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Facing Addiction: Surgeon General's Call to Action

November 23, 2016
US Surgeon General releases first ever report on alcohol, drugs, health—calling for a cultural shift to end the stigma and a focus on effective treatments, recovery.

Physicians who care for patients in chronic pain will probably not be surprised by the statistics released in the first-ever US Surgeon General's landmark report.  Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health, highlights numerous sobering facts.1 Among them:

  • One in 7 people in the US are predicted to develop a substance abuse disorder (SUD) at some time in their lives.
  • Nearly 21 million people in the US have a SUD. That's comparable with the number diagnosed with diabetes; and about 1.5 times the prevalence of all cancers.
  • Only 1 in 10 of those with a SUD gets treatment.
  • Stigma, lack of screening for disorders and a fragmented health care system explain why so many go untreated

 

At the unveiling of the report, Surgeon General Vivek Murthy, MD, MBA, along with other federal officials, researchers, and people in recovery presented data and heart-wrenching stories, illustrating that drug and alcohol abuse disorders know no racial, ethnic, or socioeconomic bounds.

  • "Recovery works," said Tara Conner, Miss USA 2006, who shared with the audience that her name became "Mess USA" after her drug and alcohol abuse came to light. "I want people to know there is a way out," said Ms. Conner, now sober.
  • Sherrie Rubin appeared on stage with her son Aaron, who fell into a coma after his opioid overdose as a young adult. "On day 26," his mother said, "he opened his eyes. He woke to a nightmare; he was blind, he could not speak, he could not move his body. There are thousands like Aaron who have survived an overdose and are buried above ground.''

Surgeon General: Keeping a Promise

"One year ago I stood on the national mall, in the shadow of the Washington Monument, and told you that people had suffered far too long in the shadows and we had to change that," said Dr. Murthy. "I told you also that millions who need treatment cannot get it and we must change that, too."

For him, the mission is personal, after years caring for patients with substance abuse issues, he said. "Addiction doesn't just affect an individual," Dr. Murthy said. "It affects families and friends."

''Only 1 in 10 with substance abuse disorders actually get treatment," he said. "What if only 1 in 10 people with cancer or diabetes got treatment?" Despite the grim statistics, he said, ''there are reasons to hope. Prevention and treatment do in fact work," he said.

What's crucial, he said, ''is a cultural shift in how we think about addiction. For far too long, people have looked at addiction as a moral failing." In fact, he and other experts agree, ''addiction is a disease of the brain."

Environmentalist Tom Steyer of Next Generation, who also spoke at the conference, called the report ''the first official endorsement that this is a health problem."

What Works?

Treatment decisions should be based on shared decision-making, said H. Westley Clark, MD, JD, MPH, Dean's Executive Professor of Public Health, Santa Clara University, a science editor for the report who edited the treatment chapter and spoke at the Facing Addiction event. An overview of what works:

Medications: Five medications are approved by the FDA and have been developed to treat opioid use and alcohol disorders. These include:

For Opioid Dependence:

Buprenorphine-naloxone (Bunavail, Suboxone, Zubsol)

Methadone (Methadose, Dolophine, generic)

Extended-release naltrexone (Vivitrol)

For Alcohol Dependence:

Acamprosate (Campral)

Disulfiram (Antabuse)

Naltrexone (ReVia)

Extended-release naltrexone (Vivitrol)

Some can be especially important to reduce cravings. For instance, naltrexone blocks the opioid receptors in the brain and gut, and thus reduces cravings and withdrawal symptoms, while diminishing the reward effects felt after alcohol and opioid abuse.

Using medicines for patients diagnosed with a chronic opioid use disorder must be given for enough time, the report says. Those who get medication-assisted treatment, called MAT, for less than 90 days do not seem to improve; one study found those who get MAT for less than three years are more likely to relapse than those who continue for three or more years.

Prescribing of the medications is regulated and varies by the drug. Methadone treatment programs, for instance, must be certified by SAMHSA (Substance Abuse and Mental Health Services Administration) and registered by the U.S. Drug Enforcement Administration (DEA). The programs include not only drug therapy but other components such as behavioral therapy. These opioid treatment programs may also provide buprenorphine and naltrexone.

Physicians prescribing buprenorphine must meet the statutory requirements for a waiver, as spelled out in the Controlled Substances Act. Even with the waiver, physicians are limited in the number of patients they may treat with the medication. The patient limit does not apply if programs dispense the buprenorphine on site, however. Physicians when first approved are limited to 30 patients; after a year, they can treat up to 100.  However, only 30,000 of the more than 435,000 primary care physicians practicing in the U.S. have a waiver, and only half are treating opioid use disorders. To address that gap, a final rule was published in 2016, stating it will allow eligible practitioners to seek approval to treat up to 275 patients.  

Naltrexone, on the other hand, is not a controlled substance, so it can be prescribed or given by any physician, nurse practitioner or physician assistant who has prescribing authority.

Behavioral therapies: Behavioral therapies are encouraged in the report. Among those with evidence: cognitive behavioral therapy or CBT, contingency management (giving tangible rewards such as food or movie vouchers to support positive behavior change) or a program called Community Reinforcement Approach Plus Vouchers, also based on rewards.

Another approach, motivational enhancement therapy, uses interviewing techniques to help people resolve lingering uncertainties about getting sober. The Matrix Model includes relapse prevention, family therapy, and drug education in a 16-week program. Participants go to group sessions on an outpatient basis three times a week, aimed at changing behaviors. Family therapy programs are plentiful and get a strong thumbs-up in the report, for both adults and teens. The programs vary. One is called family behavior therapy or FBT and includes up to 20 treatment sessions that focus on setting goals for behavior and developing skills.  

12-Step, Other: Twelve-step programs (based on the Alcholoics Anonymous model) are supported in the new report. "There is very strong evidence they work," said Keith Humphreys, PhD, professor of psychiatry and behavioral science at Stanford University and a science editor for the report. "They are not going to work for everyone," he said, ''but nothing works for every single person."

Known as 12-step mutual aid groups, these organizations include not only Alcoholics Anonymous but also Women for Sobriety, SMART Recovery and others.

Of all, AA is the best known and has the most research, the report authors say. About half of adults who start a 12-step program after getting treatment are still attending meeting 3 years later, according to the report. AA meeting are free to attend, and provide a community and support network (sponsorship, speaking engagements, commitments, etc). In addition, these programs emphasize working on the person’s character, not just stopping drinking. This includes learning new ways to cope with stressful situation, resentments, anger, etc.

Twelve-step programs such as AA are viewed as effective as a stand-alone intervention, when combined with other treatment programs such as cognitive behavioral therapy (CBT), or as an appendage to treatment, according to the report.eer support programs look promising, too, the experts said, although research on peer recovery coaches is limited.

Reactions to the Report

"The US Surgeon General's report will bring to light evidence-based treatments that we know will work and save lives,'' said Greg Williams, co-founder of Facing Addiction, the nonprofit hosting Thursday's event.

"It will assist in reducing the stigma around addiction and allow people to be more comfortable speaking about it. As the largest advocacy network for addiction, we will continue to embrace and be the voice for those who are struggling with addiction."

While the report is ''outstanding," what is also needed is an effort to develop alternatives to opioids for pain management, said William Maixner, PhD, DDS, director of the Center for Translational Pain Medicine and Innovative Pain Therapies at Duke University in a statement. "We have a fundamental problem when we are trying to manage pain for the 100 million people who have some form of chronic pain, and opioids are among the few therapies available that work."2

The American Medical Association on issued this statement from its president, Andrew Gurman, MD: "The AMA applauds Surgeon General Murthy for tackling the crisis of drug and alcohol addiction—an issue of vital importance to our patients and communities." The research and findings within the report provide ''important guidance for the nation to see that addiction is a chronic disease and must be treated as such."3

Last updated on: November 28, 2016
Continue Reading:
A Practical Guide for the Use of Opioids in Chronic Pain

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