Timothy F. Kirn

TORONTO – Fluoxetine failed to prevent relapse of anorexia nervosa in the largest controlled medication trial to date exploring the issue, Dr. B. Timothy Walsh reported at the annual meeting of the American Psychiatric Association.

“Antidepressants don't offer patients with anorexia nervosa very much,” said Dr. Walsh, director of the eating disorders research unit of the New York State Psychiatric Institute, New York City. “We can't say for sure that an antidepressant other than fluoxetine wouldn't have an effect, but it would surprise me.”

The study represents yet another failure to find an efficacious medical treatment for anorexia. These failures imply that anorexia is unlike any other psychiatric condition, Dr. Walsh said.

“Interventions that are useful for other sorts of possibly related disorders don't work terribly well for anorexia nervosa,” he said. The only evidence-based treatment for anorexia is cognitive-behavioral therapy (CBT), which helps, but “not a lot,” he added.

The investigators, whose results were later published, compared fluoxetine with placebo in a clinical trial involving 93 patients who had completed intensive treatment and maintained a body mass index (BMI) of at least 19 kg/m

Subjects were randomly assigned to receive 20 mg daily of fluoxetine (49 patients), with a goal of increasing to 60 mg, or placebo (44 patients). They were monitored by a psychiatrist for dosing, adverse effects, and general medical status. They also received CBT.

The subjects underwent assessments of depression, anxiety, self-esteem, and quality of life every month. They were followed for 50 weeks, or until they either relapsed, defined as falling back to a BMI of 16.5 for 2 weeks, or dropped out of the study.

At 25 weeks, 48% of the 49 fluoxetine-treated subjects had either dropped out or relapsed, versus 39% of the placebo controls. At 50 weeks, 58% of the fluoxetine-treated subjects and 55% of the controls had either dropped out or relapsed.

To pick up on any possible benefit of the drug, Dr. Walsh and his colleagues also considered just those who relapsed, and those who relapsed plus those who clinically appeared to be in trouble when they dropped out–either because their BMI had dropped to 17 or because they had begun binging and purging again, at least twice a week.

At 50 weeks, 27% of the fluoxetine-treated patients and 29% of the placebo controls were documented relapsers.

Considering as failures both those with documented relapse and those who clinically appeared to be not doing well when they dropped out, the percentages were 49% fluoxetine and 51% placebo.

Dr. Walsh said he also looked only at those with depression, and at those who purged or restricted food only, and treatment still made no difference in those particular patients. “However we cut it, we can find no evidence that fluoxetine prolongs time to relapse following successful initial treatment, and we've looked pretty hard,” Dr. Walsh said.

In an editorial comment accompanying the published report, Dr. Scott J. Crow of the University of Minnesota, Minneapolis, said, “While the results of previous relapse prevention trials have been mixed, the report by Walsh and colleagues has many strengths and appears convincingly negative” (JAMA 2006;295:2659–60).

The study amply demonstrates that antidepressant therapy, “a fairly common treatment practice for this illness,” provides no benefit, Dr. Crow noted.

Additional reporting was done by contributing writer Mary Ann Moon.

'We can find no evidence that fluoxetine prolongs time to relapse … and we've looked pretty hard.' DR. WALSH

TORONTO – Fluoxetine failed to prevent relapse of anorexia nervosa in the largest controlled medication trial to date exploring the issue, Dr. B. Timothy Walsh reported at the annual meeting of the American Psychiatric Association.

“Antidepressants don't offer patients with anorexia nervosa very much,” said Dr. Walsh, director of the eating disorders research unit of the New York State Psychiatric Institute, New York City. “We can't say for sure that an antidepressant other than fluoxetine wouldn't have an effect, but it would surprise me.”

The study represents yet another failure to find an efficacious medical treatment for anorexia. These failures imply that anorexia is unlike any other psychiatric condition, Dr. Walsh said.

“Interventions that are useful for other sorts of possibly related disorders don't work terribly well for anorexia nervosa,” he said. The only evidence-based treatment for anorexia is cognitive-behavioral therapy (CBT), which helps, but “not a lot,” he added.

The investigators, whose results were later published, compared fluoxetine with placebo in a clinical trial involving 93 patients who had completed intensive treatment and maintained a body mass index (BMI) of at least 19 kg/m

Subjects were randomly assigned to receive 20 mg daily of fluoxetine (49 patients), with a goal of increasing to 60 mg, or placebo (44 patients). They were monitored by a psychiatrist for dosing, adverse effects, and general medical status. They also received CBT.

The subjects underwent assessments of depression, anxiety, self-esteem, and quality of life every month. They were followed for 50 weeks, or until they either relapsed, defined as falling back to a BMI of 16.5 for 2 weeks, or dropped out of the study.

At 25 weeks, 48% of the 49 fluoxetine-treated subjects had either dropped out or relapsed, versus 39% of the placebo controls. At 50 weeks, 58% of the fluoxetine-treated subjects and 55% of the controls had either dropped out or relapsed.

To pick up on any possible benefit of the drug, Dr. Walsh and his colleagues also considered just those who relapsed, and those who relapsed plus those who clinically appeared to be in trouble when they dropped out–either because their BMI had dropped to 17 or because they had begun binging and purging again, at least twice a week.

At 50 weeks, 27% of the fluoxetine-treated patients and 29% of the placebo controls were documented relapsers.

Considering as failures both those with documented relapse and those who clinically appeared to be not doing well when they dropped out, the percentages were 49% fluoxetine and 51% placebo.

Dr. Walsh said he also looked only at those with depression, and at those who purged or restricted food only, and treatment still made no difference in those particular patients. “However we cut it, we can find no evidence that fluoxetine prolongs time to relapse following successful initial treatment, and we've looked pretty hard,” Dr. Walsh said.

In an editorial comment accompanying the published report, Dr. Scott J. Crow of the University of Minnesota, Minneapolis, said, “While the results of previous relapse prevention trials have been mixed, the report by Walsh and colleagues has many strengths and appears convincingly negative” (JAMA 2006;295:2659–60).

The study amply demonstrates that antidepressant therapy, “a fairly common treatment practice for this illness,” provides no benefit, Dr. Crow noted.

Additional reporting was done by contributing writer Mary Ann Moon.

'We can find no evidence that fluoxetine prolongs time to relapse … and we've looked pretty hard.' DR. WALSH

TORONTO – Fluoxetine failed to prevent relapse of anorexia nervosa in the largest controlled medication trial to date exploring the issue, Dr. B. Timothy Walsh reported at the annual meeting of the American Psychiatric Association.

“Antidepressants don't offer patients with anorexia nervosa very much,” said Dr. Walsh, director of the eating disorders research unit of the New York State Psychiatric Institute, New York City. “We can't say for sure that an antidepressant other than fluoxetine wouldn't have an effect, but it would surprise me.”

The study represents yet another failure to find an efficacious medical treatment for anorexia. These failures imply that anorexia is unlike any other psychiatric condition, Dr. Walsh said.

“Interventions that are useful for other sorts of possibly related disorders don't work terribly well for anorexia nervosa,” he said. The only evidence-based treatment for anorexia is cognitive-behavioral therapy (CBT), which helps, but “not a lot,” he added.

The investigators, whose results were later published, compared fluoxetine with placebo in a clinical trial involving 93 patients who had completed intensive treatment and maintained a body mass index (BMI) of at least 19 kg/m

Subjects were randomly assigned to receive 20 mg daily of fluoxetine (49 patients), with a goal of increasing to 60 mg, or placebo (44 patients). They were monitored by a psychiatrist for dosing, adverse effects, and general medical status. They also received CBT.

The subjects underwent assessments of depression, anxiety, self-esteem, and quality of life every month. They were followed for 50 weeks, or until they either relapsed, defined as falling back to a BMI of 16.5 for 2 weeks, or dropped out of the study.

At 25 weeks, 48% of the 49 fluoxetine-treated subjects had either dropped out or relapsed, versus 39% of the placebo controls. At 50 weeks, 58% of the fluoxetine-treated subjects and 55% of the controls had either dropped out or relapsed.

To pick up on any possible benefit of the drug, Dr. Walsh and his colleagues also considered just those who relapsed, and those who relapsed plus those who clinically appeared to be in trouble when they dropped out–either because their BMI had dropped to 17 or because they had begun binging and purging again, at least twice a week.

At 50 weeks, 27% of the fluoxetine-treated patients and 29% of the placebo controls were documented relapsers.

Considering as failures both those with documented relapse and those who clinically appeared to be not doing well when they dropped out, the percentages were 49% fluoxetine and 51% placebo.

Dr. Walsh said he also looked only at those with depression, and at those who purged or restricted food only, and treatment still made no difference in those particular patients. “However we cut it, we can find no evidence that fluoxetine prolongs time to relapse following successful initial treatment, and we've looked pretty hard,” Dr. Walsh said.

In an editorial comment accompanying the published report, Dr. Scott J. Crow of the University of Minnesota, Minneapolis, said, “While the results of previous relapse prevention trials have been mixed, the report by Walsh and colleagues has many strengths and appears convincingly negative” (JAMA 2006;295:2659–60).

The study amply demonstrates that antidepressant therapy, “a fairly common treatment practice for this illness,” provides no benefit, Dr. Crow noted.

Additional reporting was done by contributing writer Mary Ann Moon.

'We can find no evidence that fluoxetine prolongs time to relapse … and we've looked pretty hard.' DR. WALSH

SEATTLE – Almost half of a sample of elderly persons in Los Angeles were taking medications that they probably should not have been, and the likelihood of such a problem rose sharply with the number of medications they were taking, Gretchen E. Alkema said at the annual research meeting of AcademyHealth.

In fact, of the elderly persons who were taking 12 or more medications, 70% had one or more medication problems, and of those taking 7–9 medications, 50% had one or more medication problems.

About one-half of the individuals in the study were taking nine or more medications.

The study shows how complicated caring for the elderly has become and how frequently they end up being given a medication they should not be using, said Ms. Alkema of the Davis School of Gerontology at the University of Southern California, Los Angeles, in a poster presentation.

The study looked at a cohort of 615 individuals in a Medicaid waiver program who were living at home but were at risk for institutionalization. Their average age was 80 years, about 40% were living alone, and 60% were English speaking.

A pharmacist reviewed their medications using a validated home-health screening tool, looking for four types of medication problems:

▸ Unnecessary therapeutic duplication.

▸ Inappropriate psychotropic medication use in a person with confusion or a fall in the past 3 months.

▸ Cardiovascular medication problems, such as poorly controlled hypertension based on dizziness, blood pressure, or pulse.

▸ Inappropriate NSAID use in a patient at risk for peptic ulcer complications (over age 80 years, on an anticoagulant, or on a corticosteroid).

Overall, 49% had one medication problem, 19% had two medication problems, and 5% had three or more problems.

The most common type of problem was therapeutic duplication, in 24% of the individuals, followed by inappropriate psychotropic use and cardiovascular medication problems, each in 14% of the individuals, and finally, inappropriate NSAID use, in 13% of the individuals.

Apart from simply the number of medications a person was using, the study found that an important risk factor associated with medication error was that the individual had been to a hospital, emergency department, or skilled nursing facility in the past year. Those contacts with the medical system doubled the risk of a problem.

SEATTLE – Almost half of a sample of elderly persons in Los Angeles were taking medications that they probably should not have been, and the likelihood of such a problem rose sharply with the number of medications they were taking, Gretchen E. Alkema said at the annual research meeting of AcademyHealth.

In fact, of the elderly persons who were taking 12 or more medications, 70% had one or more medication problems, and of those taking 7–9 medications, 50% had one or more medication problems.

About one-half of the individuals in the study were taking nine or more medications.

The study shows how complicated caring for the elderly has become and how frequently they end up being given a medication they should not be using, said Ms. Alkema of the Davis School of Gerontology at the University of Southern California, Los Angeles, in a poster presentation.

The study looked at a cohort of 615 individuals in a Medicaid waiver program who were living at home but were at risk for institutionalization. Their average age was 80 years, about 40% were living alone, and 60% were English speaking.

A pharmacist reviewed their medications using a validated home-health screening tool, looking for four types of medication problems:

▸ Unnecessary therapeutic duplication.

▸ Inappropriate psychotropic medication use in a person with confusion or a fall in the past 3 months.

▸ Cardiovascular medication problems, such as poorly controlled hypertension based on dizziness, blood pressure, or pulse.

▸ Inappropriate NSAID use in a patient at risk for peptic ulcer complications (over age 80 years, on an anticoagulant, or on a corticosteroid).

Overall, 49% had one medication problem, 19% had two medication problems, and 5% had three or more problems.

The most common type of problem was therapeutic duplication, in 24% of the individuals, followed by inappropriate psychotropic use and cardiovascular medication problems, each in 14% of the individuals, and finally, inappropriate NSAID use, in 13% of the individuals.

Apart from simply the number of medications a person was using, the study found that an important risk factor associated with medication error was that the individual had been to a hospital, emergency department, or skilled nursing facility in the past year. Those contacts with the medical system doubled the risk of a problem.

SEATTLE – Almost half of a sample of elderly persons in Los Angeles were taking medications that they probably should not have been, and the likelihood of such a problem rose sharply with the number of medications they were taking, Gretchen E. Alkema said at the annual research meeting of AcademyHealth.

In fact, of the elderly persons who were taking 12 or more medications, 70% had one or more medication problems, and of those taking 7–9 medications, 50% had one or more medication problems.

About one-half of the individuals in the study were taking nine or more medications.

The study shows how complicated caring for the elderly has become and how frequently they end up being given a medication they should not be using, said Ms. Alkema of the Davis School of Gerontology at the University of Southern California, Los Angeles, in a poster presentation.

The study looked at a cohort of 615 individuals in a Medicaid waiver program who were living at home but were at risk for institutionalization. Their average age was 80 years, about 40% were living alone, and 60% were English speaking.

A pharmacist reviewed their medications using a validated home-health screening tool, looking for four types of medication problems:

▸ Unnecessary therapeutic duplication.

▸ Inappropriate psychotropic medication use in a person with confusion or a fall in the past 3 months.

▸ Cardiovascular medication problems, such as poorly controlled hypertension based on dizziness, blood pressure, or pulse.

▸ Inappropriate NSAID use in a patient at risk for peptic ulcer complications (over age 80 years, on an anticoagulant, or on a corticosteroid).

Overall, 49% had one medication problem, 19% had two medication problems, and 5% had three or more problems.

The most common type of problem was therapeutic duplication, in 24% of the individuals, followed by inappropriate psychotropic use and cardiovascular medication problems, each in 14% of the individuals, and finally, inappropriate NSAID use, in 13% of the individuals.

Apart from simply the number of medications a person was using, the study found that an important risk factor associated with medication error was that the individual had been to a hospital, emergency department, or skilled nursing facility in the past year. Those contacts with the medical system doubled the risk of a problem.

SEATTLE — The rate of opioid use varies considerably from state to state, with some of the highest rates found in Indiana and Maine, and the lowest in California and Minnesota, federal prescription claims data show.

That variation is inexplicable medically, and suggests that opioids are being used too liberally in some states, not enough in others, or both, Dr. Judy T. Zerzan said in a poster presentation at the annual research meeting of Academy Health.

Medicare and Medicaid prescribing figures from the start of 1996 to the end of 2002 show a steep national increase in opioid prescribing. The increase coincides with efforts to improve treatment of pain, noted Dr. Zerzan of the division of general internal medicine at the University of Washington, Seattle.

Over the 7 years of the study, opioid prescribing nationally increased a mean of 24% per year. In contrast, there was a mean annual increase of 12% for an index known as the “market basket” that reflects general prescribing.

But only two-thirds of the states had an increase in the opioid prescribing. And some had a greater relative increase than others, Dr. Zerzan said.

The 10 states with the highest rates of opioid prescribing were Alaska, Indiana, Louisiana, Maine, Maryland, Missouri, Mississippi, Montana, North Carolina, and West Virginia, with rates of 87–200 defined daily doses per 1,000 Medicaid beneficiaries.

The eight states with the lowest rates were California, Minnesota, New Jersey, New Mexico, New York, Pennsylvania, Tennessee, and Vermont, with rates of 0 to 39 defined daily doses per 1,000 Medicaid beneficiaries.

One possible explanation for the variation in opioid use is differing state prescription benefit policies. Other potential explanations include that marketing of the drugs has been different in different regions, and that physician attitudes toward opioids vary by region, Dr. Zerzan said.

SEATTLE — The rate of opioid use varies considerably from state to state, with some of the highest rates found in Indiana and Maine, and the lowest in California and Minnesota, federal prescription claims data show.

That variation is inexplicable medically, and suggests that opioids are being used too liberally in some states, not enough in others, or both, Dr. Judy T. Zerzan said in a poster presentation at the annual research meeting of Academy Health.

Medicare and Medicaid prescribing figures from the start of 1996 to the end of 2002 show a steep national increase in opioid prescribing. The increase coincides with efforts to improve treatment of pain, noted Dr. Zerzan of the division of general internal medicine at the University of Washington, Seattle.

Over the 7 years of the study, opioid prescribing nationally increased a mean of 24% per year. In contrast, there was a mean annual increase of 12% for an index known as the “market basket” that reflects general prescribing.

But only two-thirds of the states had an increase in the opioid prescribing. And some had a greater relative increase than others, Dr. Zerzan said.

The 10 states with the highest rates of opioid prescribing were Alaska, Indiana, Louisiana, Maine, Maryland, Missouri, Mississippi, Montana, North Carolina, and West Virginia, with rates of 87–200 defined daily doses per 1,000 Medicaid beneficiaries.

The eight states with the lowest rates were California, Minnesota, New Jersey, New Mexico, New York, Pennsylvania, Tennessee, and Vermont, with rates of 0 to 39 defined daily doses per 1,000 Medicaid beneficiaries.

One possible explanation for the variation in opioid use is differing state prescription benefit policies. Other potential explanations include that marketing of the drugs has been different in different regions, and that physician attitudes toward opioids vary by region, Dr. Zerzan said.

SEATTLE — The rate of opioid use varies considerably from state to state, with some of the highest rates found in Indiana and Maine, and the lowest in California and Minnesota, federal prescription claims data show.

That variation is inexplicable medically, and suggests that opioids are being used too liberally in some states, not enough in others, or both, Dr. Judy T. Zerzan said in a poster presentation at the annual research meeting of Academy Health.

Medicare and Medicaid prescribing figures from the start of 1996 to the end of 2002 show a steep national increase in opioid prescribing. The increase coincides with efforts to improve treatment of pain, noted Dr. Zerzan of the division of general internal medicine at the University of Washington, Seattle.

Over the 7 years of the study, opioid prescribing nationally increased a mean of 24% per year. In contrast, there was a mean annual increase of 12% for an index known as the “market basket” that reflects general prescribing.

But only two-thirds of the states had an increase in the opioid prescribing. And some had a greater relative increase than others, Dr. Zerzan said.

The 10 states with the highest rates of opioid prescribing were Alaska, Indiana, Louisiana, Maine, Maryland, Missouri, Mississippi, Montana, North Carolina, and West Virginia, with rates of 87–200 defined daily doses per 1,000 Medicaid beneficiaries.

The eight states with the lowest rates were California, Minnesota, New Jersey, New Mexico, New York, Pennsylvania, Tennessee, and Vermont, with rates of 0 to 39 defined daily doses per 1,000 Medicaid beneficiaries.

One possible explanation for the variation in opioid use is differing state prescription benefit policies. Other potential explanations include that marketing of the drugs has been different in different regions, and that physician attitudes toward opioids vary by region, Dr. Zerzan said.

SCOTTSDALE, ARIZ. — In a major study comparing carotid endarterectomy and carotid stenting, 2-year results show similar death and stroke rates for the two procedures, Dr. Rodney A. White said at an international congress on endovascular interventions sponsored by the Arizona Heart Foundation.

And those event rates appear to be better than one would expect based on some previously reported case series and studies, said Dr. White, the vascular surgery division chief at the Harbor-UCLA Medical Center, Los Angeles.

The 1-year results from the study, known as the CARESS (Carotid Revascularization Using Endarterectomy or Stenting Systems) trial, were recently published (J. Vasc. Surg. 2005;42:213–9).

At 1 year after the procedure, there were 30 deaths or strokes among the 254 patients who underwent carotid endarterectomy, for an event rate of 14%. There were 13 deaths or strokes among the 143 patients who underwent carotid stenting, for an event rate of 10%. When the researchers included in the analysis the acute myocardial infarctions that occurred among the study patients, the event rates increased to 14% and 11%, respectively.

At the 2-year follow-up, the number of events had increased somewhat, but the pattern remained the same. The death and stroke rate was 15% for the endarterectomy group and 13% for the stenting group. Adding acute myocardial infarctions did not change the event-rate percentages.

Dr. White did not report on the restenosis or reintervention rates at 2 years. In the previous 1-year follow-up report, restenosis occurred in 4% of the endarterectomy patients and 6% of the stenting patients, a difference that was not statistically significant.

Restenosis was defined as 75% narrowing, or 50% narrowing that required treatment.

A main purpose of the trial was to design a study that reflected current clinical practice, Dr. White noted. Hence, the patients were not randomized, and almost 70% of the patients in both groups had high-grade, carotid stenosis but were asymptomatic.

SCOTTSDALE, ARIZ. — In a major study comparing carotid endarterectomy and carotid stenting, 2-year results show similar death and stroke rates for the two procedures, Dr. Rodney A. White said at an international congress on endovascular interventions sponsored by the Arizona Heart Foundation.

And those event rates appear to be better than one would expect based on some previously reported case series and studies, said Dr. White, the vascular surgery division chief at the Harbor-UCLA Medical Center, Los Angeles.

The 1-year results from the study, known as the CARESS (Carotid Revascularization Using Endarterectomy or Stenting Systems) trial, were recently published (J. Vasc. Surg. 2005;42:213–9).

At 1 year after the procedure, there were 30 deaths or strokes among the 254 patients who underwent carotid endarterectomy, for an event rate of 14%. There were 13 deaths or strokes among the 143 patients who underwent carotid stenting, for an event rate of 10%. When the researchers included in the analysis the acute myocardial infarctions that occurred among the study patients, the event rates increased to 14% and 11%, respectively.

At the 2-year follow-up, the number of events had increased somewhat, but the pattern remained the same. The death and stroke rate was 15% for the endarterectomy group and 13% for the stenting group. Adding acute myocardial infarctions did not change the event-rate percentages.

Dr. White did not report on the restenosis or reintervention rates at 2 years. In the previous 1-year follow-up report, restenosis occurred in 4% of the endarterectomy patients and 6% of the stenting patients, a difference that was not statistically significant.

Restenosis was defined as 75% narrowing, or 50% narrowing that required treatment.

A main purpose of the trial was to design a study that reflected current clinical practice, Dr. White noted. Hence, the patients were not randomized, and almost 70% of the patients in both groups had high-grade, carotid stenosis but were asymptomatic.

SCOTTSDALE, ARIZ. — In a major study comparing carotid endarterectomy and carotid stenting, 2-year results show similar death and stroke rates for the two procedures, Dr. Rodney A. White said at an international congress on endovascular interventions sponsored by the Arizona Heart Foundation.

And those event rates appear to be better than one would expect based on some previously reported case series and studies, said Dr. White, the vascular surgery division chief at the Harbor-UCLA Medical Center, Los Angeles.

The 1-year results from the study, known as the CARESS (Carotid Revascularization Using Endarterectomy or Stenting Systems) trial, were recently published (J. Vasc. Surg. 2005;42:213–9).

At 1 year after the procedure, there were 30 deaths or strokes among the 254 patients who underwent carotid endarterectomy, for an event rate of 14%. There were 13 deaths or strokes among the 143 patients who underwent carotid stenting, for an event rate of 10%. When the researchers included in the analysis the acute myocardial infarctions that occurred among the study patients, the event rates increased to 14% and 11%, respectively.

At the 2-year follow-up, the number of events had increased somewhat, but the pattern remained the same. The death and stroke rate was 15% for the endarterectomy group and 13% for the stenting group. Adding acute myocardial infarctions did not change the event-rate percentages.

Dr. White did not report on the restenosis or reintervention rates at 2 years. In the previous 1-year follow-up report, restenosis occurred in 4% of the endarterectomy patients and 6% of the stenting patients, a difference that was not statistically significant.

Restenosis was defined as 75% narrowing, or 50% narrowing that required treatment.

A main purpose of the trial was to design a study that reflected current clinical practice, Dr. White noted. Hence, the patients were not randomized, and almost 70% of the patients in both groups had high-grade, carotid stenosis but were asymptomatic.

SCOTTSDALE, ARIZ. — The results of carotid stenting appear to be similar to endarterectomy results for at least 5 years after the procedure, based on a cohort study of 2,172 patients treated at four European centers.

In the cohort of patients enrolled prospectively between 1993 and 2004, the rate of ipsilateral major stroke or death from any cause was 4% at 1 year, 10% by 3 years, and 16% by 5 years, among the 138 patients followed, Dr. Patrick Peeters said at an international congress on endovascular interventions sponsored by the Arizona Heart Foundation.

Several different, self-expanding stents were used in the series, as chosen by individual interventionalists at the time of the procedure, with the most common being a closed-cell, cobalt chromium alloy stent, used in 62% of the patients. And 4% of patients received only balloon dilation.

The restenosis rates were 1% at 1 year, 2% at 3 years, and 3% at 5 years (139 patients); restenosis was considered to be 50% narrowing as imaged with ultrasound, noted Dr. Peeters, head of the department of cardiovascular and thoracic surgery at Imelda Hospital, Bonheiden, Belgium.

Previous studies reported restenosis rates at 1 year ranging from 3% to 8%. Moreover, although the earliest studies of carotid stenting had major, perioperative complication rates as high as 9%, 99.7% of cases in this series were technically successful. The results with stenting also compare well with endarterectomy, he noted. The European Carotid Surgery Trial reported a rate of major stroke or death of 15% at 3 years, very similar to the 13% rate of this series.

Although stenting did not make a significant difference in the stroke/death rate, compared with ballooning only, it did in the restenosis rate. Restenosis at 5 years was 3% in the stented patients but 15% in the ballooned-only patients.

Predilatation of the artery before stent placement also made a significant difference, Dr. Peeters said. Of the stented patients, 30% were predilated. Their stroke and death rate at 5 years was 10% (33 patients) versus 17% for those not predilated. There was no difference in stroke and death in the series between patients who were symptomatic or asymptomatic.

SCOTTSDALE, ARIZ. — The results of carotid stenting appear to be similar to endarterectomy results for at least 5 years after the procedure, based on a cohort study of 2,172 patients treated at four European centers.

In the cohort of patients enrolled prospectively between 1993 and 2004, the rate of ipsilateral major stroke or death from any cause was 4% at 1 year, 10% by 3 years, and 16% by 5 years, among the 138 patients followed, Dr. Patrick Peeters said at an international congress on endovascular interventions sponsored by the Arizona Heart Foundation.

Several different, self-expanding stents were used in the series, as chosen by individual interventionalists at the time of the procedure, with the most common being a closed-cell, cobalt chromium alloy stent, used in 62% of the patients. And 4% of patients received only balloon dilation.

The restenosis rates were 1% at 1 year, 2% at 3 years, and 3% at 5 years (139 patients); restenosis was considered to be 50% narrowing as imaged with ultrasound, noted Dr. Peeters, head of the department of cardiovascular and thoracic surgery at Imelda Hospital, Bonheiden, Belgium.

Previous studies reported restenosis rates at 1 year ranging from 3% to 8%. Moreover, although the earliest studies of carotid stenting had major, perioperative complication rates as high as 9%, 99.7% of cases in this series were technically successful. The results with stenting also compare well with endarterectomy, he noted. The European Carotid Surgery Trial reported a rate of major stroke or death of 15% at 3 years, very similar to the 13% rate of this series.

Although stenting did not make a significant difference in the stroke/death rate, compared with ballooning only, it did in the restenosis rate. Restenosis at 5 years was 3% in the stented patients but 15% in the ballooned-only patients.

Predilatation of the artery before stent placement also made a significant difference, Dr. Peeters said. Of the stented patients, 30% were predilated. Their stroke and death rate at 5 years was 10% (33 patients) versus 17% for those not predilated. There was no difference in stroke and death in the series between patients who were symptomatic or asymptomatic.

SCOTTSDALE, ARIZ. — The results of carotid stenting appear to be similar to endarterectomy results for at least 5 years after the procedure, based on a cohort study of 2,172 patients treated at four European centers.

In the cohort of patients enrolled prospectively between 1993 and 2004, the rate of ipsilateral major stroke or death from any cause was 4% at 1 year, 10% by 3 years, and 16% by 5 years, among the 138 patients followed, Dr. Patrick Peeters said at an international congress on endovascular interventions sponsored by the Arizona Heart Foundation.

Several different, self-expanding stents were used in the series, as chosen by individual interventionalists at the time of the procedure, with the most common being a closed-cell, cobalt chromium alloy stent, used in 62% of the patients. And 4% of patients received only balloon dilation.

The restenosis rates were 1% at 1 year, 2% at 3 years, and 3% at 5 years (139 patients); restenosis was considered to be 50% narrowing as imaged with ultrasound, noted Dr. Peeters, head of the department of cardiovascular and thoracic surgery at Imelda Hospital, Bonheiden, Belgium.

Previous studies reported restenosis rates at 1 year ranging from 3% to 8%. Moreover, although the earliest studies of carotid stenting had major, perioperative complication rates as high as 9%, 99.7% of cases in this series were technically successful. The results with stenting also compare well with endarterectomy, he noted. The European Carotid Surgery Trial reported a rate of major stroke or death of 15% at 3 years, very similar to the 13% rate of this series.

Although stenting did not make a significant difference in the stroke/death rate, compared with ballooning only, it did in the restenosis rate. Restenosis at 5 years was 3% in the stented patients but 15% in the ballooned-only patients.

Predilatation of the artery before stent placement also made a significant difference, Dr. Peeters said. Of the stented patients, 30% were predilated. Their stroke and death rate at 5 years was 10% (33 patients) versus 17% for those not predilated. There was no difference in stroke and death in the series between patients who were symptomatic or asymptomatic.

SAN DIEGO — Nancy Clark, a registered nurse, had been drug free and sober for 3 years when she tested positive for alcohol on the new ethyl glucuronide test, the same one used for many chemically dependent physicians who are entered into monitoring programs and are on probation.

She kept her job the first time, but then she tested positive again—and lost it.

So Ms. Clark bought a plane ticket. She flew almost 3,000 miles from Pennsylvania to San Diego to meet with the one person she thought might be able to help her and others in her situation: Dr. Greg Skipper.

“When I tested positive, I looked on the Internet, and everything I saw said this test was perfect,” said Ms. Clark of Fleetwood, Penn., at the meeting where she met with Dr. Skipper—the annual conference of the American Society of Addiction Medicine.

“I thought: How am I ever going to be able to protest this?” she said.

Recent evidence, however, suggests that while the test may be highly accurate and sensitive, it may also be fallible, said Dr. Skipper, who helped develop ethyl glucuronide (EtG) as a drug test to monitor whether a person has consumed alcohol. In essence, the evidence suggests the test may be too good, picking up people who are exposed to alcohol in any number of ways without drinking it, said Dr. Skipper of Montgomery, Ala., director of that state's physician health program.

The EtG test is used widely by physician monitoring programs. In a survey of physician health programs conducted this year, 29 of 31 responding programs reported that they use the test, compared with 17 of 46 programs that reported using it in 2004, said Dr. Michael Sucher, medical director of the physician health program in Scottsdale, Ariz. Some of those states use it routinely, others just for cause.

Dr. Skipper says he knows of at least 60 people who claim that they have not touched a drink but have had positive results on the EtG test. Consequently, some people who have not been drinking may lose their jobs, licenses, or even custody of their children. Still others may be going back to jail.

For health care workers, washing hands with alcohol-containing sanitizers such as Purell might be the reason they are testing positive, Dr. Skipper said. “We're getting data, and we're worried about what [they show],” he said in an interview.

Dr. Skipper said that he does not want to see the test abandoned. He finds it often picks up monitored physicians whose alcohol use would not be detected otherwise, and even among those who deny drinking at first, 50%–80% later admit to it.

Random EtG testing surveys of physicians who are not supposed to be drinking in monitoring programs have found that around 7% will have a positive test result. It is important to catch those physicians to get them help, Dr. Skipper said.

Given the gathering evidence, however, the test needs to be used with some clinical judgment of the individual, he added. “I am urging no use in administrative hearings and courts,” he said. “It is a clinical test.”

Moreover, if hand sanitizer can cause measurable EtG levels, then probably any product containing alcohol could, he noted. And products that contain alcohol are everywhere, ranging from the cold medicine NyQuil to asthma inhalers, topical testosterone, and bug spray.

Ethyl glucuronide is a very specific metabolite of alcohol found in urine. It is considered a better test than a blood alcohol level, because it lasts much longer—about 5 days—depending on the amount ingested and individual variation. Although it has been theorized that certain rare individuals could automatically ferment alcohol in their system, such as yeast in the bowel, it has been assumed that a positive test meant someone had to have taken a drink.

At the meeting, Dr. Michael R. Liepman presented an experiment on the EtG test that he conducted using 24 abstinent subjects.

One group of subjects washed their hands with Purell (62% alcohol) 15 times at 4-minute intervals in a small enclosed room where, presumably, they would be inhaling the fumes from the washing. Each of those subjects was accompanied by another subject who did not wash their hands but stood close enough for inhalation.

A third group washed their hands in an air-flow chamber to prevent inhalation, and a fourth group served as controls.

Three of the subjects who washed their hands and could inhale the sanitizer had positive EtG tests 30 minutes after washing, as did one of the subjects observing in the same room, said Dr. Liepman, director of addiction psychiatry and research at Michigan State University's Kalamazoo Center for Medical Studies.

That observer had a level of 350 ng/mL, while the cutoff used for a positive test in the experiment was 100 ng/mL, the same cutoff that is generally used out in the field.

None of the subjects who washed in the air-flow chamber had a positive test, though there were detectable levels.

Breathalyzer tests given to the subjects did not suggest any level of impairment.

The results confirmed that use of alcohol-containing hand wash can influence the EtG test, and the primary means appears to be inhalation, Dr. Liepman said.

“Recovering alcoholics, including those who are subject to urine monitoring, should avoid the use of alcohol-based hand sanitizer,” he said.

Dr. Liepman was motivated to perform the experiment because two nurses in his practice, both of whom were recovering opiate addicts and both of whom were pregnant, had tested positive for ethyl glucuronide and violated their recovery employment contracts, he said. Both were suspended for 1 month, just at the time they needed to be accumulating vacation hours so they could take time off for the birth of their babies.

Both denied drinking, neither tested positive for any other drugs, and both were doing well on the job.

One nurse measured 270 ng/mL on the EtG test, while the other measured 215 ng/mL, levels that might be considered fairly low for a substance abuser who has fallen off the wagon, since two drinks can produce a level of 23,000 ng/mL, Dr. Liepman said.

Both nurses reported washing their hands with sanitizer on the job upward of 30 times a day, a frequency that might explain why, among health care workers, so many of those who have been tripped up by the test have been nurses.

In the laboratory, Dr. Skipper has found that two nonalcoholic beers will cause a level of 93 ng/mL and gargling with Listerine can trigger a level of 100 ng/mL.

SAN DIEGO — Nancy Clark, a registered nurse, had been drug free and sober for 3 years when she tested positive for alcohol on the new ethyl glucuronide test, the same one used for many chemically dependent physicians who are entered into monitoring programs and are on probation.

She kept her job the first time, but then she tested positive again—and lost it.

So Ms. Clark bought a plane ticket. She flew almost 3,000 miles from Pennsylvania to San Diego to meet with the one person she thought might be able to help her and others in her situation: Dr. Greg Skipper.

“When I tested positive, I looked on the Internet, and everything I saw said this test was perfect,” said Ms. Clark of Fleetwood, Penn., at the meeting where she met with Dr. Skipper—the annual conference of the American Society of Addiction Medicine.

“I thought: How am I ever going to be able to protest this?” she said.

Recent evidence, however, suggests that while the test may be highly accurate and sensitive, it may also be fallible, said Dr. Skipper, who helped develop ethyl glucuronide (EtG) as a drug test to monitor whether a person has consumed alcohol. In essence, the evidence suggests the test may be too good, picking up people who are exposed to alcohol in any number of ways without drinking it, said Dr. Skipper of Montgomery, Ala., director of that state's physician health program.

The EtG test is used widely by physician monitoring programs. In a survey of physician health programs conducted this year, 29 of 31 responding programs reported that they use the test, compared with 17 of 46 programs that reported using it in 2004, said Dr. Michael Sucher, medical director of the physician health program in Scottsdale, Ariz. Some of those states use it routinely, others just for cause.

Dr. Skipper says he knows of at least 60 people who claim that they have not touched a drink but have had positive results on the EtG test. Consequently, some people who have not been drinking may lose their jobs, licenses, or even custody of their children. Still others may be going back to jail.

For health care workers, washing hands with alcohol-containing sanitizers such as Purell might be the reason they are testing positive, Dr. Skipper said. “We're getting data, and we're worried about what [they show],” he said in an interview.

Dr. Skipper said that he does not want to see the test abandoned. He finds it often picks up monitored physicians whose alcohol use would not be detected otherwise, and even among those who deny drinking at first, 50%–80% later admit to it.

Random EtG testing surveys of physicians who are not supposed to be drinking in monitoring programs have found that around 7% will have a positive test result. It is important to catch those physicians to get them help, Dr. Skipper said.

Given the gathering evidence, however, the test needs to be used with some clinical judgment of the individual, he added. “I am urging no use in administrative hearings and courts,” he said. “It is a clinical test.”

Moreover, if hand sanitizer can cause measurable EtG levels, then probably any product containing alcohol could, he noted. And products that contain alcohol are everywhere, ranging from the cold medicine NyQuil to asthma inhalers, topical testosterone, and bug spray.

Ethyl glucuronide is a very specific metabolite of alcohol found in urine. It is considered a better test than a blood alcohol level, because it lasts much longer—about 5 days—depending on the amount ingested and individual variation. Although it has been theorized that certain rare individuals could automatically ferment alcohol in their system, such as yeast in the bowel, it has been assumed that a positive test meant someone had to have taken a drink.

At the meeting, Dr. Michael R. Liepman presented an experiment on the EtG test that he conducted using 24 abstinent subjects.

One group of subjects washed their hands with Purell (62% alcohol) 15 times at 4-minute intervals in a small enclosed room where, presumably, they would be inhaling the fumes from the washing. Each of those subjects was accompanied by another subject who did not wash their hands but stood close enough for inhalation.

A third group washed their hands in an air-flow chamber to prevent inhalation, and a fourth group served as controls.

Three of the subjects who washed their hands and could inhale the sanitizer had positive EtG tests 30 minutes after washing, as did one of the subjects observing in the same room, said Dr. Liepman, director of addiction psychiatry and research at Michigan State University's Kalamazoo Center for Medical Studies.

That observer had a level of 350 ng/mL, while the cutoff used for a positive test in the experiment was 100 ng/mL, the same cutoff that is generally used out in the field.

None of the subjects who washed in the air-flow chamber had a positive test, though there were detectable levels.

Breathalyzer tests given to the subjects did not suggest any level of impairment.

The results confirmed that use of alcohol-containing hand wash can influence the EtG test, and the primary means appears to be inhalation, Dr. Liepman said.

“Recovering alcoholics, including those who are subject to urine monitoring, should avoid the use of alcohol-based hand sanitizer,” he said.

Dr. Liepman was motivated to perform the experiment because two nurses in his practice, both of whom were recovering opiate addicts and both of whom were pregnant, had tested positive for ethyl glucuronide and violated their recovery employment contracts, he said. Both were suspended for 1 month, just at the time they needed to be accumulating vacation hours so they could take time off for the birth of their babies.

Both denied drinking, neither tested positive for any other drugs, and both were doing well on the job.

One nurse measured 270 ng/mL on the EtG test, while the other measured 215 ng/mL, levels that might be considered fairly low for a substance abuser who has fallen off the wagon, since two drinks can produce a level of 23,000 ng/mL, Dr. Liepman said.

Both nurses reported washing their hands with sanitizer on the job upward of 30 times a day, a frequency that might explain why, among health care workers, so many of those who have been tripped up by the test have been nurses.

In the laboratory, Dr. Skipper has found that two nonalcoholic beers will cause a level of 93 ng/mL and gargling with Listerine can trigger a level of 100 ng/mL.

SAN DIEGO — Nancy Clark, a registered nurse, had been drug free and sober for 3 years when she tested positive for alcohol on the new ethyl glucuronide test, the same one used for many chemically dependent physicians who are entered into monitoring programs and are on probation.

She kept her job the first time, but then she tested positive again—and lost it.

So Ms. Clark bought a plane ticket. She flew almost 3,000 miles from Pennsylvania to San Diego to meet with the one person she thought might be able to help her and others in her situation: Dr. Greg Skipper.

“When I tested positive, I looked on the Internet, and everything I saw said this test was perfect,” said Ms. Clark of Fleetwood, Penn., at the meeting where she met with Dr. Skipper—the annual conference of the American Society of Addiction Medicine.

“I thought: How am I ever going to be able to protest this?” she said.

Recent evidence, however, suggests that while the test may be highly accurate and sensitive, it may also be fallible, said Dr. Skipper, who helped develop ethyl glucuronide (EtG) as a drug test to monitor whether a person has consumed alcohol. In essence, the evidence suggests the test may be too good, picking up people who are exposed to alcohol in any number of ways without drinking it, said Dr. Skipper of Montgomery, Ala., director of that state's physician health program.

The EtG test is used widely by physician monitoring programs. In a survey of physician health programs conducted this year, 29 of 31 responding programs reported that they use the test, compared with 17 of 46 programs that reported using it in 2004, said Dr. Michael Sucher, medical director of the physician health program in Scottsdale, Ariz. Some of those states use it routinely, others just for cause.

Dr. Skipper says he knows of at least 60 people who claim that they have not touched a drink but have had positive results on the EtG test. Consequently, some people who have not been drinking may lose their jobs, licenses, or even custody of their children. Still others may be going back to jail.

For health care workers, washing hands with alcohol-containing sanitizers such as Purell might be the reason they are testing positive, Dr. Skipper said. “We're getting data, and we're worried about what [they show],” he said in an interview.

Dr. Skipper said that he does not want to see the test abandoned. He finds it often picks up monitored physicians whose alcohol use would not be detected otherwise, and even among those who deny drinking at first, 50%–80% later admit to it.

Random EtG testing surveys of physicians who are not supposed to be drinking in monitoring programs have found that around 7% will have a positive test result. It is important to catch those physicians to get them help, Dr. Skipper said.

Given the gathering evidence, however, the test needs to be used with some clinical judgment of the individual, he added. “I am urging no use in administrative hearings and courts,” he said. “It is a clinical test.”

Moreover, if hand sanitizer can cause measurable EtG levels, then probably any product containing alcohol could, he noted. And products that contain alcohol are everywhere, ranging from the cold medicine NyQuil to asthma inhalers, topical testosterone, and bug spray.

Ethyl glucuronide is a very specific metabolite of alcohol found in urine. It is considered a better test than a blood alcohol level, because it lasts much longer—about 5 days—depending on the amount ingested and individual variation. Although it has been theorized that certain rare individuals could automatically ferment alcohol in their system, such as yeast in the bowel, it has been assumed that a positive test meant someone had to have taken a drink.

At the meeting, Dr. Michael R. Liepman presented an experiment on the EtG test that he conducted using 24 abstinent subjects.

One group of subjects washed their hands with Purell (62% alcohol) 15 times at 4-minute intervals in a small enclosed room where, presumably, they would be inhaling the fumes from the washing. Each of those subjects was accompanied by another subject who did not wash their hands but stood close enough for inhalation.

A third group washed their hands in an air-flow chamber to prevent inhalation, and a fourth group served as controls.

Three of the subjects who washed their hands and could inhale the sanitizer had positive EtG tests 30 minutes after washing, as did one of the subjects observing in the same room, said Dr. Liepman, director of addiction psychiatry and research at Michigan State University's Kalamazoo Center for Medical Studies.

That observer had a level of 350 ng/mL, while the cutoff used for a positive test in the experiment was 100 ng/mL, the same cutoff that is generally used out in the field.

None of the subjects who washed in the air-flow chamber had a positive test, though there were detectable levels.

Breathalyzer tests given to the subjects did not suggest any level of impairment.

The results confirmed that use of alcohol-containing hand wash can influence the EtG test, and the primary means appears to be inhalation, Dr. Liepman said.

“Recovering alcoholics, including those who are subject to urine monitoring, should avoid the use of alcohol-based hand sanitizer,” he said.

Dr. Liepman was motivated to perform the experiment because two nurses in his practice, both of whom were recovering opiate addicts and both of whom were pregnant, had tested positive for ethyl glucuronide and violated their recovery employment contracts, he said. Both were suspended for 1 month, just at the time they needed to be accumulating vacation hours so they could take time off for the birth of their babies.

Both denied drinking, neither tested positive for any other drugs, and both were doing well on the job.

One nurse measured 270 ng/mL on the EtG test, while the other measured 215 ng/mL, levels that might be considered fairly low for a substance abuser who has fallen off the wagon, since two drinks can produce a level of 23,000 ng/mL, Dr. Liepman said.

Both nurses reported washing their hands with sanitizer on the job upward of 30 times a day, a frequency that might explain why, among health care workers, so many of those who have been tripped up by the test have been nurses.

In the laboratory, Dr. Skipper has found that two nonalcoholic beers will cause a level of 93 ng/mL and gargling with Listerine can trigger a level of 100 ng/mL.

SAN DIEGO — Despite the recent potential easing of the federal limit on the number of opiate-addicted patients a physician can treat, substance abuse experts continue to see a pressing need for more buprenorphine slots.

At a recent meeting of the American Society of Addiction Medicine, those experts complained that there were still more potential patients than they can legally treat. These experts are lobbying government officials for a further easing of the limit.

A bill recently introduced in the U.S. Senate by Sen. Arlen Specter (R-Pa.) would in essence relax the limits further. The revision would allow those who have had their buprenorphine waiver for 1 year to apply for more patients.

The Drug Addiction Treatment Act of 2000 created the office buprenorphine prescribing program. Initially, the 30-patient limit established by the act was interpreted to mean 30 patients could be treated per site. However, in August 2005, that provision was amended to mean 30 patients could be treated per physician, regardless of the number of physicians with a waiver who were based at a particular site.

Those attending the meeting cheered and applauded when Mark L. Kraus, cochair of the society's public policy committee, said in a statement from the society that the law “makes absolutely no sense” and “constitutes rationing of care.”

“No other FDA-approved medication has an arbitrary limit as to the number of patients a physician is allowed to treat,” Dr. Kraus said. “If government's major purpose is to prevent diversion, rationing of care is not reasonably related to that goal.”

Currently, about 7,000 physicians have received the training and a waiver for office treatment of addiction with buprenorphine.

No one ventures to estimate the number of potential opiate-addicted individuals who are prevented from getting treatment because of the 30-patient limit. However, it has been reported that clinics in some cities have hundreds on their waiting lists.

And some physicians are known to be openly flouting the limit and exceeding it, with one physician in Massachusetts treating some 600 patients, government officials said at the meeting.

On the other hand, only 20% of 1,059 waivered physicians reported being at the 30-patient limit in a 2005 survey, said Arlene Stanton, Ph.D., of the Center for Substance Abuse Treatment, of the Substance Abuse and Mental Health Services Administration (SAMHSA).

The caveat to interpreting that number, however, is that only 67% of the waivered physicians reported having prescribed buprenorphine and, of those who had prescribed it, 38% used it only to detoxify patients, not for maintenance.

Regarding safety and effectiveness, the buprenorphine program appears to be going well, according to Dr. Stanton's report. In a survey of about 400 patients, 59% were free of all illicit drug use; 81% were free of all opioid use. At the same time, the Drug Abuse Warning Network recorded only 108 emergency department visits related to buprenorphine use in 2004.

By March 2005, 104,640 patients had been started on buprenorphine, with about 65,000 of those patients on maintenance treatment.

Diversion of buprenorphine may be occurring, but it is not considered a problem by federal authorities, said Denise Curry, deputy director of the Office of Diversion Control at the Drug Enforcement Agency (DEA), who spoke at the meeting.

She said there are reports that Suboxone is available on the streets and goes for about $45 a dose in Virginia, but the agency has not found any evidence of abuse and has no confirmed cases of diversion.

The DEA is much more concerned with other problems, particularly methamphetamine, Ms. Curry said.

“We have bigger fish to fry,” she said.

The other, equally important, solution to the lack of availability of buprenorphine for all those who need it is to encourage more physicians to get a waiver, said Dr. H. Westley Clark, the director of SAMHSA's Center for Substance Abuse Treatment.

There are about 500,000 ambulatory-care physicians in this country, but only 7,000 have a waiver. Getting a waiver takes only 8 hours of training, and most states require physicians to have 25 hours of continuing medical education a year, he said.

“We need to convince our colleagues in primary care that they, too, have a responsibility in this,” he said. “We have a large number of physicians who are not willing to deal with this.”

But while increasing the number of prescribers might be a solution in the cities, it may not be in rural areas, according to one person at the meeting who got up to speak.

Rural America has a big problem with illicit opioid use in general and OxyContin in particular. But most primary care physicians in rural areas are too busy already to take on treating substance abusers, said Dr. James W. Berry, of Bangor, Maine.

“As for psychiatrists, there aren't any,” he added.

SAN DIEGO — Despite the recent potential easing of the federal limit on the number of opiate-addicted patients a physician can treat, substance abuse experts continue to see a pressing need for more buprenorphine slots.

At a recent meeting of the American Society of Addiction Medicine, those experts complained that there were still more potential patients than they can legally treat. These experts are lobbying government officials for a further easing of the limit.

A bill recently introduced in the U.S. Senate by Sen. Arlen Specter (R-Pa.) would in essence relax the limits further. The revision would allow those who have had their buprenorphine waiver for 1 year to apply for more patients.

The Drug Addiction Treatment Act of 2000 created the office buprenorphine prescribing program. Initially, the 30-patient limit established by the act was interpreted to mean 30 patients could be treated per site. However, in August 2005, that provision was amended to mean 30 patients could be treated per physician, regardless of the number of physicians with a waiver who were based at a particular site.

Those attending the meeting cheered and applauded when Mark L. Kraus, cochair of the society's public policy committee, said in a statement from the society that the law “makes absolutely no sense” and “constitutes rationing of care.”

“No other FDA-approved medication has an arbitrary limit as to the number of patients a physician is allowed to treat,” Dr. Kraus said. “If government's major purpose is to prevent diversion, rationing of care is not reasonably related to that goal.”

Currently, about 7,000 physicians have received the training and a waiver for office treatment of addiction with buprenorphine.

No one ventures to estimate the number of potential opiate-addicted individuals who are prevented from getting treatment because of the 30-patient limit. However, it has been reported that clinics in some cities have hundreds on their waiting lists.

And some physicians are known to be openly flouting the limit and exceeding it, with one physician in Massachusetts treating some 600 patients, government officials said at the meeting.

On the other hand, only 20% of 1,059 waivered physicians reported being at the 30-patient limit in a 2005 survey, said Arlene Stanton, Ph.D., of the Center for Substance Abuse Treatment, of the Substance Abuse and Mental Health Services Administration (SAMHSA).

The caveat to interpreting that number, however, is that only 67% of the waivered physicians reported having prescribed buprenorphine and, of those who had prescribed it, 38% used it only to detoxify patients, not for maintenance.

Regarding safety and effectiveness, the buprenorphine program appears to be going well, according to Dr. Stanton's report. In a survey of about 400 patients, 59% were free of all illicit drug use; 81% were free of all opioid use. At the same time, the Drug Abuse Warning Network recorded only 108 emergency department visits related to buprenorphine use in 2004.

By March 2005, 104,640 patients had been started on buprenorphine, with about 65,000 of those patients on maintenance treatment.

Diversion of buprenorphine may be occurring, but it is not considered a problem by federal authorities, said Denise Curry, deputy director of the Office of Diversion Control at the Drug Enforcement Agency (DEA), who spoke at the meeting.

She said there are reports that Suboxone is available on the streets and goes for about $45 a dose in Virginia, but the agency has not found any evidence of abuse and has no confirmed cases of diversion.

The DEA is much more concerned with other problems, particularly methamphetamine, Ms. Curry said.

“We have bigger fish to fry,” she said.

The other, equally important, solution to the lack of availability of buprenorphine for all those who need it is to encourage more physicians to get a waiver, said Dr. H. Westley Clark, the director of SAMHSA's Center for Substance Abuse Treatment.

There are about 500,000 ambulatory-care physicians in this country, but only 7,000 have a waiver. Getting a waiver takes only 8 hours of training, and most states require physicians to have 25 hours of continuing medical education a year, he said.

“We need to convince our colleagues in primary care that they, too, have a responsibility in this,” he said. “We have a large number of physicians who are not willing to deal with this.”

But while increasing the number of prescribers might be a solution in the cities, it may not be in rural areas, according to one person at the meeting who got up to speak.

Rural America has a big problem with illicit opioid use in general and OxyContin in particular. But most primary care physicians in rural areas are too busy already to take on treating substance abusers, said Dr. James W. Berry, of Bangor, Maine.

“As for psychiatrists, there aren't any,” he added.

SAN DIEGO — Despite the recent potential easing of the federal limit on the number of opiate-addicted patients a physician can treat, substance abuse experts continue to see a pressing need for more buprenorphine slots.

At a recent meeting of the American Society of Addiction Medicine, those experts complained that there were still more potential patients than they can legally treat. These experts are lobbying government officials for a further easing of the limit.

A bill recently introduced in the U.S. Senate by Sen. Arlen Specter (R-Pa.) would in essence relax the limits further. The revision would allow those who have had their buprenorphine waiver for 1 year to apply for more patients.

The Drug Addiction Treatment Act of 2000 created the office buprenorphine prescribing program. Initially, the 30-patient limit established by the act was interpreted to mean 30 patients could be treated per site. However, in August 2005, that provision was amended to mean 30 patients could be treated per physician, regardless of the number of physicians with a waiver who were based at a particular site.

Those attending the meeting cheered and applauded when Mark L. Kraus, cochair of the society's public policy committee, said in a statement from the society that the law “makes absolutely no sense” and “constitutes rationing of care.”

“No other FDA-approved medication has an arbitrary limit as to the number of patients a physician is allowed to treat,” Dr. Kraus said. “If government's major purpose is to prevent diversion, rationing of care is not reasonably related to that goal.”

Currently, about 7,000 physicians have received the training and a waiver for office treatment of addiction with buprenorphine.

No one ventures to estimate the number of potential opiate-addicted individuals who are prevented from getting treatment because of the 30-patient limit. However, it has been reported that clinics in some cities have hundreds on their waiting lists.

And some physicians are known to be openly flouting the limit and exceeding it, with one physician in Massachusetts treating some 600 patients, government officials said at the meeting.

On the other hand, only 20% of 1,059 waivered physicians reported being at the 30-patient limit in a 2005 survey, said Arlene Stanton, Ph.D., of the Center for Substance Abuse Treatment, of the Substance Abuse and Mental Health Services Administration (SAMHSA).

The caveat to interpreting that number, however, is that only 67% of the waivered physicians reported having prescribed buprenorphine and, of those who had prescribed it, 38% used it only to detoxify patients, not for maintenance.

Regarding safety and effectiveness, the buprenorphine program appears to be going well, according to Dr. Stanton's report. In a survey of about 400 patients, 59% were free of all illicit drug use; 81% were free of all opioid use. At the same time, the Drug Abuse Warning Network recorded only 108 emergency department visits related to buprenorphine use in 2004.

By March 2005, 104,640 patients had been started on buprenorphine, with about 65,000 of those patients on maintenance treatment.

Diversion of buprenorphine may be occurring, but it is not considered a problem by federal authorities, said Denise Curry, deputy director of the Office of Diversion Control at the Drug Enforcement Agency (DEA), who spoke at the meeting.

She said there are reports that Suboxone is available on the streets and goes for about $45 a dose in Virginia, but the agency has not found any evidence of abuse and has no confirmed cases of diversion.

The DEA is much more concerned with other problems, particularly methamphetamine, Ms. Curry said.

“We have bigger fish to fry,” she said.

The other, equally important, solution to the lack of availability of buprenorphine for all those who need it is to encourage more physicians to get a waiver, said Dr. H. Westley Clark, the director of SAMHSA's Center for Substance Abuse Treatment.

There are about 500,000 ambulatory-care physicians in this country, but only 7,000 have a waiver. Getting a waiver takes only 8 hours of training, and most states require physicians to have 25 hours of continuing medical education a year, he said.

“We need to convince our colleagues in primary care that they, too, have a responsibility in this,” he said. “We have a large number of physicians who are not willing to deal with this.”

But while increasing the number of prescribers might be a solution in the cities, it may not be in rural areas, according to one person at the meeting who got up to speak.

Rural America has a big problem with illicit opioid use in general and OxyContin in particular. But most primary care physicians in rural areas are too busy already to take on treating substance abusers, said Dr. James W. Berry, of Bangor, Maine.

“As for psychiatrists, there aren't any,” he added.

ATLANTA — The general perception is that society is at the mercy of sexual abusers and molesters, with little recourse besides knowing where they live.

But that view is not shared by experts and professionals in the field.

Prevention probably is possible, and treatment—which can break the cycle of the abused becoming abusers—can be effective, a group of those experts said at a meeting of the National Adolescent Perpetration Network. Actually, many who commit acts of child molestation want help and will seek it out, said Deborah Donovan-Rice, director of public policy for the Stop It Now! campaign.

Illustrating her contention, she said her group's Minnesota program had sponsored a single billboard in the Minneapolis-St. Paul area. The billboard had a simple design: It showed a man, with one hand on his forehead, gesturing anguish, and the other raised as if to ward something off. It asked: “Having sexual thoughts of children?”

Then, the billboard gave the number of the confidential helpline.

The billboard doubled the number of calls from Minnesota that the helpline had been receiving each month, Ms. Donovan-Rice said. It was not a slew of calls, but somewhere around 18. Even so, that is a big number for sexual abuse, she added.

“It's very exciting to think that the people who are having sexualized thoughts about children would call before they acted on those thoughts,” she said.

In addition, the organization has been conducting focus groups with people convicted of child sexual abuse crimes. It has found that many members of those groups state that they would have wanted help but did not know where to turn. Those individuals also often report that they had previously sought help for psychiatric problems, such as depression, meaning they were accessible to mental health professionals and thereby could have potentially been identified, Ms. Donovan-Rice said.

In an interview, Ms. Donovan-Rice said that Vermont was one of the first states in the country to establish a Stop It Now! chapter and helpline. The Vermont group also found that passage of the federal Megan's Law, which requires states to provide public information on where known sex offenders reside, had a noticeably chilling effect on calls to the helpline.

Prevention requires being able to identify the persons likely to commit sexual abuse, to target them with intervention. And a new, very large survey suggests there may be a way to do that, although with a fairly narrow window of opportunity, Nora Harlow, a researcher with the Child Molestation Research and Prevention Institute in Atlanta, said in another presentation at the meeting.

Ms. Harlow's institute has a database of sexual-interest screening test results from 13,000 adult males who admitted child sexual abuse, and 10,000 adolescents who also took the test for a variety of reasons.

The test, designed by Ms. Harlow's husband and partner in the institute, Dr. Gene Abel, is administered at more than 500 sites across the country and Canada, and it is used by law enforcement personnel, lawyers, counselors, and others. And it is set up so that all test results come back to a confidential database. A review of the results of the adult tests suggests that 84% of child victims of sexual abuse are abused by people who meet criteria for the DSM-IV diagnosis of pedophilia, Ms. Harlow said.

While that may seem obvious, it is an observation that could have tremendous implications, said Ms. Harlow, who noted that the diagnosis does not require that the individual has actually touched a child.

“This is huge,” she said. “It is very important for public health, because it is such a big cause. There are a zillion causes of lung cancer, but when we found smoking it changed our entire society.”

Further, the data show that 47% of the men reported having been abused themselves as children, a figure consistent with other research.

The data from the adolescents' tests show that among those who admitted sexually abusing another child (5,682 individuals) and who had been abused themselves, the average age of their own abuse was 7 years and the average age of their first abuse of someone else was 11 years, she noted.

Among the sexually abused adolescent males who had taken the test, 72% had sexually abused younger children, as had 54% of sexually abused adolescent females. Though those who are younger that 16 years cannot receive the diagnosis of pedophilia, the screening test found that about 40% of the adolescent abusers had pedophilia-like interest or fantasies about younger children.

This information suggests that child sexual abuse is an “an early onset disorder,” but one that does have markers that could be exploited for prevention, Ms. Harlow said at the meeting, which was sponsored by the University of Colorado.

Other relevant presentations at the meeting included two from representatives of the Centers for Disease Control and Prevention. Those officials noted that the CDC is actively working to improve some of the science about sexual abuse and abusers, to help design effective prevention efforts. And they described a dearth of information on sexual abuse, and the psychology behind it, despite an abundance of theories.

Presently, most studies of sexual abusers are limited case-control studies and none has followed the individuals for very long, said Daniel J. Whitaker, Ph.D., a behavioral scientist with the division of violence prevention at the CDC, who recently conducted a metaanalysis of the studies that have looked at the psychological profile of sexual abusers of children compared with other individuals.

Others were more optimistic about what could be achieved, right now, in the absence of a full understanding of the factors that contribute to child sexual abuse.

“People feel like we do not have any control over [sexual abuse], but we actually have a lot of control over this,” Ms. Harlow said.

This billboard in the Minneapolis-St. Paul area is credited with doubling the number of calls that an existing confidential helpline received each month. Courtesy Stop It Now! Minnesota

ATLANTA — The general perception is that society is at the mercy of sexual abusers and molesters, with little recourse besides knowing where they live.

But that view is not shared by experts and professionals in the field.

Prevention probably is possible, and treatment—which can break the cycle of the abused becoming abusers—can be effective, a group of those experts said at a meeting of the National Adolescent Perpetration Network. Actually, many who commit acts of child molestation want help and will seek it out, said Deborah Donovan-Rice, director of public policy for the Stop It Now! campaign.

Illustrating her contention, she said her group's Minnesota program had sponsored a single billboard in the Minneapolis-St. Paul area. The billboard had a simple design: It showed a man, with one hand on his forehead, gesturing anguish, and the other raised as if to ward something off. It asked: “Having sexual thoughts of children?”

Then, the billboard gave the number of the confidential helpline.

The billboard doubled the number of calls from Minnesota that the helpline had been receiving each month, Ms. Donovan-Rice said. It was not a slew of calls, but somewhere around 18. Even so, that is a big number for sexual abuse, she added.

“It's very exciting to think that the people who are having sexualized thoughts about children would call before they acted on those thoughts,” she said.

In addition, the organization has been conducting focus groups with people convicted of child sexual abuse crimes. It has found that many members of those groups state that they would have wanted help but did not know where to turn. Those individuals also often report that they had previously sought help for psychiatric problems, such as depression, meaning they were accessible to mental health professionals and thereby could have potentially been identified, Ms. Donovan-Rice said.

In an interview, Ms. Donovan-Rice said that Vermont was one of the first states in the country to establish a Stop It Now! chapter and helpline. The Vermont group also found that passage of the federal Megan's Law, which requires states to provide public information on where known sex offenders reside, had a noticeably chilling effect on calls to the helpline.

Prevention requires being able to identify the persons likely to commit sexual abuse, to target them with intervention. And a new, very large survey suggests there may be a way to do that, although with a fairly narrow window of opportunity, Nora Harlow, a researcher with the Child Molestation Research and Prevention Institute in Atlanta, said in another presentation at the meeting.

Ms. Harlow's institute has a database of sexual-interest screening test results from 13,000 adult males who admitted child sexual abuse, and 10,000 adolescents who also took the test for a variety of reasons.

The test, designed by Ms. Harlow's husband and partner in the institute, Dr. Gene Abel, is administered at more than 500 sites across the country and Canada, and it is used by law enforcement personnel, lawyers, counselors, and others. And it is set up so that all test results come back to a confidential database. A review of the results of the adult tests suggests that 84% of child victims of sexual abuse are abused by people who meet criteria for the DSM-IV diagnosis of pedophilia, Ms. Harlow said.

While that may seem obvious, it is an observation that could have tremendous implications, said Ms. Harlow, who noted that the diagnosis does not require that the individual has actually touched a child.

“This is huge,” she said. “It is very important for public health, because it is such a big cause. There are a zillion causes of lung cancer, but when we found smoking it changed our entire society.”

Further, the data show that 47% of the men reported having been abused themselves as children, a figure consistent with other research.

The data from the adolescents' tests show that among those who admitted sexually abusing another child (5,682 individuals) and who had been abused themselves, the average age of their own abuse was 7 years and the average age of their first abuse of someone else was 11 years, she noted.

Among the sexually abused adolescent males who had taken the test, 72% had sexually abused younger children, as had 54% of sexually abused adolescent females. Though those who are younger that 16 years cannot receive the diagnosis of pedophilia, the screening test found that about 40% of the adolescent abusers had pedophilia-like interest or fantasies about younger children.

This information suggests that child sexual abuse is an “an early onset disorder,” but one that does have markers that could be exploited for prevention, Ms. Harlow said at the meeting, which was sponsored by the University of Colorado.

Other relevant presentations at the meeting included two from representatives of the Centers for Disease Control and Prevention. Those officials noted that the CDC is actively working to improve some of the science about sexual abuse and abusers, to help design effective prevention efforts. And they described a dearth of information on sexual abuse, and the psychology behind it, despite an abundance of theories.

Presently, most studies of sexual abusers are limited case-control studies and none has followed the individuals for very long, said Daniel J. Whitaker, Ph.D., a behavioral scientist with the division of violence prevention at the CDC, who recently conducted a metaanalysis of the studies that have looked at the psychological profile of sexual abusers of children compared with other individuals.

Others were more optimistic about what could be achieved, right now, in the absence of a full understanding of the factors that contribute to child sexual abuse.

“People feel like we do not have any control over [sexual abuse], but we actually have a lot of control over this,” Ms. Harlow said.

This billboard in the Minneapolis-St. Paul area is credited with doubling the number of calls that an existing confidential helpline received each month. Courtesy Stop It Now! Minnesota

ATLANTA — The general perception is that society is at the mercy of sexual abusers and molesters, with little recourse besides knowing where they live.

But that view is not shared by experts and professionals in the field.

Prevention probably is possible, and treatment—which can break the cycle of the abused becoming abusers—can be effective, a group of those experts said at a meeting of the National Adolescent Perpetration Network. Actually, many who commit acts of child molestation want help and will seek it out, said Deborah Donovan-Rice, director of public policy for the Stop It Now! campaign.

Illustrating her contention, she said her group's Minnesota program had sponsored a single billboard in the Minneapolis-St. Paul area. The billboard had a simple design: It showed a man, with one hand on his forehead, gesturing anguish, and the other raised as if to ward something off. It asked: “Having sexual thoughts of children?”

Then, the billboard gave the number of the confidential helpline.

The billboard doubled the number of calls from Minnesota that the helpline had been receiving each month, Ms. Donovan-Rice said. It was not a slew of calls, but somewhere around 18. Even so, that is a big number for sexual abuse, she added.

“It's very exciting to think that the people who are having sexualized thoughts about children would call before they acted on those thoughts,” she said.

In addition, the organization has been conducting focus groups with people convicted of child sexual abuse crimes. It has found that many members of those groups state that they would have wanted help but did not know where to turn. Those individuals also often report that they had previously sought help for psychiatric problems, such as depression, meaning they were accessible to mental health professionals and thereby could have potentially been identified, Ms. Donovan-Rice said.

In an interview, Ms. Donovan-Rice said that Vermont was one of the first states in the country to establish a Stop It Now! chapter and helpline. The Vermont group also found that passage of the federal Megan's Law, which requires states to provide public information on where known sex offenders reside, had a noticeably chilling effect on calls to the helpline.

Prevention requires being able to identify the persons likely to commit sexual abuse, to target them with intervention. And a new, very large survey suggests there may be a way to do that, although with a fairly narrow window of opportunity, Nora Harlow, a researcher with the Child Molestation Research and Prevention Institute in Atlanta, said in another presentation at the meeting.

Ms. Harlow's institute has a database of sexual-interest screening test results from 13,000 adult males who admitted child sexual abuse, and 10,000 adolescents who also took the test for a variety of reasons.

The test, designed by Ms. Harlow's husband and partner in the institute, Dr. Gene Abel, is administered at more than 500 sites across the country and Canada, and it is used by law enforcement personnel, lawyers, counselors, and others. And it is set up so that all test results come back to a confidential database. A review of the results of the adult tests suggests that 84% of child victims of sexual abuse are abused by people who meet criteria for the DSM-IV diagnosis of pedophilia, Ms. Harlow said.

While that may seem obvious, it is an observation that could have tremendous implications, said Ms. Harlow, who noted that the diagnosis does not require that the individual has actually touched a child.

“This is huge,” she said. “It is very important for public health, because it is such a big cause. There are a zillion causes of lung cancer, but when we found smoking it changed our entire society.”

Further, the data show that 47% of the men reported having been abused themselves as children, a figure consistent with other research.

The data from the adolescents' tests show that among those who admitted sexually abusing another child (5,682 individuals) and who had been abused themselves, the average age of their own abuse was 7 years and the average age of their first abuse of someone else was 11 years, she noted.

Among the sexually abused adolescent males who had taken the test, 72% had sexually abused younger children, as had 54% of sexually abused adolescent females. Though those who are younger that 16 years cannot receive the diagnosis of pedophilia, the screening test found that about 40% of the adolescent abusers had pedophilia-like interest or fantasies about younger children.

This information suggests that child sexual abuse is an “an early onset disorder,” but one that does have markers that could be exploited for prevention, Ms. Harlow said at the meeting, which was sponsored by the University of Colorado.

Other relevant presentations at the meeting included two from representatives of the Centers for Disease Control and Prevention. Those officials noted that the CDC is actively working to improve some of the science about sexual abuse and abusers, to help design effective prevention efforts. And they described a dearth of information on sexual abuse, and the psychology behind it, despite an abundance of theories.

Presently, most studies of sexual abusers are limited case-control studies and none has followed the individuals for very long, said Daniel J. Whitaker, Ph.D., a behavioral scientist with the division of violence prevention at the CDC, who recently conducted a metaanalysis of the studies that have looked at the psychological profile of sexual abusers of children compared with other individuals.

Others were more optimistic about what could be achieved, right now, in the absence of a full understanding of the factors that contribute to child sexual abuse.

“People feel like we do not have any control over [sexual abuse], but we actually have a lot of control over this,” Ms. Harlow said.

This billboard in the Minneapolis-St. Paul area is credited with doubling the number of calls that an existing confidential helpline received each month. Courtesy Stop It Now! Minnesota

SOUTH LAKE TAHOE, CALIF. – The next time you see a patient with a migraine headache, you might want to try intranasal lidocaine, Dr. John Richards said at an emergency medicine conference sponsored by the University of California, Davis.

“It's a very easy block, and it doesn't involve a needle,” said Dr. Richards of the department of emergency medicine at the UC Davis Medical Center, Sacramento. “So it's worth a try.”

The literature on lidocaine treatment for migraine is not extensive, and at least one study found it to be of no benefit. But in some studies, lidocaine successfully resolved the migraine in 30%–50% of patients, with a relapse rate of about 20%.

Dr. Richards said he has had good experience with lidocaine. “I've had success with it for migraines, cluster headaches, and just headaches in general,” he said.

With cluster headaches, there usually is not complete relief, “but it does help them quite a bit,” he said.

The technique for treatment is to apply 4% lidocaine jelly to a long cotton swab, then aim the swab straight down the nasal canal all the way until it stops, on the side of the headache, or bilaterally if the headache is bilateral. The target is the sphenopalatine ganglion, which is located in the pterygopalatine fossa, posterior to the middle turbinate and inferior to the maxillary nerve. “It is covered by a small amount of mucous membrane [1.5 mm thick], so it is actually pretty easy to get to,” Dr. Richards said.

A second technique is to lay the patient back, with the head over the edge of the table at a 45-degree angle, and administer lidocaine drops, which will pool in the appropriate area. In one successful randomized trial, 10 drops were used, and the patients remained in their positions for 30 minutes, he said.

SOUTH LAKE TAHOE, CALIF. – The next time you see a patient with a migraine headache, you might want to try intranasal lidocaine, Dr. John Richards said at an emergency medicine conference sponsored by the University of California, Davis.

“It's a very easy block, and it doesn't involve a needle,” said Dr. Richards of the department of emergency medicine at the UC Davis Medical Center, Sacramento. “So it's worth a try.”

The literature on lidocaine treatment for migraine is not extensive, and at least one study found it to be of no benefit. But in some studies, lidocaine successfully resolved the migraine in 30%–50% of patients, with a relapse rate of about 20%.

Dr. Richards said he has had good experience with lidocaine. “I've had success with it for migraines, cluster headaches, and just headaches in general,” he said.

With cluster headaches, there usually is not complete relief, “but it does help them quite a bit,” he said.

The technique for treatment is to apply 4% lidocaine jelly to a long cotton swab, then aim the swab straight down the nasal canal all the way until it stops, on the side of the headache, or bilaterally if the headache is bilateral. The target is the sphenopalatine ganglion, which is located in the pterygopalatine fossa, posterior to the middle turbinate and inferior to the maxillary nerve. “It is covered by a small amount of mucous membrane [1.5 mm thick], so it is actually pretty easy to get to,” Dr. Richards said.

A second technique is to lay the patient back, with the head over the edge of the table at a 45-degree angle, and administer lidocaine drops, which will pool in the appropriate area. In one successful randomized trial, 10 drops were used, and the patients remained in their positions for 30 minutes, he said.

SOUTH LAKE TAHOE, CALIF. – The next time you see a patient with a migraine headache, you might want to try intranasal lidocaine, Dr. John Richards said at an emergency medicine conference sponsored by the University of California, Davis.

“It's a very easy block, and it doesn't involve a needle,” said Dr. Richards of the department of emergency medicine at the UC Davis Medical Center, Sacramento. “So it's worth a try.”

The literature on lidocaine treatment for migraine is not extensive, and at least one study found it to be of no benefit. But in some studies, lidocaine successfully resolved the migraine in 30%–50% of patients, with a relapse rate of about 20%.

Dr. Richards said he has had good experience with lidocaine. “I've had success with it for migraines, cluster headaches, and just headaches in general,” he said.

With cluster headaches, there usually is not complete relief, “but it does help them quite a bit,” he said.

The technique for treatment is to apply 4% lidocaine jelly to a long cotton swab, then aim the swab straight down the nasal canal all the way until it stops, on the side of the headache, or bilaterally if the headache is bilateral. The target is the sphenopalatine ganglion, which is located in the pterygopalatine fossa, posterior to the middle turbinate and inferior to the maxillary nerve. “It is covered by a small amount of mucous membrane [1.5 mm thick], so it is actually pretty easy to get to,” Dr. Richards said.

A second technique is to lay the patient back, with the head over the edge of the table at a 45-degree angle, and administer lidocaine drops, which will pool in the appropriate area. In one successful randomized trial, 10 drops were used, and the patients remained in their positions for 30 minutes, he said.

SAN DIEGO – The switch from the use of intramuscular buprenorphine to sublingual buprenorphine probably has improved the completion rate of short-term, inpatient opiate detoxification, according to the experience at the Center for Chemical Dependence at Johns Hopkins Bayview Medical Center, Baltimore.

When that 26-bed detoxification unit switched to sublingual buprenorphine, the withdrawal-treatment completion rate went from 73% in the 3 months before the change to 86% in the 3 months after, said Dr. Janet Soeffing of the center at the annual conference of the American Society of Addiction Medicine.

In the 3 months before the switch, which occurred in November 2004, 483 patients were admitted for opiate withdrawal and treated with intramuscular buprenorphine. In the 3 months after, 473 patients were admitted and treated with the sublingual agent.

Among a control group of patients who entered the unit but did not receive treatment for opioid dependence, the rates of treatment completion were 89% in the 3 months before November 2004 and 83% after, a difference that was not statistically significant, Dr. Soeffing said.

The patients who did not complete treatment either left against medical advice or were dismissed by staff for breaking the rules of the unit.

The administration protocol for the intramuscular buprenorphine was a standard one in which patients received 0.3 mg twice daily for 3 days.

The protocol for the sublingual buprenorphine was based on a regimen developed in Australia (Drug Alcohol Depend. 2003;70:287–94); patients received 8 mg the first and second day, 6 mg the third day, and 2 mg on the morning of discharge.

“There are some studies to suggest that the sublingual formulation of buprenorphine may be associated with a faster onset of action or even a greater bioavailability,” said Dr. Soeffing, speculating on the possible reason why completion improved. “But these studies are hard to replicate.”

The sublingual formulation was approved in this country in October 2002 and immediately began to replace intramuscular buprenorphine as the agent of choice for detoxifying, Dr. Soeffing said.

Withdrawal-treatment completion is extremely important because patients who fail to complete tend to drop out of the medical and dependence-recovery system altogether, Dr. Soeffing said.

Previous studies have shown that some of the factors associated with not completing withdrawal treatment include young age, a shorter duration of drug use, female sex, dual diagnosis, and the medication used for symptom control during withdrawal, she added.

SAN DIEGO – The switch from the use of intramuscular buprenorphine to sublingual buprenorphine probably has improved the completion rate of short-term, inpatient opiate detoxification, according to the experience at the Center for Chemical Dependence at Johns Hopkins Bayview Medical Center, Baltimore.

When that 26-bed detoxification unit switched to sublingual buprenorphine, the withdrawal-treatment completion rate went from 73% in the 3 months before the change to 86% in the 3 months after, said Dr. Janet Soeffing of the center at the annual conference of the American Society of Addiction Medicine.

In the 3 months before the switch, which occurred in November 2004, 483 patients were admitted for opiate withdrawal and treated with intramuscular buprenorphine. In the 3 months after, 473 patients were admitted and treated with the sublingual agent.

Among a control group of patients who entered the unit but did not receive treatment for opioid dependence, the rates of treatment completion were 89% in the 3 months before November 2004 and 83% after, a difference that was not statistically significant, Dr. Soeffing said.

The patients who did not complete treatment either left against medical advice or were dismissed by staff for breaking the rules of the unit.

The administration protocol for the intramuscular buprenorphine was a standard one in which patients received 0.3 mg twice daily for 3 days.

The protocol for the sublingual buprenorphine was based on a regimen developed in Australia (Drug Alcohol Depend. 2003;70:287–94); patients received 8 mg the first and second day, 6 mg the third day, and 2 mg on the morning of discharge.

“There are some studies to suggest that the sublingual formulation of buprenorphine may be associated with a faster onset of action or even a greater bioavailability,” said Dr. Soeffing, speculating on the possible reason why completion improved. “But these studies are hard to replicate.”

The sublingual formulation was approved in this country in October 2002 and immediately began to replace intramuscular buprenorphine as the agent of choice for detoxifying, Dr. Soeffing said.

Withdrawal-treatment completion is extremely important because patients who fail to complete tend to drop out of the medical and dependence-recovery system altogether, Dr. Soeffing said.

Previous studies have shown that some of the factors associated with not completing withdrawal treatment include young age, a shorter duration of drug use, female sex, dual diagnosis, and the medication used for symptom control during withdrawal, she added.

SAN DIEGO – The switch from the use of intramuscular buprenorphine to sublingual buprenorphine probably has improved the completion rate of short-term, inpatient opiate detoxification, according to the experience at the Center for Chemical Dependence at Johns Hopkins Bayview Medical Center, Baltimore.

When that 26-bed detoxification unit switched to sublingual buprenorphine, the withdrawal-treatment completion rate went from 73% in the 3 months before the change to 86% in the 3 months after, said Dr. Janet Soeffing of the center at the annual conference of the American Society of Addiction Medicine.

In the 3 months before the switch, which occurred in November 2004, 483 patients were admitted for opiate withdrawal and treated with intramuscular buprenorphine. In the 3 months after, 473 patients were admitted and treated with the sublingual agent.

Among a control group of patients who entered the unit but did not receive treatment for opioid dependence, the rates of treatment completion were 89% in the 3 months before November 2004 and 83% after, a difference that was not statistically significant, Dr. Soeffing said.

The patients who did not complete treatment either left against medical advice or were dismissed by staff for breaking the rules of the unit.

The administration protocol for the intramuscular buprenorphine was a standard one in which patients received 0.3 mg twice daily for 3 days.

The protocol for the sublingual buprenorphine was based on a regimen developed in Australia (Drug Alcohol Depend. 2003;70:287–94); patients received 8 mg the first and second day, 6 mg the third day, and 2 mg on the morning of discharge.

“There are some studies to suggest that the sublingual formulation of buprenorphine may be associated with a faster onset of action or even a greater bioavailability,” said Dr. Soeffing, speculating on the possible reason why completion improved. “But these studies are hard to replicate.”

The sublingual formulation was approved in this country in October 2002 and immediately began to replace intramuscular buprenorphine as the agent of choice for detoxifying, Dr. Soeffing said.

Withdrawal-treatment completion is extremely important because patients who fail to complete tend to drop out of the medical and dependence-recovery system altogether, Dr. Soeffing said.

Previous studies have shown that some of the factors associated with not completing withdrawal treatment include young age, a shorter duration of drug use, female sex, dual diagnosis, and the medication used for symptom control during withdrawal, she added.