon- mains the drug of choice for American and applications are accessible by under- ade (Mike’s Hard Beverage), Smirnoff youth (U.S. Health and Human Services, age users (Mart 2009). These new media Twisted V and Smirnoff Ice (Diageo), and 2007). Advertisements promoting alco- can increase product exposure to specific Bacardi Silver (Anheuser-Busch InBev/ holic beverages are insidious, and over- target audiences—especially youth—ex- Bacardi) (Beverage Information Group, sight is left to ineffective self-regulation ponentially. Social networks are widely 2009). The producers use traditional and by the alcohol industry (Gomes 2008). used to promote alcopops and alcoholic social media, contests, and sponsorships Exposure to alcohol advertising increases energy drinks, alcoholic beverages that to push alcopop messages to youth. The positive expectancies and attitudes about Alcopops and Alcoholic energy are popular with youth audiences. Mike’s Hard Lemonade Facebook page, alcoholic beverages and drinking behav- drinks: Youth-friendly products with nearly 12,000 fans, showcases the iors in youth populations (Austin 2000). “Mike’s Hard Punch Sweepstakes.” Click- Exposure to alcohol advertising contrib- ing on the sweepstakes link takes the user utes to higher levels of risky drinking Alcopops are ready-to-drink, sweet to the related website with no age-gating behaviors in youth: earlier initiation of alcoholic beverages, usually carbon- mechanism to deter underage Internet drinking and higher consumption among ated and/or fruit-flavored, and sold in users. Both the company’s Facebook page underage youth who drink (Anderson, de single-serving bottles or cans. Alcopops and its product website offer prizes of free Bruijn et al 2009). Youth in markets with resemble soft drinks in both their liquid music downloads from Warner Broth- greater alcohol advertising expenditures form and their packaging. They contain ers Music, with all entries automatically drink more; each additional dollar spent roughly the same amount of alcohol as submitted for big prizes such as a trip to on alcohol advertising raises the number traditional beer (5% alcohol by volume), London, a Les Paul guitar, a Warner Broth- of drinks consumed by three percent although some alcopops contain as much ers Rock Gift Package, and Mike’s “Hard (Snyder 2006). as 12% alcohol by volume. The alcohol PunchContinued Rocks” t-shirts. on the following page . . . In 2005, the alcohol industry spent industry calls these drinks “flavored malt With the addition of caffeine and 30 sAn frAncisco medicine June 2010 www.sfms.org approximatelywww.sfms.org $6 billion or more on beverages,” “malternatives,” and “flavored June 2010 sAn frAncisco medicine 31 Continued from the previous page . . .

away free product-related merchandise Institute ($130,500) (California Secretary other stimulants such as guarana to alco- or free samples of the product at bars, of State 2010). hol products, Big Alcohol created another sponsored parties, or on campus); con- Physicians play an important role in new product: alcoholic energy drinks tests with big prizes such as trips, sports supporting evidence-based policies and (AEDs). With names such as Four Loko, ormusicequipment, orcash;and branded illuminating the harm Big Alcohol causes, JOOSE, Liquid Charge, Max Vibe, Torque, merchandise such as t-shirts, caps, and from providing testimony at legislative Hard Wired, Evil Eye, Vicious Vodka, jackets. Social networks list hundreds of hearings to sharing their expertise on Slingshot Party Gel, and 3 A.M. Vodka, posts that mix product promotion with alcohol-related public health issues with AEDs communicate a clear message to bragging about harmful consequences. the press. Mary Claire O’Brien, a physician youth: Drink caffeine plus alcohol, stay One Four Loko fan encouraged others to researcher at Wake Forest University, is awake, and drink longer/more. Recent “share the love of four loko and spread the an excellent example of such advocacy: research has found that a quarter of col- word . . . AND GET DRUNK” (Four Loko Shehaspublished andpresentedresearch lege student drinkers mix energy drinks Page 2010). A JOOSE user wrote, “Just dis- regarding the increased negative conse- with alcohol, and that students who do covered joose . . . amazing, our vomiting quences, excessive drinking behaviors, so are at higher risk of alcohol-related and breaking of furniture rates at parties and other risks associated with youth harm, including physical injuries, injuries have skyrocketed” (JOOSE Page 2010). consumption of alcohol mixed with en- requiring medical treatment, being the Over the last two years, state and fed- ergy drinks. O’Brien has discussed the victim or perpetrator of sexual violence, eral officials have challenged producers of issues and available research extensively and riding with an intoxicated driver AEDs about the safety of their products. with national and local media outlets. She (O’Brien 2008). As a result of investigations by state attor- has also communicated with and made Additional research has found that neys general, Anheuser-Busch InBev and in-depth reviews of the literature on youth drinkers ages fourteen to twenty MillerCoors agreed to remove stimulants this topic available to the Food and Drug who mixedalcoholwith energy drinksdid from their respective caffeinated alcohol Administration and groups of attorneys so in order to hide the flavor of alcohol, products. In November 2009, the FDA general (Arria, O’Brien et al 2008). drink more, not look as drunk, and stay called for nearly thirty manufacturers of This kind of physician leadership awake longer (Song 2008). These youth AEDs to provide scientific evidence that in the public health arena is crucial in were at higher risk for heavy drinking and adding caffeine or other stimulants to the fight against Bi g Alcohol and its alcohol-related harm, such as violence alcoholic beverages is GRAS, or generally harmful products. Together, physicians, and driving while intoxicated, than youth recognized as safe. Meanwhile California, researchers, advocates, and youth can who drank alcohol only (Song 2008). Washington, and New York introduced stand against alcohol-related harm. The Despite the serious health risks and legislation in early 2010 to ban alcoholic futureofSarah our Mart youth is and research their communities and policy problems posed by AEDs, producers con- energy drinks from being produced, dis- dependsmanager onat it.Marin Institute, an alcohol- tinue to target young people directly with what we can dotributed, or sold in those states. industrywatchdog(http://www.marinin - both theproducts and their ad campaigns. stitute.org). Her recent research includes AEDproducersfollow thealcopops model alcohol promotion on Facebook and Big with sugary-sweet flavors such as Four In order to stop Big Alcohol from Alcohol’s political contributions and lob- Loko’s fruit punch, blue raspberry, or- harming youth in our communities, we byingtoinfluencepublichealthlegislation. ange, watermelon, and grape. The added need three majorpolicychanges: Increase A full list of references is available flavors easily mask the high alcohol levels the price of alcohol, stop youth-oriented online at www.sfms.org. of AEDs, many of which contain as much alcoholic beverages, and restrict alco- as 12% alcohol. The volume of AEDs is hol advertising. These are some of the san francisco influenza and nearly twice as much as noncaffeinated most cost-effective policies available to infectious disease forum 2010 alcoholic beverages (23.5 or 24 ounces affect significant reductions in alcohol Pertussis, Measles and Flu…What’s a versus a 12- or 16-ounce bottle of beer), consumption and incidence of alcohol- Clinician to Do? thus putting the equivalent of four or five related harm (Anderson, Chisholm et al standard alcoholic drinks into one can. 2009). Big Alcohol spends large amounts Learnabout the new ways AED cans and bottles are also brightly ofmoneyto influence policy makers,how - vaccine-preventable diseases are affecting colored and look just like energy drinks ever. In 2009, the alcohol industry spent our community. Thursday, July 29, from that don’t contain alcohol. more than $1.5 million to lobby California 9:00 a.m. to 12:00 p.m. at Pier 1, San Fran- cisco. Breakfast and Free CEUs provided. AED producesinexpensivesocial me- legislators. The top lobbyist clients in this [email protected] dia to develop loyal youth drinkers: social list included Diageo ($220,697), Anheus- http://sfcdcp.org/izs.html for updates. networks including Facebook, Twitter, er-Busch InBev ($166,068), MillerCoors YouTube, and MySpace; “consumer edu- ($165,000), Wine and Spirits Wholesalers 32 sAn frAncisco medicine June 2010 cators” (young, beautiful women giving of California ($150,000), and the Wine www.sfms.org addIcTIon and recovery

lessons in urban survival

A Hustler Tells All

Eisha Zaid

“Y oucantellalotbyaperson’sshoes. cutwithotherdrugs,suchaslidocaine,caf - money, which he often did not have. Thus One looktellsmeif they are worth feine, methamphetamine,3 ephedrine, and he borrowed from street lenders and still my efforts,” he said. phencyclidine. When cocaine is heated had to pay back his debt. My patient, a forty-something gentle- in an alkaline solution, it transforms into The chronic use had left his life in man, was educating me about what he “crack,” which is sold in 100–150 mg shambles. He went from having it all—a

called “urban survival.” “rocks” that can be smoked, while3 a “line” condo, a girlfriend, and a stable job—to AsanativeoftheTenderloin,herelied weighs 20–30 mg and is snorted. having nothing. He was living on the on certain tactics to make ends meet. He ***** streets, had made many enemies, and was an expert-level street hustler. He was When I first met him, he was com- relied on hustling to get his daily fix. one of the successful ones and was ca- pletely suicidal and was brought into the Hehadbeenadmittedtoourinpatient pable of making a small fortune, probably SFGHPsychiatricEmergencyServicesafter unit numerous times before for suicide enough to p ay rent and live comfortably being placed on a 5150 hold for being a attempts and was in and out of residential in a nice apartment somewhere outside danger to himself. After the initial evalu- treatment programs. He was followed by the Tenderloin. ation, he was transferred to the inpatient a case manager and was plugged into an Sadly, he burned through his earn- psychiatric unit. At the time, he had no extensive network of social support ser- ings, spending massive amounts on one home and was completely out of money. vices, but he had difficulty committing to thing—crack cocaine. He was a tall, thin, middle-aged man appointmentsand taking his medications. “Sometimes it feels like I am drown- with a pinkish complexion. His hair was The hospital had become his security net, ing just thinking about how much money combed and slicked back. He wore a lime a revolving door for him. I owe. But I want it [crack]. I need it. And I green collar shirt over blue hospital gown ***** have to get it.” pants. His two front teeth protruded out- Addictiontodrugsresultsfromaltera - Erythroxylon coca***** ward and had been eaten away and were tions in neurochemical processes, which Cocaine is derived from the leaves of stained brown. ultimately lead to increased drug-seeking , a plant endemic to the During our first meeting, it was as behavior.Cocaine,likemanyotherdrugsof Andes.Inhistoricalrecords,cocainechew - though everything was in slow motion. abuse, ishighly addictive because it blocks ing was documented in South America He moved aimlessly and spoke slowly dop amine uptake and results in increased

as far back as 4,000 years ago, and for when recounting the details of his suicide dopamine4 levels in the nucleus accum-

the last hundred years the plant has had attempt. He had a flat affect, showing little bens. Withrespecttobehavior,dopamine 5

medicinal uses because1,2 of its vasocon- facial expression. He ap peared remorse- promotes reward-seeking behavior. stricting effects. Cocaine has multiple ful but remained deeply depressed. At Interestingly, with increased cocaine actions, including that of local anesthetic, times he would become teary-eyed when use, dopamine release results from ex- CNS stimulant, appetite depressant, and talking about being abused as a child and posure to certain stimuli, such as drug vasoconstrictor. The effects are largely about his life in the Tenderloin. He was paraphernalia or environmental cues,

mediated through the inhibition of nor- diagnosedwithbipolarandpolysubstance findings that have6 been demonstrated in

epinephrine,3 dopamine, and serotonin dependence. animalmodels. Thisconditionedresponse uptake. “WhenIgetlow,Igetreallylowandgo explains the drug-seeking behavior ob- Cocaine has become a popular street intothese dark bouts of depression. There served in chronic users, who are driven drug that can be sniffed, smoked, or in- is no reason to live for me. No one gives a to do whatever it takes to get their neuro- jected intraveneously. As a recreational shit about me,” he said. chemical fix. agent, cocaine has variable purity. The His past addiction was alcohol; his Continued on***** the following page . . . purest forms are white powder, while less current substance was cocaine. His heavy Over his two-week hospitalization, I 32 sAn frAncisco medicine June 2010 www.sfms.org pureformsaremoreyellowandhavebeenwww.sfms.org drug use required excessive amounts of June 2010 sAn frAncisco medicine 33 Continued from the previous page . . .

and Havingpays close things. attention to hygiene and had entered his life. came to know him well. Although initially dress. When he left the unit, I wished him reserved, he opened up and enjoyed talk- Being cool. The hustler seeks to well. I never knew what became of him. ingabouthimselfandhisurbanlife;hewas acquire material wealth. One can only hope he was successful this always seeking an audience. He became The hustler is character- time in his residential treatment program. animated when he described the subcul- ized Beingby a criminallydetached able.persona and calm A part of me fears he might have tried to ture of street hustlers. demeanor. killhimself again, whileanotherpart ofme Hewasvaguewhendescribingexactly The hustler has thinks he may have ended up back on the what he did when he stood on the streets the knowledgeHaving heart. to accomplish the neces- streets, hustling his way to bricks of crack. of the financial district wearing an expen- sary acts to sustain a living. Whatever the outcome, his story sive European blazer and pair of polished The hustler can protect makes me think about the intersections Italian shoes. He had mastered the art of oneself from victimization or danger. of substance abuse, addiction, and psy- “talk” and was able to assume an entirely The authors conclude, “The self- chiatric illness, a sad reality in our urban different persona when he worked in the described hustlers in our research suc- neighborhoods. Although it is easy to shadows of the black suits, where he des- ceeded, at least in their own minds, in blame the patient for his addiction, we perately desired to be. establishing an identity whose status is at mustrememberthataddictionisanillness , Like him, many ofhis colleagueswere the top of the crack economy rather than which, like many other medical diseases, substance abusers who generated funds at the bottom”—much like my patient, requires an interdisciplinary approach to in a similar fashion. He admitted that his who prides himself7 on being successful at treatE itsisha neurochemical Zaid is entering and her psychological fourth year tactics were aimed at getting money from his line of work. ofbases. medical school at UCSF this fall. the “sharks,” themenin businesssuits. Un- ***** like other hustlers, he felt his tactics were Closer to the end of his hospitaliza- references less seedy; he did not pursue women and tion, my patient laid out his requests: He was not overly aggressive. wanted to be admitted into one particular “I just have a way of getting what I residentialtreatmentprograminSanFran - Nunes E. A brief historyNEJM. of cocaine: want,” he said. cisco, and after he completed the program From Inca monarchs to Cali cartels: 500 Despitehisskills,hewasconsumedby he wanted a new apartment outside the years of cocaine dealing. 2006. what he called “self-destructive behavior.” Tenderloin. These were his stipulations 355;11. PoisoningandDrug He had made many street enemies and for recovery. OverdoseMurphy NG, Benowitz NL. Cocaine there was no escape living in the Tender- At times it felt like we were negotiat- (chapter).InOlsonKR: loin district, where every street corner ing the terms of an agreement. And when . http://www.accessmedicine. harbors a dealer and the environment we could deliver, his attitude changed. He com/content.aspx?aID=2683517.Basic and Clinical Pharma- reinforces his addiction-forming habit. He instantly became invested in recovery and cologyLuscherC.Chapter32.DrugsofAbuse. feltweak, completely disabled andpower - thetreatmentprogram,seekingimmediate In Katzung BG: less to break the habit. discharge even before the bed was made . http://www.accessmedicine.com/ “I am spiraling and digging myself available. When we had trouble securing content.aspx?aID=4519820. deeper and deeper into an early grave,” the bed, he drifted into a depressed mood Volkow N, Wang G et al. Cocaine he said. and pleaded with us. cues andJournal dopamine of Neuroscience. in dorsal striatum: ***** He intrigued me. A part of me was Mechanism of craving in cocaine ad- With an expanding drug economy, a drawn to him, sympathizing with him, diction. 2006. subculture of hustlers has emerged as a completely consumed by his story. I could 26(24):6583-6588; doi:10.1523/JNEU- powerful force with a unique social iden- not even fathom how he survived years ROSCI.1544-06.2006. tity. In a study that examines the social of childhood abuse, living in the streets, Science.Schultz W, Dayan P, Montague PR. A identity formation of street hustlers in a and relying on urban survival. I wanted neural substrate ofpredictionand reward. group of twenty-eight criminals prosecut- to see him recover and get back the life 1997. 275:1593–1599. ed for violent street crimes, the authors he once had. Di Ciano P, Everitt BJ. Direct interac- cite how hustlers involved in the drug At the same time, the skeptic in me tions between the basolateral amygdalaJ Neu- economymakeeveryefforttodifferentiate awakened.Attimes,Iwonderedhowmuch rosci.and nucleus . accumbens core underlie themselves from the crackheads,7 who are of his story was true and how much of it cocaine-seeking behavior by rats. of lower social status. was concocted. He was well versed in the 2004 24:7167–7173. The following qualities were identi- art of talk. He knew exactly what to say to Copes H, Hochstetler A, Williams JP. fied asBeing central clean. components of the hustler get what he wanted. After all, he was an We weren’tSocial Problems. like no regular dope fiends: identity: expert hustler. I often wondered whether Negotiating hustler and crackhead identi- 34 sAn frAncisco medicine April 2010 35 sAn frAncisco medicine June 2010 The hustler has morals Iwasbeinghustled,likeeveryoneelsewho ties. 2008. www.sfms.org www.sfms.org 55:254-270. One in three Elderly Drinkers Tracy Zweig Associates Face High Risk of Harm, Study INC. Finds A R E G I S T R Y & P L A C E M E N T F I R M

One-thirdofAmerican drinkers over agesixtyconsume Physicians � excessiveamountsofalcohol,areatriskofdangerous interac- Nurse Practitioners ~ Physician Assistants � tions betweenalcoholandmedications, or have illnesses that can be exacerbated by drinking, according to researchers at the David Geffen School of Medicine at UCLA. A study of 3,308 clinic patients in California found that 34.7% of drinkers were considered high risk,with more than half falling into at least two of the three risk categories. Pa- tients ages sixty to sixty-four were twice as likely to beat-risk drinkers than those over age eighty, and risk was also higher among drinkers who were more affluent and less educated. Researchers said the findings could help physicians Locum Tenens ~ Permanent Placement identify at-risk patients, noting that doctors may be less aware of the problems of drug interactions and comorbidity Voice: 800-919-9141 or 805-641-9141 � than they are of heavy drinking among older patients. Journal of General Internal Medicine FAX: 805-641-9143 � The findings were published in the May edition of the . The full text is available [email protected] at http://www.jointogether.org/news/research/summa- www.tracyzweig.com ries/2010/one-in-three-elderly-drinkers.html.

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35 sAn frAncisco medicine June 2010 www.sfms.org A2878_SFMedicine.indd 1 4/26/10 2:37 PM book revIew

Steve Heilig, MPH

The pain Behind Addiction—and a miracle cure?

America Anonymous: Eight Addicts in Search of a Life

of loss of self-control colors the book, and early on he addresses TheBy Benoit End of Denizet-Lewis My Addiction (Simon & Schuster) the tension caused by an ever-broadening definition of addiction. “Ibelievethatgambling,sex,food,spending,andwork(toname a few) can, for some people, be as addictive and debilitating as an By Olivier Ameisen, MD (Farrar, Straus & Giroux) addiction to drugs,” he writes. But calling every such behavior “ad- diction”canwaterdownthe“diseasemodel”nowwidelyaccepted A ddiction to drugs, especially legal ones such as nicotine for drug addiction. Bycalling most troubling behaviors addictions, and alcohol, results in incalculable costs and suffering we risk eliciting more denial of those who actually are addicted. in America. The cumulative medical expense, accidents, So what to do when true addiction is undeniably present? As lost productivity, and legal and jail expenses have resulted in the with other diseases, many have longed for a “magic bullet,” such American Medical Association identifying substance abuse as our as antibiotics were hoped to be for infections. French cardiologist worst public health problem. OlivierAmeisen,MD,thinkshefoundonesuchweapon.Utterlyde - “Today,nearly23millionAmericans—9.2%ofthepopulation railedbyhisalcoholism,he’dtriedallmanneroftreatmentsbuthad twelve or older—are hooked on alcohol or drugs, another 61 mil- all but given up until he came upon a generic prescription muscle lion smoke cigarettes,America and millionsAnonymous more are slaves to gambling, relaxant called baclofen. “Freed by baclofen not only from the bio- compulsive overeating, and sex and pornography,” writes Benoit logicalThe prison End of of My addiction Addiction but also from the crippling anxiety that Denizet-Lewis in . That opening statement preceded it, I was finally at ease with myself and others,” he exults. hints at both some of the strengths and perils of his heartfelt book. is Ameisen’s moving story of his de- Behind every health statistic is a personal story, and here are cline, fall, and redemption, and his crusade to get baclofen widely eight men and women from all walks of life who are addicted to recognized and used. He’s understandably evangelistic: “I ask all alcohol, heroin, methamphetamine, crack, prescription drugs, physicians who treat addiction to consider prescribing baclofen,” steroids,tobacco,gambling,food,sex,pornography,andshoplifting , he says. He also urges more research, while noting that the lack of orsomecombinationthereof.Theirstoriesarediverseandmoving a patent for the drug is a huge financial disincentive and that his in their commonness and tragedy. own brave published report met “a deafening silence.” Research is Direct exposure to addiction doesn’t alwaysUSA Today help us under- indeed underway, but the jury is still out. stand and sympathize, as Denizet-Lewis notes. “Even the family History is replete with “miracle” cures for diseases, including members of addicts seem conflicted. In a /HBO drug addiction,butfewhavestoodthetestoftime.Denizet-Lewisquotes addictionpollofadultswithanaddictedfamilymember,76%called renownedaddictionresearcherDr.WalterLing’scaution: “I would addictiona‘disease’butamajorityofthosesamerespondentsiden - distrust anyone who says they can cure addiction.” But another tified ‘lacking willpower’ as the main impediment facing addicts.” truism in this arena is thatAmericaAnonymous whatever works is good. The personal stories here—with names and locations On a broader scale, though, as recovering polydrug addict alteredforprivacy—shareacommondynamic.As“Bobby,”addicted “Jody”acutelyobservesin ,“Treatmentworks. to OxyContin, succinctly recalls, “It started as a weekend thing, but Maybe not the first time, but it works if you do it right, if you give it then before I knew it I was craving it, and then I needed it to func- the time it needs. For that, you need to . . . fund it. But we don’t do tion.” But “function” here is a relative term, and that bar is lowered that. We’d rather build jails and spend millions of dollars cleaning as the addiction takes hold. Beyond the progressive dependence upthemessesofaddicts,whenwecouldspend muchlessandhelp lies varying levels of conflict with others, self-debasement, denial, themAn stop earlier making version messes!” of this review appeared in the crime, even violence and incarceration. And therein. lies yet another tragic story. Denizet-Lewis discloses that for himself, it was compulsive, San Francisco 3637anonymous sA n frA nciscosex that m tookedicine control June of his 2010 life. His own experience Chronicle www.sfms.org publIc healTh reporT

Robert P. Cabaj, MD, and David Hersh, MD

sfdpH public sector services for substance use disorders

S an Francisco citizens have a wide array of services to help To better coordinate patient assessment and placement into with substance use-related problems and disorders. Pri- the City’s wide array of funded substance use, dual diagnosis, marily targeted for people with little or no insurance or and mental health services, the Behavioral Health Access Center who are covered by Medi-Cal, Medicare, or a combination of the (BHAC) was created in 2008. The BHAC represents the coloca- two, services range from substance use assessments, treatment tion and integration of several formally separate City substance planning, and brief interventions at the extensive Department of use and mental health evaluation, stabilization, and treatment- Public Health (DPH) Community Oriented Primary Care Clinics linkageservices,includingtheTreatmentAccessProgram(general (COPC) to the network of specialized substance abuse treatment substance use and dual diagnosis), Centralized Op iate Program modalities for serious and persistent substance abusers offered Evaluation (COPE) Service (methadone and buprenorphine), through DPH Community Behavioral Health Services (CBHS). Mental Health Access Program, and the Buprenorphine Induc- The specialty substance abuse services are provided mainly tion Clinic. The CBHS Pharmacy, also housed at BHAC, provides by community-based organizations, under contracts with CBHS. psychotropic medications to patients seen at City mental health Since 2000, San Francisco has had an official Harm Reduction clinics and BHAC, as well as Suboxone to patients enrolled in the Policy that applies to the health department and all contractors City’s buprenorphine program. who deliver substance use, mental health, sexually transmitted PatientspresentingtoBHACreceiveathoroughbiopsychoso - diseases, and HIV/AIDS treatment and prevention services, and/ cial assessment that guides the determination of the level of care orwhoservedrugandalcoholusersintheirprograms.Inaddition, andtreatmentmodality most likelytomeetthe patients’needs.In since2003,whenCBHSwasorganizedbycombiningmentalhealth addition,staffgiveconsiderationtowhichspecificprogramswould andsubstanceabuseadministrations,thevisionoftheDepartment bestmeeteachpatient’sparticularneeds,takingintoaccountsuch has been, “Any door is the right door”—meaning that any client factorsasgender,languagecapacity,ethnicity,race,sexualorienta - or family seeking services can be seen and assessed at any site tion,housingneeds,familyconnections,andotherrelevantfactors. operated by or contracted to CBHS. If a particular program does DPHprovidesfundingforprimaryandsecondaryprevention, not offer the level of care needed, that p rogram will make sure detoxification (social model and residential medically assisted), the client or family is referred to the proper site and engaged. An outpatient (intensive and low-intensity, including medication open-access policy means all people seeking help will be seen in management and smoking cessation treatment), opiate agonist forty-eighthoursorless,sotherearenowaitinglistsexceptatsome treatment (methadone and buprenorphine), drop-in, drug court residential care programs. If a client has to wait for a residential and other criminal justice follow-up, and residential (substance- program, he or she will still be engaged by the referring provider use, dual diagnosis, mental health) services. Patients are referred with support services. to BHAC from programs and services across the City, including People can seek services by walking into any community primary care, mental health, case-management, substance-use, clinic or by going to the Behavioral Health Access Center at 1380 and homeless outreach. Howard Street (at 10th Street), which houses the Treatment DPH funds thousands of treatment slots and beds across the Access Program (which serves as the gatekeeper for residential City, including more than 2,200 methadone and 200 buprenor- services) and the Access Team (which screens for mental health phine maintenance slots. To expand and enhance access to these andsubstanceabuseconcerns).Peoplecanalsogetinformationor opiate-agonist treatment services, DPH has implemented several be screened for referrals by telephoning the central access line at extremely innovative programs, including a Mobile Methadone (415) 255-3737. Other ways of accessing care are through any of Van,an Office-BasedMethadonePilotProgram(alsoknownasof - the COPC sites and through programs such as the Homeless Out- fice-basedopiatetreatmentorOBOT),acentralizedopiateagonist reachTeamandProjectHomelessConnect,whichtargethomeless treatmentassessment/linkageservice(COPE),andtheIntegrated 36 sAn frAncisco medicine June 2010 37 sAn frAncisco medicine June 2010 www.sfms.org clientswww.sfms.org who often need substance-abuse services. Buprenorphine InterventionJune 2010 sAn frAncisco medicine 37 Service (IBIS). The methadone vans In MeMorIaM

Nancy thomson, MD are for stable methadone clients that operate in neighborhoods that are not close to narcotic treatment program sites (NTP). Ser- vices from these vans are now covered by Drug Medi-Cal. Byron cone pevehouse, md The IBIS program, a city-wide buprenorphine treatment program, integrates buprenorphine (Suboxone) treatment with patients’ primary care, mental health, or “drug-free” substance- Byron Cone Pevehouse was born in Lubbock, Texas, on April 5, use treatment. More than fifteen DPH community-based sites 1927. He died at age 83 on April 16 in Bellevue, Washington. participate in IBIS. To support IBIS providers, the City created After serving for twenty-two months in the U.S. Naval Hospital the first buprenorphine induction clinic in the country. OBOT al- Corps during World War II, he received his MD from Baylor Medical lows physicians at COPC clinics to order methadone for selected, School in 1952. He took his neurosurgery residency at UCSF from stablemethadoneclientswhocangettheirmethadoneatspecially 1954 to 1958. licensed pharmacies. OBOT clients no longer need to go to their Dr. Pevehouse was an honorary member of the SFMS—an honor regular NTP, allowing that treatment site to open methadone given to him for his contribution to the fields of neuroscience and neu- slots to new clients who would not have been served otherwise. rosurgery. He served as the chief of neurosurgical services for UCSF at Again, use of buprenorphine has allowed clients in regular COPC San Francisco General Hospital and as chief of pediatric seurosurgery and mental health outpatient programs to receive opiate replace- at the U.C. Medical Center for many years, being promoted to clinical ment care and operate their lives in ways that might be difficult professor in 1978. In 1967, he was appointed chairman of the Depart- to do when tied to a traditional methadone program (given work ment of Neurological Surgery at University of the Pacific-Presbyterian schedules and the need to access primary care and so on). Medical Center, serving in this position for twenty-three years. He also To better meet the needs of alcohol-dependent individu- served in many professional organizations including the San Francisco als, DPH has collaborated with community providers to create Neurological Society (president, 1973), American Association of Neu- several innovative services, including the City’s residential rological Surgeons (president, 1984), and the Society of Neurological medication-assisted detoxification program and Sobering Center. Surgeons (president, 1987), as well as the SFMS. The detoxification program provides 24/7 medical coverage to Heretired fromactivepractice in1990andwasappointedbyPres - patients who are likely to develop significant alcohol withdrawal ident George Bush as a senior consultant and member of the National symptoms if unmedicated. Sites and programs across the City, Committee of Vital and Health Statistics, advisory to the Department including emergency departments, primary care and mental of Health and Human Services (1991–1995). He received the Harvey health clinics, and BHAC, have access to these beds. The Sobering Cushing Medal in 1994 from the American Association of Neurological Center provides a respite for alcohol-dependent individuals who Surgeons (AANS), the Distinguished Service Award from the California are acutely intoxicated and serves as a launching pad for access AssociationofNeurologicalSurgeons in1991,andthesameawardfrom to ongoing treatment. the AANS in 1998. In 1997 he was elected a distinguished alumnus by As dual diagnosis is the rule and not the exception, the inte- Baylor College of Medicine. gration of substance-use and mental health services has become Dr. Pevehouse married Maxine Elizabeth Smith in 1951, and they a primary DPH focus. All substance-use and mental health pro- had three daughters. Maxine died in an accident in 1978. He married grams are expected to provide dual-treatment services to their Lucy Seguin Beck, a Houston attorney, in 1981. patients. Several outp atient and residential treatment programs He is survived by his sister, Nona Burgamy of Lubbock, are specifically set up to provide intensive dual-diagnosis treat- Texas; his second wife, Lucy Beck Pevehouse; his daughters De ment. Further integration with COPC over the coming year will Ann Freitag (Erik) of Alameda, California, Carol Palato (Paul) of expand treatment access. Lake Balboa, California, and Lesa Howell (Rick) of Vancouver, CBHS monitors outcomes with data collected on all clients Washington; nine grandchildren, and one great-granddaughter. through the CalOHMS state system as well as other outcomes Beloved husband, father, and grandfather, he enjoyed photography, data.Anevaluationof allthesubstanceabuseservicesiscurrently fishing, skiing, and tennis. Honoring his request, only a family memo- underway to help determine what works best for San Francisco rial ceremony was held. residentsandwhatserviceneedsmightstillneedtobeaddressed. classified Ad Sincethemajorityoffundingforpublicsubstance-abuseprograms is dependent on City general funding, the current financial crisis facingDr. the Robert City of Cabaj San Franciscois director could of San impact Francisco services Community in the com Be- Bay Area Pain Management Group seeking opportu- ihavioralng years. Health Services, and Dr. David Hersh is medical director of nity to SUB-LEASE day-rate space in San Francisco medical CBHSOpiateReplacementServicesintheSanFranciscoDepartment office. One day/week, negotiable rate; Four exam rooms of Public Health. preferred, on clinic “off” days. Group would bring own staff/computers. Call Mari Cyphers, CAO, (510) 590-3518 3839 sA n frAncisco medicine June 2010 or email [email protected]. www.sfms.org In MeMorIaM book revIew

Erica Goode, MD

Addiction: “nothing is enough”

In the Realm of Hungry Ghosts

week lead to an outlay of $8,000 in CDs. These regular buying By Gabor Maté, MD (Random House) In the Realm of Hungry cycles were later enhanced by a righteous rage, as his wife and Ghosts family called him on these conflicted, unproductive behaviors. A new book by Gabor Maté, MD, His empathy toward the addicts he treats is compelling, as , provides essential reading for anyone who he links degrees of neglect and trauma described by these hap- has ever been a parent, fetus, young child, child care less, unloved patients to his early upbringing. He has scrutinized worker, teacher, or physician. This testament to Dr. Mate’s own his own issues by entering the realm of twelve-step, cognitive addiction—to classical music CDs, of all things—and his work treatments that have allowed critical shifts in his own behavior. with street addicts in British Columbia, where he practices gen- Maté is Jewish; as a one-year-old, his adoring mother felt she had eral medicine and psychiatry, is compelling for many reasons. to hand him off to distant relatives while she was in a relocation His thesis (backed by hundreds of studies exploring brain campinBudapest, living in bleakconditions with almostno food. function, neurochemistry, and early childhood growth and This separation, while devastating, was less traumatic than the development) is that one must look primarily to the paucity of stories told by addicts—each with a parent or other powerful societal supports for close, loving, intimate family relationships adult(s) who, as an addict, alcoholic, or abuser, impacted the to explain much of what we view as addiction. infant or child in physically or sexually damaging way s. In many Starting with industrialization and loss of a quieter, safer cases of orphaned or foster children, they are simply neglected life for families, neighborhoods, and wider communities of the or ignored; this too provides a hollow precursor to addiction. world, we begin to see more of the fragmentation of bonds As Dr. Maté nears the end of this assessment of the roots between family members. The people who get lost, with each and hopefully the amelioration of addiction, he notes, “A broken generation seeming more beleaguered than the previous one, vessel can be mended, but the cracks remain.” are the children. Infants’ and toddlers’ brains are burgeoning The essential trick for us as physicians istodetermine, every with new synaptic connections, and if these aren’t satisfied day, whether the advice we provide is something we could feed with strong doses of love and time with parents and families to ourselves. Did we choose to seek power, the exhilaration of who will cherish, read, sing, dance, and play with them during emergencies, the thrill of accolades, as essentials for our lives as those early months or years, a yawning void can develop, which physicians? Or can we step back, care for ourselves, our families, proves difficult to replenish. our planet, without needing the unattainablesense of wholeness In the Buddhist circle of life, the Hungry Ghosts are the from these externalities? Each adult, to evolve toward the higher addicts, with gaunt bodies, pot bellies, a vacant stare, and levels of that Buddhist circle of life, must weigh his or her mo- huge, open mouths. Nothing is enough. No item, collection, pile tives, and to do this, we need to recall those earliest memories, of money ever satisfies the personal, inner void, the afflicted and put them to rest as best we can. resort to drugs, alcohol, tobacco, food (bingeing, with purging Olivier Ameisen, MD, the alcoholic chief of cardiology at or extreme obesity), compulsive shopping, sex addiction, ac- Cornell (whose own book is reviewed on page 36 of this issue), quisition of all manner of power or things—inhaving a vain attempt recalls being driven to excel to ward off overwhelming anxiety, to have “enough.” starting at the age of three. His ultimate solution is baclofen; Matédescribeshispersonal compulsion of toacquire and indeed, I have found this to provide surcease for compulsive the next Beethoven collection du jour, or whatever it might be. eating and insomnia in some of my patients. But, as always, a When this feeling comes, he finds himself powerless to act other- pill alone can never fully fix a damaged human spirit. It can wise. He once left his eight-year-old son alone in a store, another sometimes settle the chatter of discomfort enough to provide time abandoned a woman in late-stage labor (the RN delivered a pathway toward understanding the need to keep going, on an 38 sAn frAncisco medicine June 2010 39 sAn frAncisco medicine June 2010 www.sfms.org thewww.sfms.org infant), as another cycle of his addiction surged. His worst illuminated trajectory.June 2010 sAn frAncisco medicine 39 hospITal news

cpmc saint francis Kaiser Michael Rokeach, MD Patricia Galamba, MD Robert Mithun, MD

Bay Area House Call Dentists, a division AsIpreparedtotacklethetopicofaddiction Overcoming addictions is tough work. So San Francisco of the Blende Dental Group, was featured in and recovery, I realized that I needed to tap into when patients are willing, we must be ready to Chronicle the March 29, 2010, issue of the some of our local experts. My first contact was provide comprehensive and integrated treat- . The group, run by Dr. David Blende, withourBehavioralHealthPartialDayProgram ment. Addiction treatment on demand has long chief of the Dental Division at CPMC, special- (BHPDP). This is one of few adult outpatient beenconsideredagoalofaddictionandrecovery izes in working with seniors and people with rehab day programs in the City. Although the health care. When providers have the ability to disabilities or other special needs. The latter programisnotaprimarydestinationforpersons treat patients when they are most receptive to can includephobic,obese,or immobilepeople, with addictions,itseems to be a secondary stop intervention, it increases their rate of success peop le with dementia, the homebound, and for a fair percent of our outpatient clients who dramatically.ThegoalofKaiserPermanenteSan people who can’t control their movements. have issues related to depression, anxiety, and Francisco’saddictiontreatmentclinic,knownas A dentist and registered dental assistant mania. To assist our clients, we have started the Chemical Dep endency Recovery Program will make a house call for an initial screening a weekly support group to address addictive (CDRP), is to capture patients in the change and X-rays using a portable unit. Performed personality.Inaddition,thehospitalhostsSmart mindset quickly and get them on the road to while the person sits in a favorite chair or RecoveryprogramsandDepressionandBipolar recovery as soon as possible. This is best ac- wheelchair or lies in bed, this process takes Support Alliance meetings. complishedbyconsultingoninpatientswhoare about an hour. House calls are available Of note, John Mendelson, MD, has been a hospitalizedwithadru g andalcoholdependence within 50 miles of San Francisco on weekdays colleague here at Saint Francis for more than comorbidity, accepting referrals from primary between 8:00 a.m. and 6:00 p.m. Emergency twenty y ears and is a nationally recognized care, and taking calls from patients directly. care is available around the clock. authority in pharmacotherapies for addiction. CDRPoffersanintegrated,“one-stopshop - Procedures that can be done at home He conducted clinical trials (at CPMC Research ping” approach to treatment. Therapists and include cleaning, extracting, and making or Institute) that led to approval of Suboxone (a medical providers, in partnership with support repairing dentures. The coordinator also combination of buprenorphine and naloxone), staff, provide an environment for safely detoxi- schedulesappointments,arranges transporta- a new medication for the treatment of opiate fying from drugs and provide a framework for tion, and facilitates communication between addictionthatwasapprovedbytheFDAin2000. stayingsober.BecauseCDRPembracesevidence - the dentists and the patient or caregiver. His clinical practice is closely associated with based medicine, patients are offered therapy CPMCnurses JoanneDavantesandLaura Saint Francis Memorial Hospital. groups that are both educational and process Euphrat were recently featured in the April MelBlaustein,MD,medicaldirectorofpsy - driven. Physicians and staff also strongly en- Parade 2010 issue of the international magazine chiatry, reports that substance abuse is a major couragetheuseofcommunityresources,which . They are the cofounders of “Little problem in San Francisco. In our twenty-four- increases the likelihood of success for clients. Wishes”, a program that helps grant small bed inpatient unit, frequently as many as two- With an eye to the future, the CDRP pro- wishes for pediatric patients. thirds of our patients test positive for cocaine, gram provides training for the next generation In the seven years since they started the methamphetamine, heroin, and/or marijuana, of phy sicians, psychologists, and marriage and group, they’ve helped grant more than 4,000 not to mention the ongoing use of alcohol. This family therapists. Training programs include wishes. A branch of Little Wishes was also dramaticallyimpacts ourmental healthsystem. a two-year addiction medicine and addiction launched at Sutter Medical Center in Sacra- Exceptfortreatmentsforalcoholandheroinad - psychiatry fellowship, taught in collaboration mento in 2006 and at Sacred Heart Children’s diction,thereislittleatpresenttotreatsubstance with the University of California, San Francisco, Hospital in Spokane, Washington, last year. disorder. To make matters worse, people who andVeteransAdministration;andapostdoctoral Volunteers in each place have put their own abuse drugs tend to be impulsive, depressed, psychology fellowship. Additionally, training stamp on the program. In Sacramento, two and therefore at risk for suicide. On a positive is offered in the internal medicine residency therapy dogs help carry thegiftswhilethestaff note, our inpatient unit becomes a haven for program at Kaiser Foundation Hospital in San recites a special poem. In Spokane, the nurses many of these patients to get through recurring Francisco. Ourmissionistoprovidestate-of-the - sing, accompanied by a strolling guitarist. crises and, we hope, not act on their impulses. artaddictiontreatmentquicklyandeffectivelyb y We are deeply committed to the eradication of providingpatientsthetoolsforlifelongrecover y 4041 sA n frAncisco medicine June 2010 this serious health issue in our society. in a multitude of settings. www.sfms.org hospITal news

st. mary’s Veterans ucsf Richard Podolin, MD Diana Nicoll, MD, Elena Gates, MD PhD, MPA

St. Mary’s Medical Center is home to the Recently sixteen mice were sent aboard The Ernest Gallo Clinic and Research Cen- only dedicated adolescent inpatient mental the space shuttle Discovery to spend thirteen ter, affiliated with the Department of Neurology healthprogram in San Francisco.TheMcAuley days aboard the International Space Station atUCSF,isapreeminentacademiccenterfor the Institute was opened in 1954, offering the (ISS) as part of an experiment designed by a study of the biological basis of alcohol and sub- most comprehensive and diversified psychiat- San Francisco V.A. Medical Center researcher. stanceusedisorders.GalloCenterdiscoveriesof ric program for children and adults in North- The experiment will investigate why T cells potentialmoleculartargetsforthedevelopment ern California. Today, we focus on the needs stop working in the absence of gravity, which oftherapeuticmedicationsareextendedthrough of San Francisco youth. We are a multidisci- has imp lications for disease on earth as well. preclinicalandproof-of-conceptclinicalstudies. plinary institute with nurses, psychologists, The experiment is meant to shed light on the The Gallo Center focuses on translating their psychiatrists, social workers, and even teach- genetic mechanisms behind T-cell shutdown, research into treatments for diseases with dev- ers on staff totreat up totwelve inpatients and according to principal investigator Millie astating personal and socioeconomic impacts. eighteen patients in day treatment. Hughes-Fulford,PhD,directoroftheLaborato - In the United States, for example, ap- Sadly, drug addiction is something our ry for CellGrowthat SFVAMCandanastronaut proximately one in 12 adults abuses alcohol or patients know all too well. Nearly every who flew aboard the space shuttle in 1991. is alcohol-dependent, according to the National patient has been affected by drug addiction, “From the beginning of the U.S. Apollo InstitutesofHealth.InarecentGalloCenterfind - either directly or indirectly. Many of our youth moon program, we’ve known that about half ing, a drug prescribed for hormonal disorders come from households where their parents or of our astronauts develop suppressed im- could hold the key to more effective treatment guardians have chemical dependencies, and mune systems either during flight or shortly for alcoholism. Alcohol binge-drinking rodents, somepatientshave dependenciesoftheirown. afterward, and we have since learned that when treated with the drug cabergoline—an WeofferNarcoticsAnonymoussessionsonsite nonfunctioning T cells are at least partly re- FDA-approved drug marketed as Dostinex— totreatdrugproblems,althoughourmaingoal sponsible,” says Hughes-Fulford. “If we can get decreased excessive alcohol consumption and is to focus on treating mental health issues. to the root cause, wecan potentially helpolder alcohol craving and were less likely to relapse. Our staff understands these adolescents are people, people with HIV/AIDS, and anyone “Alcohol use and abuse disorders are vulnerable and in crisis, so we strive to offer else who is immunocompromised. We will widespread yet very few effective medications compassionate care. also overcome a serious obstacle to long-term exist. Our results are encouraging, since unlike Students from the San Francisco Uni- space exploration.” other medications, cabergoline is specific for fied School District come to McAuley’s Day In previous experiments with humancell alcohol and does not affect general reward. Treatment Program when they have mental culturesaboard the ISS, Hughes-Fulfordfound Someexistingdrugsusedtotreatalcoholismalso health challenges, and this June we will see that a group of forty-seven genes associated decrease pleasure, which can make compliance two seniors graduate. We are proud of these with T-cell activation are not expressed in an obstacle to sobriety,” said Dorit Ron, PhD, students and the progress they have made. the absence of gravity. “Now we’re taking this professor of neurology at UCSF and the study’s The McAuley institute was named after research one step further by investigating principal investigator. The research builds Catherine McAuley, one of theSisters of Mercy this phenomenon in live mice on the space on earlier work by Ron and her colleagues in from Ireland whose work led to the founding station,” she says. “Hopefully, this will allow us whichtheproteinGDNF(glialcellline-deprived of St. Mary’s Medical Center. Today we think to pare down our list of nonexpressing genes neurotrophicfactor),administeredintotherats’ Catherine would be proud of the center that to a much smaller number and give us a better brains,reducedtherodents’alcoholcravingsand bears her name. We keep her mission alive handle on what’s happening.” prevented relapses after a period of abstinence. by serving those youth in psychiatric crisis, Hughes-Fulford, who was a payload However, GDNF is too large to cross the human as well as those with long-term mental health specialistaboardshuttleflightSTS-40in 1991, blood-brain barrier, so the researchers next challenges.We strive toeducate,providealter - says the ultimate goal of her experiment is to turned to cabergoline, which the investigators native coping strategies, and assist patients point the way toward gene therapy for people found to increase GDNF levels in the brain. Hu- in reaching their potential by helping them with nonfunctioning immune systems. man clinical trials still are needed. “We hope regain a sense of stability and self-sufficiency that cabergoline eventually will be prescribed 40 sAn frAncisco medicine June 2010 41 sAn frAncisco medicine June 2010 www.sfms.org inwww.sfms.org their lives. April 2010 sAn frAncisco medicine 41for alcohol addiction,” said Ron. FroM The cMa FoundaTIon

Carol A. lee, Esq. diabetes and cardiovascular disease

A Comprehensive Guide for Physicians

developing the guide 2009/2010 Diabetes and Cardiovascular t Diseasehe California Reference Medical Guide Association (CMA) Foundation will soon release the In late 2009, several participating physicians in the CMA . The guide aims to support clini- Foundation’s Quality Collaborative expressed the need for re- diabetes and cardiovascular disease prevalence: cians’ management of diabetes-related complications. sources that better linked diabetes with cardiovascular disease. nationally and locally They shared with Foundation staff that during visits with their diabetic patients, they actively discussed hypertension, high cholesterol, and other issues related to cardiovascular disease. Nearly half of all adults in the United States have one chronic Many felt overwhelmed by the daunting task of addressing condition associated with an increased risk of cardiovascular diabetes and its cardiovascular complications. disease. According to the Centers for Disease Control and Pre- The CMA Foundation took action and convened an expert vention, 45% of individuals twenty years of age and older have panel of physicians and other health care professionals to hypercholesterolemia, hypertension, or diabetes. In fact, the develop this comprehensive guide. More than thirty experts major complication of diabetes and the leading cause of death engaged in its development, including representatives from the among patients with diabetes is cardiovascular disease. Adults American College of Cardiology, American Association of Clini- with diabetes are also two to four times more likely to have cal Endocrinologists, National Medical Association, American heart disease or suffer a stroke than those without diabetes. College of Physicians, California Department of Health Care And approximately 65% of patients with diabetes die from Services, California Diabetes Program, California Diabetes Co- heart disease or stroke. Individuals with type II diabetes also alition, and representatives from a number of health plans and experience high rates of elevated blood pressure, lipid problems, guide contentsother provider organizations. and obesity, all contributing factors to cardiovascular disease. San Francisco County ranks thirtieth out of fifty-eight coun- ties for the percent of county residents eighteen and older with The 2009/2010 guide, which will be updated annually, diabetes, as reported by the California Diabetes Program. This includes guidelines supporting the screening and diagnosis of translates to 6.2% of residents diagnosed with diabetes com- type II diabetes, dyslipidemia, and hypertension; approaches pared to 7% of statewide. In the county, 24.2% of residents have to the clinical management of type II diabetes and its related been diagnosed with hypercholesterolemia, compared to 37.8% cardiovascular complications; strategies for preventing and of statewide residents; 65.1% have been diagnosed with high more effectively managing type II diabetes complications; ef- blood pressure, slightly worse than the state average of 61.5%. fective communications with patients; and education resources The impact of diabetes is especially visible among San for physicians, other health care professionals, and patients Francisco County’s African American population. Compared with diabetes. to the county’s overall population, 21.8% of African Americans The CMA Foundation’s Diabetes and Cardiovascular Disease eighteenand over havebeen diagnosed with diabetes,withmore Reference Guide will soon be available on the Advancing than a third reporting to be either overweight (39.9%) or obese Practice Excellence in Diabetes Project section of www. (35.5%). In San Francisco County, among those diagnosed with thecmafoundation.org. For more information, please contact diabetes, 85.0% of whites and 41.2% of African Americans were SenelyCarolA.Lee,Esq.,ispresidentandCEOoftheCMAFoundation. Navarrete, MPH, Project Director, at (916) 779-6638 or reported to have high blood pressure, and 27.8% of whites and [email protected]. 17.3% of African Americans reported having high cholesterol.

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