Benzodiazepine Tapering: A Marathon, Not a Sprint.

Tobacco use is a major threat to public health in the United States, and the number one cause of preventable death. Although most smokers try to quit unaided, robust data indicate that pairing behavioral support to US Food Drug Administration-approved cessation medications significantly increase cessation rates. Those who do receive assistance in quitting usually receive very low intensity treatment, regardless of the severity of their dependence or their medical and environmental circumstances. This is in stark contrast to how other substance use disorders are treated, where there are varying levels of care depending on addiction severity and biopsychosocial circumstances. The American Society of Addiction Medicine (ASAM) developed a formal algorithm for assessing substance use disorders and determining the optimal level of care. The ASAM Patient Placement Criteria are regularly used to determine the appropriate level of care for all substance use disorders except tobacco. This paper will review key aspects of the ASAM dimensions of care and placement levels, with emphasis on how they apply to tobacco use and present case examples of typical smokers who would benefit from a higher intensity of tobacco dependence treatment. We also present current barriers to reimbursing healthcare providers for these services. We conclude with a commentary and discussion regarding recommendations for improvements in tobacco dependence treatment care.

The Centers for Disease Control have recently described opioid use and resultant deaths as an epidemic. At this point in time, treating this disease well with medication requires skill and time that are not generally available to primary care doctors in most practice models. Suboptimal treatment has likely contributed to expansion of the epidemic and concerns for unethical practices. At the same time, access to competent treatment is profoundly restricted because few physicians are willing and able to provide it. This “Practice Guideline” was developed to assist in the evaluation and treatment of opioid use disorder, and in the hope that, using this tool, more physicians will be able to provide effective treatment. Although there are existing guidelines for the treatment of opioid use disorder, none have included all of the medications used at present for its treatment. Moreover, few of the existing guidelines address the needs of special populations such as pregnant women, individuals with co-occurring psychiatric disorders, individuals with pain, adolescents, or individuals involved in the criminal justice system. This Practice Guideline was developed using the RAND Corporation (RAND)/University of California, Los Angeles (UCLA) Appropriateness Method (RAM) – a process that combines scientific evidence and clinical knowledge to determine the appropriateness of a set of clinical procedures. The RAM is a deliberate approach encompassing review of existing guidelines, literature reviews, appropriateness ratings, necessity reviews, and document development. For this project, American Society of Addiction Medicine selected an independent committee to oversee guideline development and to assist in writing. American Society of Addiction Medicine's Quality Improvement Council oversaw the selection process for the independent development committee. Recommendations included in the guideline encompass a broad range of topics, starting with the initial evaluation of the patient, the selection of medications, the use of all the approved medications for opioid use disorder, combining psychosocial treatment with medications, the treatment of special populations, and the use of naloxone for the treatment of opioid overdose. Topics needing further research were noted.

Introduction. The American Society of Addiction Medicine (ASAM) has focused on two primary political issues in the last year: (1) The growing demand for legalized marijuana and state legislatures' work in addressing medical practice through the introduction of marijuana allegedly for medicinal purposes; (2) The extremely rapid increase in opioid use disorder incidence over the past decade due to a confluence of driving forces. Conclusion. Our talk will address ASAM's response to these difficult situations, as well as discussion of our opening membership to non-physicians, our work with NIAAA/NIDA, and our release of the third edition of the ASAM Criteria.

Appropriate Use and Regulatory Control of Benzodiazepines

In 2013, the American Society of Addiction Medicine (ASAM) approved its Standards of Care for the Addiction Specialist Physician. Subsequently, an ASAM Performance Measures Panel identified and prioritized the standards to be operationalized into performance measures. The goal of this study is to describe the process of operationalizing 3 of these standards into quality measures, and to present the initial measure specifications and results of pilot testing these measures in a large health care system. By presenting the process rather than just the end results, we hope to shed light on the measure development process to educate, and also to stimulate debate about the decisions that were made. Each measure was decomposed into major concepts. Then each concept was operationalized using commonly available administrative data sources. Alternative specifications examined and sensitivity analyses were conducted to inform decisions that balanced accuracy, clinical nuance, and simplicity. Using data from the US Veterans Health Administration (VHA), overall performance and variation in performance across 119 VHA facilities were calculated. Three measures were operationalized and pilot tested: pharmacotherapy for alcohol use disorder, pharmacotherapy for opioid use disorder, and timely follow-up after medically managed withdrawal (aka detoxification). Each measure was calculable with available data, and showed ample room for improvement (no ceiling effects) and wide facility-level variability. Next steps include conducting feasibility and pilot testing in other health care systems and other contexts such as standalone addiction treatment programs, and also to study the specification and predictive validity of these measures.

The study examined the feasibility of implementing treatment recommendations derived from the American Society of Addiction Medicine (ASAM) Patient Placement Criteria in an urban addiction treatment program that offered a continuum of levels of care (LOC). A cohort of 281 applicants for alcoholism treatment were evaluated and the reasons for observed differences ("mismatches") between recommended and actual LOC placements were determined. Overall, 88% of the applicants entered treatment, and 72% of these were matched to LOC vs. 28% who were mismatched. Presumptive overtreatment (59%) was more common than undertreatment (41%) among the mismatched patients. The reasons for overtreatment were availability of Medicaid coverage for inpatient rehabilitation (93%), referral sources' treatment philosophy of gradually "stepping down" from inpatient detoxification (59%), social pressures on patients (28%), and mandated treatment (8%). The reasons for presumptive undertreatment were work schedule conflicts (72%), patient reluctance (48%), insurance coverage (15%), and interference with family or personal responsibilities (9%). These results indicate multiple barriers that need to be overcome to enable full implementation of the ASAM Criteria in real world program settings, even when a continuum of care is available.

The Department of Health and Human Services (HHS) announced proposed changes to 42 CFR Part 2, referred to as Part 2, last year (see https://onlinelibrary.wiley.com/doi/10.1002/adaw.33628). These rules regard the confidentiality of substance use disorder (SUD) patient records, and the American Society of Addiction Medicine (ASAM) has a history of opposing the requirement that patients give consent to have their records released when it comes to physicians treating them. According to ASAM, it's important for doctors to know about a patient's past (or present) SUD treatment. The federal government under the Substance Abuse and Mental Health Services Administration (SAMHSA) began efforts to eliminate the consent requirement, and other aspects of the decades‐old regulation, in 2010, largely due to the prevalence of electronic health records (EHRs) and the difficulty of incorporating individual patient consent for records release.

Last week we asked the American Society of Addiction Medicine (ASAM), which is spearheading the call for methadone reform, to respond to questions about their proposal. Specifically, there is a bill in Congress that would allow pharmacies to fill prescriptions for methadone for opioid use disorder (OUD) providing that the prescribers were either from opioid treatment programs (OTPs) or certified by ASAM. Currently, only OTPs are allowed to prescribe and dispense methadone for OUD. The bill is called the Opioid Treatment Access Act (OTAA). For more on the history of this proposal, see NASEM workshop focuses on nonlegislative expansion of methadone, ADAW March 14; https://onlinelibrary.wiley.com/doi/10.1002/adaw.33371.

The ASAM Criteria, utilized by treatment providers, insurance companies, and others, is a set of standards for assessment and evaluation of treatment for substance use disorders (SUDs). The new edition will be published by Hazelden Publishing. First developed by the American Society of Addiction Medicine (ASAM) in the 1980s, the criteria define one set of metrics for providing treatment based on outcomes and results. Both ASAM and Hazelden announced the forthcoming publication last week and called for public comments.

Standardized patient placement criteria such as those developed by the American Society of Addiction Medicine are increasingly common in substance abuse treatment, but it is unclear what factors are associated with their use or with treatment units' provision of related services. This study examined these issues in the context of a national survey of outpatient substance abuse treatment units. Regressions using 2005 data revealed that both public and private managed care were associated with a greater likelihood of using American Society of Addiction Medicine criteria to develop client treatment plans. However, only public managed care was associated with a greater likelihood of offering more resource-intensive services. Associations between client population severity and resource-intensive service provision were sparse but positive.

Clinical assessment isthe professional foundation for developing a clear understanding of the gestalt of problems that a client needs treatment for within the framework of co-occurring disorders. The assessment process takes a biopsychosocial and culturally sensitive perspective to learning about and understanding the unique issues a client presents. This is a vital step in formulating a clinical picture of the client and in determining a diagnosis, and there are multiple screening and assessment tools that have been found to be both valid and reliable for aiding in the diagnostic development. These assessment tools are often used by counselors, but in some cases, trained psychologists or psychiatrists will be needed for anin-depth assessment ofclients with complex issues. Once the assessment is complete and a diagnosis is formed with a clear indication of the severity of issues a client is facing, medical necessity determinesthe least intrusive level of care needed to support effective treatment ofthe client, guided by the standards of the American Society of Addiction Medicine (ASAM). This chapter explores the concepts of assessment, diagnosis, and levels of care based on ASAM criteria.

Back to table of contents Previous article Next article Association NewsFull AccessCoalition Vows to Broaden Access to Buprenorphine TrainingJoan Arehart-TreichelJoan Arehart-TreichelSearch for more papers by this authorPublished Online:6 Aug 2010https://doi.org/10.1176/pn.45.15.psychnews_45_15_005AbstractA program funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) is designed to expand buprenorphine treatment for opioid dependence. The program is called the Physicians' Clinical Support System for Buprenorphine (PCSS-B).During the past six years, the PCSS-B was administered by the American Society of Addiction Medicine, but its administration will now become the responsibility of the American Academy of Addiction Psychiatry (AAAP), APA, and the American Osteopathic Academy of Addiction Medicine (AOAAM), with the hope that such collaboration will further the program's mission.Each of the three organizations will be responsible for various aspects of the PCSS-B. For example, the AAAP and the AOAAM will offer four hours of self-study, followed by four hours of face-to-face training in how to treat opioid-dependent patients with buprenorphine in an office setting. APA will offer monthly webinars (interactive Web-based seminars) on the subject. It will also continue to offer buprenorphine courses on the Web and at the APA annual meeting and Institute on Psychiatric Services.John Renner, M.D., an associate professor of psychiatry and director of the addiction psychiatry residency program at Boston University, is a co-principal investigator for the PCSS-B program and responsible for APA's portion of the activities. “Over the next three years we would like to see an increase in the number of psychiatrists who are comfortable treating opioid dependence and who obtain the [Drug Enforcement Administration] waiver to prescribe buprenorphine,” he told Psychiatric News.Stephen Wyatt, D.O., an addiction psychiatrist and director of the Dual Day Treatment Program at Middlesex Hospital in Middletown, Conn., is also a co-principal investigator for the PCSS-B program, representing the AOAAM.“There has been a huge rise in the misuse of, and dependence on, pharmaceutical opiates in this country during the past 20 years,” he noted. As a result, it is the PCSS-B's mission to inform clinicians about the problem and what they can do in their private office settings to help patients who have become dependent on opiates, he said.Elinore McCance-Katz, M.D., Ph.D., a professor of psychiatry at the University of California, San Francisco, and an addiction specialist, is the medical director of the PCSS-B. “Our program is designed to establish a means by which we can continue to provide the federally mandated training needed for physicians to become eligible to practice office-based treatment of opioid dependence, as well as to provide ongoing mentorship to trainees as they engage in this practice,” she said. “The collaboration of AAAP, APA, and AOAAM will help us reach large numbers of physicians and clinicians, both in urban centers and rural parts of the country.”She added that this collaboration also plans to broaden the buprenorphine training curriculum “to provide information on screening, brief intervention, referral, and treatment, as well as the use of FDA-approved pharmacotherapies for the treatment of substance use disorders that can be undertaken in outpatient settings.“What I would like to see,” she said, “is addiction medicine [including] addiction psychiatry brought into the mainstream of medicine in the United States and hopefully, with time, in other countries as well.”Information about the PCSS-B is posted at <www.apaeducation.org>. ISSUES NewArchived

Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine

Beliefs about the consequences of using benzodiazepines among persons with opioid use disorder

Editor's Note