Timothy F. Kirn

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 into 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, there are about 7,000 physicians who 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 inducted onto 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.

Ms. Curry said there are reports that Suboxone is available on the streets and that it 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 into 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, there are about 7,000 physicians who 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 inducted onto 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.

Ms. Curry said there are reports that Suboxone is available on the streets and that it 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 into 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, there are about 7,000 physicians who 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 inducted onto 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.

Ms. Curry said there are reports that Suboxone is available on the streets and that it 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 – The new long-acting, injectable formulation of naltrexone takes effect rapidly and probably does not need to be combined with an oral dose to prevent alcohol-dependent patients from early hazardous drinking, according to a company presentation at the annual meeting of the American Society of Addiction Medicine.

Nor does it appear that treating a person with the new formulation decreases their motivation to attend self-help meetings such as those sponsored by Alcoholics Anonymous (AA), according to another presentation.

In a subgroup analysis of the 624 subjects in the randomized, placebo-controlled trial of injectable, extended-release naltrexone (Vivitrol) conducted for the formulation's approval, drinking was reduced significantly in just 2 days after the injection, said Dr. Domenic A. Ciraulo, professor of psychiatry at Boston University, in a poster presentation.

Two days after the first injection, the median number of drinks taken by those 209 subjects who received placebo was two. That compared with a median of one drink for the group of 210 subjects who received an injection dose of 190 mg, and a median of no drinks in the group of 205 subjects who received an injection dose of 380 mg, the dose that was approved.

Moreover, to be enrolled in the study, the subjects had to report a minimum of 2 days per week of “heavy” drinking in the month before they were screened, with heavy drinking being defined as a day in which male subjects had five or more drinks and female subjects had four or more drinks.

But in the first 3 days after the injection, while 35% of the subjects who received placebo reported a heavy drinking day, 32% of the subjects who received the lower dose and 20% of the subjects who received the higher dose reported a heavy drinking day.

The difference between the placebo and the high-dose percentages is statistically significant, Dr. Ciraulo said.

Of note, about 90% of the subjects enrolled in the study were not abstinent when they received their first injection, and only 43% stated that their goal was abstinence.

During the first month of treatment, the median number of heavy drinking days was 6.5 for the placebo group, 5.7 for the low-dose group, and 4.1 for the high-dose group. That compared with a baseline of a median of 19 heavy drinking days per month before treatment.

Pharmacokinetic data from healthy volunteers show that the peak plasma concentration of extended-release naltrexone is reached on day 3 after injection, at about 27–28 ng/mL, and then falls thereafter, reaching 1 ng/mL, the minimum concentration thought to be effective, on day 30, Dr. Ciraulo said in the poster.

The analysis suggests that one does not need to give oral naltrexone to patients starting treatment in order to carry them over until the injectable, timed-release formulation takes over, and for most patients, the long-acting naltrexone treatment is going to have significant advantages over oral naltrexone, Dr. Ciraulo said in an interview.

“With depot agents, you never know about release,” he said. “In my clinical practice, I would go to this [extended-release formulation] first.”

Injectable, extended-release naltrexone was approved by the Food and Drug Administration in April. The approval is for one intramuscular, gluteal injection every 30 days.

In the 624 patient study, funded and conducted by Alkermes Inc., Cambridge, Mass., patients were treated for 6 months. The study found a 48% greater reduction in heavy drinking days with the high-dose regimen, compared with placebo.

The median number of days of heavy drinking, which had been about 19 days per month prior to treatment, dropped to 6 days per month in the placebo group and to about 3 days in the group on high-dose naltrexone.

Sixty-four percent of the study subjects remained compliant in the study and received all six doses of medication.

The other study presented at the meeting looked at whether that success with the medication inspired complacency.

But if anything, it seemed to be associated with a “trickle-up effect,” said Dr. David R. Gastfriend, a vice president of Alkermes.

In the month before treatment, 11% of the subjects attended a self-help group such as AA. During the trial, 10% of the placebo-treated patients attended such groups each month, as did 11% of those subjects who received the low-dose injections and 13% of those who received the high dose.

Moreover, among the patients who had some abstinence going into the study, reductions in drinking were even greater than for the study population overall, Dr. Gastfriend said.

Eighty-two subjects had 4 days of abstinence leading into their first injection; 53 patients had 7 days of abstinence.

In the patients with 4 days of abstinence, the median number of days to their first drink following treatment initiation was 12 days in the placebo group (28 subjects), 24 days for the low-dose group (26 subjects), and 42 days for the high-dose group (28 subjects).

In the patients with 7 days of abstinence, the median was 84 days for the high-dose group (17 subjects).

The groups with 4 and 7 days of abstinence who received the high dose both also reduced their median days of heavy drinking per month to 0.2 days.

SAN DIEGO – The new long-acting, injectable formulation of naltrexone takes effect rapidly and probably does not need to be combined with an oral dose to prevent alcohol-dependent patients from early hazardous drinking, according to a company presentation at the annual meeting of the American Society of Addiction Medicine.

Nor does it appear that treating a person with the new formulation decreases their motivation to attend self-help meetings such as those sponsored by Alcoholics Anonymous (AA), according to another presentation.

In a subgroup analysis of the 624 subjects in the randomized, placebo-controlled trial of injectable, extended-release naltrexone (Vivitrol) conducted for the formulation's approval, drinking was reduced significantly in just 2 days after the injection, said Dr. Domenic A. Ciraulo, professor of psychiatry at Boston University, in a poster presentation.

Two days after the first injection, the median number of drinks taken by those 209 subjects who received placebo was two. That compared with a median of one drink for the group of 210 subjects who received an injection dose of 190 mg, and a median of no drinks in the group of 205 subjects who received an injection dose of 380 mg, the dose that was approved.

Moreover, to be enrolled in the study, the subjects had to report a minimum of 2 days per week of “heavy” drinking in the month before they were screened, with heavy drinking being defined as a day in which male subjects had five or more drinks and female subjects had four or more drinks.

But in the first 3 days after the injection, while 35% of the subjects who received placebo reported a heavy drinking day, 32% of the subjects who received the lower dose and 20% of the subjects who received the higher dose reported a heavy drinking day.

The difference between the placebo and the high-dose percentages is statistically significant, Dr. Ciraulo said.

Of note, about 90% of the subjects enrolled in the study were not abstinent when they received their first injection, and only 43% stated that their goal was abstinence.

During the first month of treatment, the median number of heavy drinking days was 6.5 for the placebo group, 5.7 for the low-dose group, and 4.1 for the high-dose group. That compared with a baseline of a median of 19 heavy drinking days per month before treatment.

Pharmacokinetic data from healthy volunteers show that the peak plasma concentration of extended-release naltrexone is reached on day 3 after injection, at about 27–28 ng/mL, and then falls thereafter, reaching 1 ng/mL, the minimum concentration thought to be effective, on day 30, Dr. Ciraulo said in the poster.

The analysis suggests that one does not need to give oral naltrexone to patients starting treatment in order to carry them over until the injectable, timed-release formulation takes over, and for most patients, the long-acting naltrexone treatment is going to have significant advantages over oral naltrexone, Dr. Ciraulo said in an interview.

“With depot agents, you never know about release,” he said. “In my clinical practice, I would go to this [extended-release formulation] first.”

Injectable, extended-release naltrexone was approved by the Food and Drug Administration in April. The approval is for one intramuscular, gluteal injection every 30 days.

In the 624 patient study, funded and conducted by Alkermes Inc., Cambridge, Mass., patients were treated for 6 months. The study found a 48% greater reduction in heavy drinking days with the high-dose regimen, compared with placebo.

The median number of days of heavy drinking, which had been about 19 days per month prior to treatment, dropped to 6 days per month in the placebo group and to about 3 days in the group on high-dose naltrexone.

Sixty-four percent of the study subjects remained compliant in the study and received all six doses of medication.

The other study presented at the meeting looked at whether that success with the medication inspired complacency.

But if anything, it seemed to be associated with a “trickle-up effect,” said Dr. David R. Gastfriend, a vice president of Alkermes.

In the month before treatment, 11% of the subjects attended a self-help group such as AA. During the trial, 10% of the placebo-treated patients attended such groups each month, as did 11% of those subjects who received the low-dose injections and 13% of those who received the high dose.

Moreover, among the patients who had some abstinence going into the study, reductions in drinking were even greater than for the study population overall, Dr. Gastfriend said.

Eighty-two subjects had 4 days of abstinence leading into their first injection; 53 patients had 7 days of abstinence.

In the patients with 4 days of abstinence, the median number of days to their first drink following treatment initiation was 12 days in the placebo group (28 subjects), 24 days for the low-dose group (26 subjects), and 42 days for the high-dose group (28 subjects).

In the patients with 7 days of abstinence, the median was 84 days for the high-dose group (17 subjects).

The groups with 4 and 7 days of abstinence who received the high dose both also reduced their median days of heavy drinking per month to 0.2 days.

SAN DIEGO – The new long-acting, injectable formulation of naltrexone takes effect rapidly and probably does not need to be combined with an oral dose to prevent alcohol-dependent patients from early hazardous drinking, according to a company presentation at the annual meeting of the American Society of Addiction Medicine.

Nor does it appear that treating a person with the new formulation decreases their motivation to attend self-help meetings such as those sponsored by Alcoholics Anonymous (AA), according to another presentation.

In a subgroup analysis of the 624 subjects in the randomized, placebo-controlled trial of injectable, extended-release naltrexone (Vivitrol) conducted for the formulation's approval, drinking was reduced significantly in just 2 days after the injection, said Dr. Domenic A. Ciraulo, professor of psychiatry at Boston University, in a poster presentation.

Two days after the first injection, the median number of drinks taken by those 209 subjects who received placebo was two. That compared with a median of one drink for the group of 210 subjects who received an injection dose of 190 mg, and a median of no drinks in the group of 205 subjects who received an injection dose of 380 mg, the dose that was approved.

Moreover, to be enrolled in the study, the subjects had to report a minimum of 2 days per week of “heavy” drinking in the month before they were screened, with heavy drinking being defined as a day in which male subjects had five or more drinks and female subjects had four or more drinks.

But in the first 3 days after the injection, while 35% of the subjects who received placebo reported a heavy drinking day, 32% of the subjects who received the lower dose and 20% of the subjects who received the higher dose reported a heavy drinking day.

The difference between the placebo and the high-dose percentages is statistically significant, Dr. Ciraulo said.

Of note, about 90% of the subjects enrolled in the study were not abstinent when they received their first injection, and only 43% stated that their goal was abstinence.

During the first month of treatment, the median number of heavy drinking days was 6.5 for the placebo group, 5.7 for the low-dose group, and 4.1 for the high-dose group. That compared with a baseline of a median of 19 heavy drinking days per month before treatment.

Pharmacokinetic data from healthy volunteers show that the peak plasma concentration of extended-release naltrexone is reached on day 3 after injection, at about 27–28 ng/mL, and then falls thereafter, reaching 1 ng/mL, the minimum concentration thought to be effective, on day 30, Dr. Ciraulo said in the poster.

The analysis suggests that one does not need to give oral naltrexone to patients starting treatment in order to carry them over until the injectable, timed-release formulation takes over, and for most patients, the long-acting naltrexone treatment is going to have significant advantages over oral naltrexone, Dr. Ciraulo said in an interview.

“With depot agents, you never know about release,” he said. “In my clinical practice, I would go to this [extended-release formulation] first.”

Injectable, extended-release naltrexone was approved by the Food and Drug Administration in April. The approval is for one intramuscular, gluteal injection every 30 days.

In the 624 patient study, funded and conducted by Alkermes Inc., Cambridge, Mass., patients were treated for 6 months. The study found a 48% greater reduction in heavy drinking days with the high-dose regimen, compared with placebo.

The median number of days of heavy drinking, which had been about 19 days per month prior to treatment, dropped to 6 days per month in the placebo group and to about 3 days in the group on high-dose naltrexone.

Sixty-four percent of the study subjects remained compliant in the study and received all six doses of medication.

The other study presented at the meeting looked at whether that success with the medication inspired complacency.

But if anything, it seemed to be associated with a “trickle-up effect,” said Dr. David R. Gastfriend, a vice president of Alkermes.

In the month before treatment, 11% of the subjects attended a self-help group such as AA. During the trial, 10% of the placebo-treated patients attended such groups each month, as did 11% of those subjects who received the low-dose injections and 13% of those who received the high dose.

Moreover, among the patients who had some abstinence going into the study, reductions in drinking were even greater than for the study population overall, Dr. Gastfriend said.

Eighty-two subjects had 4 days of abstinence leading into their first injection; 53 patients had 7 days of abstinence.

In the patients with 4 days of abstinence, the median number of days to their first drink following treatment initiation was 12 days in the placebo group (28 subjects), 24 days for the low-dose group (26 subjects), and 42 days for the high-dose group (28 subjects).

In the patients with 7 days of abstinence, the median was 84 days for the high-dose group (17 subjects).

The groups with 4 and 7 days of abstinence who received the high dose both also reduced their median days of heavy drinking per month to 0.2 days.

SCOTTSDALE, ARIZ. – Most physicians who treat alcohol-dependent patients know that studies have shown that depressed patients are much less likely to quit, or reduce, their drinking.

It is less well known that treating depression in these patients can improve alcohol treatment results, Dr. Edward V. Nunes said at the annual meeting of the American Academy of Addiction Psychiatry. “The evidence shows if you do careful diagnosis–preferably in the setting of abstinence, but not absolutely so–treatment works,” said Dr. Nunes, research director at the Substance Treatment and Research Service, New York.

Until fairly recently, treating depression in alcoholic patients has not been a standard practice, because researchers have had difficulty proving that it had any benefit, said Dr. Nunes, who reviewed the history of the research. Studies conducted before the 1980s were mostly inconsistent, largely because of the absence of a standardized diagnosis for depression that differentiated the depressive effects of heavy alcohol use from primary depression in a person abusing alcohol, said Dr. Nunes, who also is a psychiatrist at the New York State Psychiatric Institute.

Then the use of selective serotonin reuptake inhibitors (SSRIs) came into practice. But studies with SSRIs were generally seen as disappointing. Researchers interpreted study results to mean that the drugs appeared to reduce drinking behavior but had little impact on mood.

One study even suggested that SSRI treatment might increase drinking behavior in individuals with early onset alcoholism. So, for a while it was thought that depression treatment was irrelevant to people seeking help with an alcohol problem.

A study conducted by Dr. Nunes helped rekindle the idea of addressing depression in alcohol abusers. He gave imipramine to a group of alcoholic patients who appeared to have depression. He then continued the study with the patients who responded to the treatment to potentially identify only those who had a true primary depression. These patients were randomized to continued treatment or to placebo. Patients who were switched to placebo tended to get worse and relapse, whereas, those who remained on imipramine continued to respond (Am. J. Psychiatry 1993;150:963–5).

The study has since been replicated, without the first phase, using instead a newly available diagnostic tool that helps identify primary depression from alcohol-induced depression, he said (Arch. Gen. Psychiatry 1996;53:232–40).

The more recent study suggested a response rate of 50% with imipramine treatment, compared with 25% for patients on placebo. Though the number of patients who achieved complete abstinence from alcohol was low, the study was able to show that drinking decreased and that mood was correlated with drinking behavior.

Recently, Dr. Nunes conducted a literature review and an analysis of 14 of the most rigorously conducted trials of depression treatment in substance abusers (mostly alcoholics), out of the 44 placebo-controlled trials identified in the review (JAMA 2004;291:1887–96).

Overall, the data from those studies suggest that drug treatment for depression has a significant benefit, as measured by Hamilton Depression Scale scores. Not surprisingly, the benefit is similar in degree to that seen in drug studies for general depression: Fifty percent of treated patients showed improvement, compared with 30% of placebo controls.

Deeper analysis showed that the six studies that failed to show a benefit from treatment tended to have high placebo response rates, in the range of 40%–60%. This suggests that perhaps the placebo response masked the true response.

These six studies also tended to have patients receive structured alcohol treatment psychotherapy, which probably alleviated some depression and increased the placebo-response rate, Dr. Nunes said.

SCOTTSDALE, ARIZ. – Most physicians who treat alcohol-dependent patients know that studies have shown that depressed patients are much less likely to quit, or reduce, their drinking.

It is less well known that treating depression in these patients can improve alcohol treatment results, Dr. Edward V. Nunes said at the annual meeting of the American Academy of Addiction Psychiatry. “The evidence shows if you do careful diagnosis–preferably in the setting of abstinence, but not absolutely so–treatment works,” said Dr. Nunes, research director at the Substance Treatment and Research Service, New York.

Until fairly recently, treating depression in alcoholic patients has not been a standard practice, because researchers have had difficulty proving that it had any benefit, said Dr. Nunes, who reviewed the history of the research. Studies conducted before the 1980s were mostly inconsistent, largely because of the absence of a standardized diagnosis for depression that differentiated the depressive effects of heavy alcohol use from primary depression in a person abusing alcohol, said Dr. Nunes, who also is a psychiatrist at the New York State Psychiatric Institute.

Then the use of selective serotonin reuptake inhibitors (SSRIs) came into practice. But studies with SSRIs were generally seen as disappointing. Researchers interpreted study results to mean that the drugs appeared to reduce drinking behavior but had little impact on mood.

One study even suggested that SSRI treatment might increase drinking behavior in individuals with early onset alcoholism. So, for a while it was thought that depression treatment was irrelevant to people seeking help with an alcohol problem.

A study conducted by Dr. Nunes helped rekindle the idea of addressing depression in alcohol abusers. He gave imipramine to a group of alcoholic patients who appeared to have depression. He then continued the study with the patients who responded to the treatment to potentially identify only those who had a true primary depression. These patients were randomized to continued treatment or to placebo. Patients who were switched to placebo tended to get worse and relapse, whereas, those who remained on imipramine continued to respond (Am. J. Psychiatry 1993;150:963–5).

The study has since been replicated, without the first phase, using instead a newly available diagnostic tool that helps identify primary depression from alcohol-induced depression, he said (Arch. Gen. Psychiatry 1996;53:232–40).

The more recent study suggested a response rate of 50% with imipramine treatment, compared with 25% for patients on placebo. Though the number of patients who achieved complete abstinence from alcohol was low, the study was able to show that drinking decreased and that mood was correlated with drinking behavior.

Recently, Dr. Nunes conducted a literature review and an analysis of 14 of the most rigorously conducted trials of depression treatment in substance abusers (mostly alcoholics), out of the 44 placebo-controlled trials identified in the review (JAMA 2004;291:1887–96).

Overall, the data from those studies suggest that drug treatment for depression has a significant benefit, as measured by Hamilton Depression Scale scores. Not surprisingly, the benefit is similar in degree to that seen in drug studies for general depression: Fifty percent of treated patients showed improvement, compared with 30% of placebo controls.

Deeper analysis showed that the six studies that failed to show a benefit from treatment tended to have high placebo response rates, in the range of 40%–60%. This suggests that perhaps the placebo response masked the true response.

These six studies also tended to have patients receive structured alcohol treatment psychotherapy, which probably alleviated some depression and increased the placebo-response rate, Dr. Nunes said.

SCOTTSDALE, ARIZ. – Most physicians who treat alcohol-dependent patients know that studies have shown that depressed patients are much less likely to quit, or reduce, their drinking.

It is less well known that treating depression in these patients can improve alcohol treatment results, Dr. Edward V. Nunes said at the annual meeting of the American Academy of Addiction Psychiatry. “The evidence shows if you do careful diagnosis–preferably in the setting of abstinence, but not absolutely so–treatment works,” said Dr. Nunes, research director at the Substance Treatment and Research Service, New York.

Until fairly recently, treating depression in alcoholic patients has not been a standard practice, because researchers have had difficulty proving that it had any benefit, said Dr. Nunes, who reviewed the history of the research. Studies conducted before the 1980s were mostly inconsistent, largely because of the absence of a standardized diagnosis for depression that differentiated the depressive effects of heavy alcohol use from primary depression in a person abusing alcohol, said Dr. Nunes, who also is a psychiatrist at the New York State Psychiatric Institute.

Then the use of selective serotonin reuptake inhibitors (SSRIs) came into practice. But studies with SSRIs were generally seen as disappointing. Researchers interpreted study results to mean that the drugs appeared to reduce drinking behavior but had little impact on mood.

One study even suggested that SSRI treatment might increase drinking behavior in individuals with early onset alcoholism. So, for a while it was thought that depression treatment was irrelevant to people seeking help with an alcohol problem.

A study conducted by Dr. Nunes helped rekindle the idea of addressing depression in alcohol abusers. He gave imipramine to a group of alcoholic patients who appeared to have depression. He then continued the study with the patients who responded to the treatment to potentially identify only those who had a true primary depression. These patients were randomized to continued treatment or to placebo. Patients who were switched to placebo tended to get worse and relapse, whereas, those who remained on imipramine continued to respond (Am. J. Psychiatry 1993;150:963–5).

The study has since been replicated, without the first phase, using instead a newly available diagnostic tool that helps identify primary depression from alcohol-induced depression, he said (Arch. Gen. Psychiatry 1996;53:232–40).

The more recent study suggested a response rate of 50% with imipramine treatment, compared with 25% for patients on placebo. Though the number of patients who achieved complete abstinence from alcohol was low, the study was able to show that drinking decreased and that mood was correlated with drinking behavior.

Recently, Dr. Nunes conducted a literature review and an analysis of 14 of the most rigorously conducted trials of depression treatment in substance abusers (mostly alcoholics), out of the 44 placebo-controlled trials identified in the review (JAMA 2004;291:1887–96).

Overall, the data from those studies suggest that drug treatment for depression has a significant benefit, as measured by Hamilton Depression Scale scores. Not surprisingly, the benefit is similar in degree to that seen in drug studies for general depression: Fifty percent of treated patients showed improvement, compared with 30% of placebo controls.

Deeper analysis showed that the six studies that failed to show a benefit from treatment tended to have high placebo response rates, in the range of 40%–60%. This suggests that perhaps the placebo response masked the true response.

These six studies also tended to have patients receive structured alcohol treatment psychotherapy, which probably alleviated some depression and increased the placebo-response rate, Dr. Nunes said.

SCOTTSDALE, ARIZ. – Sometimes an alcohol abuser prescribed a medication such as disulfiram, acamprosate, or naltrexone has no improvement in their drinking behavior. Sometimes the reason is that the patient has not been adherent to the medication, but not willfully so. In those cases, there are strategies a physician can use to help, Dr. Roger D. Weiss said at the annual meeting of the American Academy of Addiction Psychiatry.

No one knows for sure what level of adherence is necessary for the drugs used to treat alcohol dependence, and it is probably different for each drug, but it is clear that adherence does dictate efficacy, said Dr. Weiss, clinical director of the alcohol and drug abuse treatment program at McLean Hospital in Belmont, Mass.

In a classic study of disulfiram, patients who were largely adherent to their medication had an 80% likelihood of becoming abstinent during the study, whereas those who were nonadherent had only a 20% chance. Most patients were nonadherent, Dr. Weiss said.

In a study of naltrexone treatment, the relapse rates were 10% for those adherent to naltrexone and 34% for those adherent to placebo. But in nonadherent patients, the relapse rates were roughly the same: 42% and 40%.

When a patient's treatment is not working, the treating physician needs to ask about adherence, Dr. Weiss said. He said he does not ask the patient if he or she is taking their medication. Instead, he asks, “How much are you taking your medication?” The more specific question invites discussion that can be enlightening.

“By doing that, I found a lot of people who are taking more than prescribed, less than prescribed, and all kinds of odd dosing patterns,” he said.

Nonadherence can involve patients who, often because they are impatient, take too much of a medication, and this can be as big a problem as omission because they run out or develop side effects that discourage them from continuing the regimen.

Dr. Weiss said he also keeps in mind that patients tend to exaggerate their adherence, for a variety of reasons apart from conscious deception, and that the most common reason patients miss a dose of medication is that they forget–and then they forget that they forgot.

When the patient is nonadherent, possible strategies include:

▸ Reeducation. Be certain the patient understands his or her condition, the need for the medication, and the importance of following the drug regimen, Dr. Weiss recommended. If the physician has doubts or uncertainty about a medication, that can be communicated to the patient and needs to be dealt with. As with all medications, the placebo effect and the commitment the patient makes to their treatment can be the most important components of the treatment's success.

▸ More appointments. Patients tend to be most adherent during the 5 days preceding and the 5 days after a doctor visit, a well-known phenomenon waggishly known as “white-coat adherence.”

▸ Reminders. Notes on the bathroom mirror, pillboxes with individual wells for each day of the week or month, and alarm watches help forgetful patients remember.

▸ Education of the family. Family members who are aware of the condition and need for medication can be strong allies.

▸ Mutual thanking. One research study of alcohol-dependent patients and their significant others developed a script for reminding patients to take their medication, which was disulfiram. This strategy has since come to be known as the “Antabuse contract.”

According to the study's script, the significant other first gently reminded the patient when it was time to take the medication. When the patient took the medication, he or she thanked the other for the reminder. The significant other then thanked the patient for taking the medication.

One crucial part of this contract was that the couple was not allowed to discuss any past drinking or future drinking events. Although the participants found the interaction uncomfortable initially, the researchers showed that it improved not only outcomes, but relationship satisfaction as well.

▸ Simple regimens. Even patients with diabetes or asthma are adherent to their medications only an average of 40%–60% of the time. And full adherence to a regimen drops dramatically when once-daily dosing is changed to twice-daily dosing. That means long-acting medications are more forgiving than short-acting ones. A depot formulation of naltrexone has recently been developed, and when it becomes available, it could be extremely useful for nonadherent patients, Dr. Weiss said. In a recent 6-month trial of once-monthly injections, 74% of patients came in and received between four and six of their injections, and 64% received all six (100% adherence). Overall, the median number of heavy drinking days declined 48%.

▸ Blood levels. Measuring blood levels, even when possible, is expensive but not practical or entirely foolproof, because patients may be more adherent than usual before an appointment. Still, it is an option, Dr. Weiss said.

SCOTTSDALE, ARIZ. – Sometimes an alcohol abuser prescribed a medication such as disulfiram, acamprosate, or naltrexone has no improvement in their drinking behavior. Sometimes the reason is that the patient has not been adherent to the medication, but not willfully so. In those cases, there are strategies a physician can use to help, Dr. Roger D. Weiss said at the annual meeting of the American Academy of Addiction Psychiatry.

No one knows for sure what level of adherence is necessary for the drugs used to treat alcohol dependence, and it is probably different for each drug, but it is clear that adherence does dictate efficacy, said Dr. Weiss, clinical director of the alcohol and drug abuse treatment program at McLean Hospital in Belmont, Mass.

In a classic study of disulfiram, patients who were largely adherent to their medication had an 80% likelihood of becoming abstinent during the study, whereas those who were nonadherent had only a 20% chance. Most patients were nonadherent, Dr. Weiss said.

In a study of naltrexone treatment, the relapse rates were 10% for those adherent to naltrexone and 34% for those adherent to placebo. But in nonadherent patients, the relapse rates were roughly the same: 42% and 40%.

When a patient's treatment is not working, the treating physician needs to ask about adherence, Dr. Weiss said. He said he does not ask the patient if he or she is taking their medication. Instead, he asks, “How much are you taking your medication?” The more specific question invites discussion that can be enlightening.

“By doing that, I found a lot of people who are taking more than prescribed, less than prescribed, and all kinds of odd dosing patterns,” he said.

Nonadherence can involve patients who, often because they are impatient, take too much of a medication, and this can be as big a problem as omission because they run out or develop side effects that discourage them from continuing the regimen.

Dr. Weiss said he also keeps in mind that patients tend to exaggerate their adherence, for a variety of reasons apart from conscious deception, and that the most common reason patients miss a dose of medication is that they forget–and then they forget that they forgot.

When the patient is nonadherent, possible strategies include:

▸ Reeducation. Be certain the patient understands his or her condition, the need for the medication, and the importance of following the drug regimen, Dr. Weiss recommended. If the physician has doubts or uncertainty about a medication, that can be communicated to the patient and needs to be dealt with. As with all medications, the placebo effect and the commitment the patient makes to their treatment can be the most important components of the treatment's success.

▸ More appointments. Patients tend to be most adherent during the 5 days preceding and the 5 days after a doctor visit, a well-known phenomenon waggishly known as “white-coat adherence.”

▸ Reminders. Notes on the bathroom mirror, pillboxes with individual wells for each day of the week or month, and alarm watches help forgetful patients remember.

▸ Education of the family. Family members who are aware of the condition and need for medication can be strong allies.

▸ Mutual thanking. One research study of alcohol-dependent patients and their significant others developed a script for reminding patients to take their medication, which was disulfiram. This strategy has since come to be known as the “Antabuse contract.”

According to the study's script, the significant other first gently reminded the patient when it was time to take the medication. When the patient took the medication, he or she thanked the other for the reminder. The significant other then thanked the patient for taking the medication.

One crucial part of this contract was that the couple was not allowed to discuss any past drinking or future drinking events. Although the participants found the interaction uncomfortable initially, the researchers showed that it improved not only outcomes, but relationship satisfaction as well.

▸ Simple regimens. Even patients with diabetes or asthma are adherent to their medications only an average of 40%–60% of the time. And full adherence to a regimen drops dramatically when once-daily dosing is changed to twice-daily dosing. That means long-acting medications are more forgiving than short-acting ones. A depot formulation of naltrexone has recently been developed, and when it becomes available, it could be extremely useful for nonadherent patients, Dr. Weiss said. In a recent 6-month trial of once-monthly injections, 74% of patients came in and received between four and six of their injections, and 64% received all six (100% adherence). Overall, the median number of heavy drinking days declined 48%.

▸ Blood levels. Measuring blood levels, even when possible, is expensive but not practical or entirely foolproof, because patients may be more adherent than usual before an appointment. Still, it is an option, Dr. Weiss said.

SCOTTSDALE, ARIZ. – Sometimes an alcohol abuser prescribed a medication such as disulfiram, acamprosate, or naltrexone has no improvement in their drinking behavior. Sometimes the reason is that the patient has not been adherent to the medication, but not willfully so. In those cases, there are strategies a physician can use to help, Dr. Roger D. Weiss said at the annual meeting of the American Academy of Addiction Psychiatry.

No one knows for sure what level of adherence is necessary for the drugs used to treat alcohol dependence, and it is probably different for each drug, but it is clear that adherence does dictate efficacy, said Dr. Weiss, clinical director of the alcohol and drug abuse treatment program at McLean Hospital in Belmont, Mass.

In a classic study of disulfiram, patients who were largely adherent to their medication had an 80% likelihood of becoming abstinent during the study, whereas those who were nonadherent had only a 20% chance. Most patients were nonadherent, Dr. Weiss said.

In a study of naltrexone treatment, the relapse rates were 10% for those adherent to naltrexone and 34% for those adherent to placebo. But in nonadherent patients, the relapse rates were roughly the same: 42% and 40%.

When a patient's treatment is not working, the treating physician needs to ask about adherence, Dr. Weiss said. He said he does not ask the patient if he or she is taking their medication. Instead, he asks, “How much are you taking your medication?” The more specific question invites discussion that can be enlightening.

“By doing that, I found a lot of people who are taking more than prescribed, less than prescribed, and all kinds of odd dosing patterns,” he said.

Nonadherence can involve patients who, often because they are impatient, take too much of a medication, and this can be as big a problem as omission because they run out or develop side effects that discourage them from continuing the regimen.

Dr. Weiss said he also keeps in mind that patients tend to exaggerate their adherence, for a variety of reasons apart from conscious deception, and that the most common reason patients miss a dose of medication is that they forget–and then they forget that they forgot.

When the patient is nonadherent, possible strategies include:

▸ Reeducation. Be certain the patient understands his or her condition, the need for the medication, and the importance of following the drug regimen, Dr. Weiss recommended. If the physician has doubts or uncertainty about a medication, that can be communicated to the patient and needs to be dealt with. As with all medications, the placebo effect and the commitment the patient makes to their treatment can be the most important components of the treatment's success.

▸ More appointments. Patients tend to be most adherent during the 5 days preceding and the 5 days after a doctor visit, a well-known phenomenon waggishly known as “white-coat adherence.”

▸ Reminders. Notes on the bathroom mirror, pillboxes with individual wells for each day of the week or month, and alarm watches help forgetful patients remember.

▸ Education of the family. Family members who are aware of the condition and need for medication can be strong allies.

▸ Mutual thanking. One research study of alcohol-dependent patients and their significant others developed a script for reminding patients to take their medication, which was disulfiram. This strategy has since come to be known as the “Antabuse contract.”

According to the study's script, the significant other first gently reminded the patient when it was time to take the medication. When the patient took the medication, he or she thanked the other for the reminder. The significant other then thanked the patient for taking the medication.

One crucial part of this contract was that the couple was not allowed to discuss any past drinking or future drinking events. Although the participants found the interaction uncomfortable initially, the researchers showed that it improved not only outcomes, but relationship satisfaction as well.

▸ Simple regimens. Even patients with diabetes or asthma are adherent to their medications only an average of 40%–60% of the time. And full adherence to a regimen drops dramatically when once-daily dosing is changed to twice-daily dosing. That means long-acting medications are more forgiving than short-acting ones. A depot formulation of naltrexone has recently been developed, and when it becomes available, it could be extremely useful for nonadherent patients, Dr. Weiss said. In a recent 6-month trial of once-monthly injections, 74% of patients came in and received between four and six of their injections, and 64% received all six (100% adherence). Overall, the median number of heavy drinking days declined 48%.

▸ Blood levels. Measuring blood levels, even when possible, is expensive but not practical or entirely foolproof, because patients may be more adherent than usual before an appointment. Still, it is an option, Dr. Weiss said.

SAN DIEGO – Physicians who have a patient who smokes need to do more than just advise them to quit. Most smokers need much more help than that, Dr. Linda Hyder Ferry said at the annual conference of the American Society of Addiction Medicine.

Specifically, pharmacotherapy tends to be greatly underused, asserted Dr. Ferry, who runs the smoking cessation program in the preventive medicine clinic at the Jerry L. Pettis Memorial Veterans Affairs Medical Center, Loma Linda, Calif.

“Minimal intervention, in my experience, and in looking at the literature, is not what is appropriate and effective for the high-risk, hard-core smoker,” she said.

As people have quit over the years, and fewer start, it tends to be the more highly dependent smokers–the high-risk smokers–who remain among the ranks of those who would like to quit, Dr. Ferry said.

And most smokers do want to quit. Currently, 50% of all smokers will attempt to quit in any year. But only 3%–5% of those who try to quit will be successful for a year.

When she encounters a patient who is willing to try quitting, she first gauges the person's level of tobacco dependence, because that helps dictate the amount and kind of assistance the patient needs, Dr. Ferry said.

She assesses dependence with four basic questions and categorizes patients into three levels of dependence: low, moderate, and high. People in the low category tend to be the most successful at quitting on their own. Those with moderate dependence may need some kind of cognitive-behavioral program or counseling. And people who are highly dependent probably need nicotine replacement or medication, in addition to counseling.

The first question Dr. Ferry asks is, “How many cigarettes do you smoke a day?” Fewer than 15 indicates low dependence. More than 25 cigarettes indicates high dependence. Moderate falls in between. The second question is, “How soon do you smoke when you wake up in the morning?” Those who wait at least 30 minutes are likely to have low dependence, and those who smoke within 10 minutes are highly dependent. The third question is, “How long did your previous quit attempt last?” Those who lasted less than a week have high dependence. Those who lasted 3–6 weeks are going to have a higher likelihood of success in their next attempt, Dr. Ferry said.

Finally, the last question is, “When your last quit attempt failed, what was the reason?” If it was because of withdrawal symptoms, the person will probably need nicotine replacement therapy or medication.

In her program, the cognitive-behavioral component includes four 1-hour group sessions, augmented, when necessary, with individual counseling and telephone follow-up. The success rate at 6 months is approximately 25%–30%, and the rate does not appear to change from year to year. “I've never been able to get it up above about 30%,” she said.

On the issue of pharmacotherapy, Dr. Ferry described the following methods:

▸ Nicotine replacement therapy. The choice of replacement type–gum, patch, or nasal spray–is based on susceptibility to side effects, patient preference, and availability, Dr. Ferry said.

The key to nicotine replacement is that patients need a dose that is sufficient to prevent any withdrawal symptoms. The patch, Dr. Ferry noted, comes in three doses, 7 mg, 14 mg, and 21 mg. The 21-mg patch is equivalent to about a pack a day.

Low-dependence smokers may need a patch for only 3–6 weeks to begin eliminating their psychological dependence and their habit patterns. Highly dependent individuals may need to use the patch for 4–6 months. The average time needed in Dr. Ferry's clinic is about 12 weeks, she said.

▸ Bupropion. Many have the idea that this drug works best in individuals who are depressed. Bupropion can be used in smokers who are depressed, to address both, but it actually works better for smokers who are not depressed, Dr. Ferry said. Moreover, it works best when combined with nicotine replacement therapy, though there is a need to monitor blood pressure when using both methods.

▸ Clonidine. This drug is used as a second-line agent because it has lots of side effects. However, it appears to work well for highly dependent patients and for women.

▸ Varenicline. This new drug is a nicotine receptor partial agonist with much promise. In one trial, the 1-year quit rates were 20% for the drug and 10% for placebo. In a short-term trial lasting 7 weeks, varenicline was compared with bupropion, as well as with placebo. The quit rates were almost 50% for varenicline, 33% for bupropion, and 16% for placebo, Dr. Ferry said.

SAN DIEGO – Physicians who have a patient who smokes need to do more than just advise them to quit. Most smokers need much more help than that, Dr. Linda Hyder Ferry said at the annual conference of the American Society of Addiction Medicine.

Specifically, pharmacotherapy tends to be greatly underused, asserted Dr. Ferry, who runs the smoking cessation program in the preventive medicine clinic at the Jerry L. Pettis Memorial Veterans Affairs Medical Center, Loma Linda, Calif.

“Minimal intervention, in my experience, and in looking at the literature, is not what is appropriate and effective for the high-risk, hard-core smoker,” she said.

As people have quit over the years, and fewer start, it tends to be the more highly dependent smokers–the high-risk smokers–who remain among the ranks of those who would like to quit, Dr. Ferry said.

And most smokers do want to quit. Currently, 50% of all smokers will attempt to quit in any year. But only 3%–5% of those who try to quit will be successful for a year.

When she encounters a patient who is willing to try quitting, she first gauges the person's level of tobacco dependence, because that helps dictate the amount and kind of assistance the patient needs, Dr. Ferry said.

She assesses dependence with four basic questions and categorizes patients into three levels of dependence: low, moderate, and high. People in the low category tend to be the most successful at quitting on their own. Those with moderate dependence may need some kind of cognitive-behavioral program or counseling. And people who are highly dependent probably need nicotine replacement or medication, in addition to counseling.

The first question Dr. Ferry asks is, “How many cigarettes do you smoke a day?” Fewer than 15 indicates low dependence. More than 25 cigarettes indicates high dependence. Moderate falls in between. The second question is, “How soon do you smoke when you wake up in the morning?” Those who wait at least 30 minutes are likely to have low dependence, and those who smoke within 10 minutes are highly dependent. The third question is, “How long did your previous quit attempt last?” Those who lasted less than a week have high dependence. Those who lasted 3–6 weeks are going to have a higher likelihood of success in their next attempt, Dr. Ferry said.

Finally, the last question is, “When your last quit attempt failed, what was the reason?” If it was because of withdrawal symptoms, the person will probably need nicotine replacement therapy or medication.

In her program, the cognitive-behavioral component includes four 1-hour group sessions, augmented, when necessary, with individual counseling and telephone follow-up. The success rate at 6 months is approximately 25%–30%, and the rate does not appear to change from year to year. “I've never been able to get it up above about 30%,” she said.

On the issue of pharmacotherapy, Dr. Ferry described the following methods:

▸ Nicotine replacement therapy. The choice of replacement type–gum, patch, or nasal spray–is based on susceptibility to side effects, patient preference, and availability, Dr. Ferry said.

The key to nicotine replacement is that patients need a dose that is sufficient to prevent any withdrawal symptoms. The patch, Dr. Ferry noted, comes in three doses, 7 mg, 14 mg, and 21 mg. The 21-mg patch is equivalent to about a pack a day.

Low-dependence smokers may need a patch for only 3–6 weeks to begin eliminating their psychological dependence and their habit patterns. Highly dependent individuals may need to use the patch for 4–6 months. The average time needed in Dr. Ferry's clinic is about 12 weeks, she said.

▸ Bupropion. Many have the idea that this drug works best in individuals who are depressed. Bupropion can be used in smokers who are depressed, to address both, but it actually works better for smokers who are not depressed, Dr. Ferry said. Moreover, it works best when combined with nicotine replacement therapy, though there is a need to monitor blood pressure when using both methods.

▸ Clonidine. This drug is used as a second-line agent because it has lots of side effects. However, it appears to work well for highly dependent patients and for women.

▸ Varenicline. This new drug is a nicotine receptor partial agonist with much promise. In one trial, the 1-year quit rates were 20% for the drug and 10% for placebo. In a short-term trial lasting 7 weeks, varenicline was compared with bupropion, as well as with placebo. The quit rates were almost 50% for varenicline, 33% for bupropion, and 16% for placebo, Dr. Ferry said.

SAN DIEGO – Physicians who have a patient who smokes need to do more than just advise them to quit. Most smokers need much more help than that, Dr. Linda Hyder Ferry said at the annual conference of the American Society of Addiction Medicine.

Specifically, pharmacotherapy tends to be greatly underused, asserted Dr. Ferry, who runs the smoking cessation program in the preventive medicine clinic at the Jerry L. Pettis Memorial Veterans Affairs Medical Center, Loma Linda, Calif.

“Minimal intervention, in my experience, and in looking at the literature, is not what is appropriate and effective for the high-risk, hard-core smoker,” she said.

As people have quit over the years, and fewer start, it tends to be the more highly dependent smokers–the high-risk smokers–who remain among the ranks of those who would like to quit, Dr. Ferry said.

And most smokers do want to quit. Currently, 50% of all smokers will attempt to quit in any year. But only 3%–5% of those who try to quit will be successful for a year.

When she encounters a patient who is willing to try quitting, she first gauges the person's level of tobacco dependence, because that helps dictate the amount and kind of assistance the patient needs, Dr. Ferry said.

She assesses dependence with four basic questions and categorizes patients into three levels of dependence: low, moderate, and high. People in the low category tend to be the most successful at quitting on their own. Those with moderate dependence may need some kind of cognitive-behavioral program or counseling. And people who are highly dependent probably need nicotine replacement or medication, in addition to counseling.

The first question Dr. Ferry asks is, “How many cigarettes do you smoke a day?” Fewer than 15 indicates low dependence. More than 25 cigarettes indicates high dependence. Moderate falls in between. The second question is, “How soon do you smoke when you wake up in the morning?” Those who wait at least 30 minutes are likely to have low dependence, and those who smoke within 10 minutes are highly dependent. The third question is, “How long did your previous quit attempt last?” Those who lasted less than a week have high dependence. Those who lasted 3–6 weeks are going to have a higher likelihood of success in their next attempt, Dr. Ferry said.

Finally, the last question is, “When your last quit attempt failed, what was the reason?” If it was because of withdrawal symptoms, the person will probably need nicotine replacement therapy or medication.

In her program, the cognitive-behavioral component includes four 1-hour group sessions, augmented, when necessary, with individual counseling and telephone follow-up. The success rate at 6 months is approximately 25%–30%, and the rate does not appear to change from year to year. “I've never been able to get it up above about 30%,” she said.

On the issue of pharmacotherapy, Dr. Ferry described the following methods:

▸ Nicotine replacement therapy. The choice of replacement type–gum, patch, or nasal spray–is based on susceptibility to side effects, patient preference, and availability, Dr. Ferry said.

The key to nicotine replacement is that patients need a dose that is sufficient to prevent any withdrawal symptoms. The patch, Dr. Ferry noted, comes in three doses, 7 mg, 14 mg, and 21 mg. The 21-mg patch is equivalent to about a pack a day.

Low-dependence smokers may need a patch for only 3–6 weeks to begin eliminating their psychological dependence and their habit patterns. Highly dependent individuals may need to use the patch for 4–6 months. The average time needed in Dr. Ferry's clinic is about 12 weeks, she said.

▸ Bupropion. Many have the idea that this drug works best in individuals who are depressed. Bupropion can be used in smokers who are depressed, to address both, but it actually works better for smokers who are not depressed, Dr. Ferry said. Moreover, it works best when combined with nicotine replacement therapy, though there is a need to monitor blood pressure when using both methods.

▸ Clonidine. This drug is used as a second-line agent because it has lots of side effects. However, it appears to work well for highly dependent patients and for women.

▸ Varenicline. This new drug is a nicotine receptor partial agonist with much promise. In one trial, the 1-year quit rates were 20% for the drug and 10% for placebo. In a short-term trial lasting 7 weeks, varenicline was compared with bupropion, as well as with placebo. The quit rates were almost 50% for varenicline, 33% for bupropion, and 16% for placebo, Dr. Ferry said.

SCOTTSDALE, ARIZ. – Using jelly, applesauce, or another semisolid chaser instead of water is a better way to have patients swallow pills or tablets, particularly in patients with dysphagia.

Pills swallowed with water tend to get stuck in the esophagus fairly often, but a pill swallowed with jelly is more likely to travel the entire way down the esophagus into the stomach, Dr. Hiromi Chisaka said at the annual meeting of the Dysphagia Research Society.

In a pilot study, Dr. Chisaka and colleagues found that when volunteers swallowed barium pills with water, the fluoroscope showed that the pills became stuck in the esophagus 30% of the time.

The researchers were interested because it has been estimated that 15% of nursing home residents have difficulty swallowing pills and tablets, said Dr. Chisaka of the University of Occupational and Environmental Health, Kitakyushu City, Japan, in a poster presentation.

Dr. Chisaka's controlled study involved 20 elderly volunteers who did not have dysphagia. The volunteers swallowed hard gelatin capsules filled with barium sulfate and were observed with videofluoroscopy. Capsules were taken three times with 15 mL of water and three times with jelly.

When volunteers swallowed the capsules with water, seven pills were retained in transit, defined as a capsule that remained in the same position for at least 15 seconds. Only two pills swallowed with jelly were retained anywhere in the esophagus.

SCOTTSDALE, ARIZ. – Using jelly, applesauce, or another semisolid chaser instead of water is a better way to have patients swallow pills or tablets, particularly in patients with dysphagia.

Pills swallowed with water tend to get stuck in the esophagus fairly often, but a pill swallowed with jelly is more likely to travel the entire way down the esophagus into the stomach, Dr. Hiromi Chisaka said at the annual meeting of the Dysphagia Research Society.

In a pilot study, Dr. Chisaka and colleagues found that when volunteers swallowed barium pills with water, the fluoroscope showed that the pills became stuck in the esophagus 30% of the time.

The researchers were interested because it has been estimated that 15% of nursing home residents have difficulty swallowing pills and tablets, said Dr. Chisaka of the University of Occupational and Environmental Health, Kitakyushu City, Japan, in a poster presentation.

Dr. Chisaka's controlled study involved 20 elderly volunteers who did not have dysphagia. The volunteers swallowed hard gelatin capsules filled with barium sulfate and were observed with videofluoroscopy. Capsules were taken three times with 15 mL of water and three times with jelly.

When volunteers swallowed the capsules with water, seven pills were retained in transit, defined as a capsule that remained in the same position for at least 15 seconds. Only two pills swallowed with jelly were retained anywhere in the esophagus.

SCOTTSDALE, ARIZ. – Using jelly, applesauce, or another semisolid chaser instead of water is a better way to have patients swallow pills or tablets, particularly in patients with dysphagia.

Pills swallowed with water tend to get stuck in the esophagus fairly often, but a pill swallowed with jelly is more likely to travel the entire way down the esophagus into the stomach, Dr. Hiromi Chisaka said at the annual meeting of the Dysphagia Research Society.

In a pilot study, Dr. Chisaka and colleagues found that when volunteers swallowed barium pills with water, the fluoroscope showed that the pills became stuck in the esophagus 30% of the time.

The researchers were interested because it has been estimated that 15% of nursing home residents have difficulty swallowing pills and tablets, said Dr. Chisaka of the University of Occupational and Environmental Health, Kitakyushu City, Japan, in a poster presentation.

Dr. Chisaka's controlled study involved 20 elderly volunteers who did not have dysphagia. The volunteers swallowed hard gelatin capsules filled with barium sulfate and were observed with videofluoroscopy. Capsules were taken three times with 15 mL of water and three times with jelly.

When volunteers swallowed the capsules with water, seven pills were retained in transit, defined as a capsule that remained in the same position for at least 15 seconds. Only two pills swallowed with jelly were retained anywhere in the esophagus.

SAN DIEGO — Drug abuse treatment has a fairly dismal success rate among most groups, with one notable exception: physicians.

Now, a group of experts wants to find out what it is about doctors or the assistance they receive that is so helpful so that the lessons learned can be applied to treatment for others.

“It's easy to say that physicians are different from other addicts, but our [theoretical] model is that this is a biological disease,” said Dr. Robert L. DuPont at a presentation made by this group of experts at the annual conference of the American Society of Addiction Medicine.

The trigger for this study effort was an article published in the Journal of the American Medical Association last year. The article reported on a study that looked at relapse in 292 physicians in Washington state who had successfully gone through drug or alcohol treatment and were involved in a physician monitoring program.

The aim of the study was to see whether it was true that physicians who abused opiates—especially anesthesiologists—relapsed more often than did physicians who abused primarily other drugs or alcohol.

The study found that opiate abusers did not relapse more frequently, except when they also had a coexisting psychiatric disorder. But the relevant part of the study for the expert group was that only 25% of the physicians had any relapse, said Dr. DuPont, a former director of the National Institute on Drug Abuse who is now in private practice in Rockville, Md.

In contrast, it is estimated that most nonphysicians receive treatment for relapse in the first year after initial treatment. Some reports suggest physician success rates may be even higher than 70%–75%, the experts said.

The experts expect that one of the obvious reasons that physicians tend to do well is because they have a lot of “recovery capital,” that is, they are educated and have a lot to lose. Another probable reason is that their families tend to be strongly involved in the process.

But it is also true that physicians tend to get enrolled in physician health monitoring programs that last a long time, insist on complete abstinence, conduct drug testing, and do not ignore early warning signs of an impending relapse, such as when the individual begins to opt out of continued counseling or attendance at Alcoholics Anonymous meetings.

The length of the programs may be almost as important as the fact that they can be punitive, because studies suggest that recovery from drug addiction and alcoholism is not really stable for 5 years, said William White, a senior research consultant with Chestnut Health Systems, Bloomington, Ill.

Treatment for the general population tends to be done on an “ER model,” with the active phase of treatment being only a few months or less, Mr. White said. Some of the experts suggested that major problems in the alcohol/drug abuse treatment industry are being illuminated.

Eighty percent of drug/alcohol treatment programs in this country receive almost all their recompense from the government, and get less than 12% of their revenues from private insurance. Government funding “has taken market forces out of the field,” said A. Thomas McLellan, Ph.D., a professor in the department of psychiatry at the University of Pennsylvania, and director of the Treatment Research Institute, Philadelphia.

He sees many problems in the field, including the fact that most programs have nothing to offer but group therapy and do not take an evidence-based approach. “If this was another industry, things would change,” he said.

In a survey of 175 programs, 12% closed over a 13-month period, Dr. McLellan said. Moreover, counselor turnover in all of the programs was roughly 50% a year, and many of the directors—17% of whom had no college education—had less than 1 year on the job. Fifty-four percent of the programs had no physician on staff.

The expert group has received a $100,000 grant from the Robert Wood Johnson Foundation, funds it has been spending to get organized and obtain information from the state physician health programs about how they manage their recovering doctors.

“What we're after right now is evidence” of what is done and how it works, Dr. DuPont said. “We are optimistic that this effort is going to be helpful.”

SAN DIEGO — Drug abuse treatment has a fairly dismal success rate among most groups, with one notable exception: physicians.

Now, a group of experts wants to find out what it is about doctors or the assistance they receive that is so helpful so that the lessons learned can be applied to treatment for others.

“It's easy to say that physicians are different from other addicts, but our [theoretical] model is that this is a biological disease,” said Dr. Robert L. DuPont at a presentation made by this group of experts at the annual conference of the American Society of Addiction Medicine.

The trigger for this study effort was an article published in the Journal of the American Medical Association last year. The article reported on a study that looked at relapse in 292 physicians in Washington state who had successfully gone through drug or alcohol treatment and were involved in a physician monitoring program.

The aim of the study was to see whether it was true that physicians who abused opiates—especially anesthesiologists—relapsed more often than did physicians who abused primarily other drugs or alcohol.

The study found that opiate abusers did not relapse more frequently, except when they also had a coexisting psychiatric disorder. But the relevant part of the study for the expert group was that only 25% of the physicians had any relapse, said Dr. DuPont, a former director of the National Institute on Drug Abuse who is now in private practice in Rockville, Md.

In contrast, it is estimated that most nonphysicians receive treatment for relapse in the first year after initial treatment. Some reports suggest physician success rates may be even higher than 70%–75%, the experts said.

The experts expect that one of the obvious reasons that physicians tend to do well is because they have a lot of “recovery capital,” that is, they are educated and have a lot to lose. Another probable reason is that their families tend to be strongly involved in the process.

But it is also true that physicians tend to get enrolled in physician health monitoring programs that last a long time, insist on complete abstinence, conduct drug testing, and do not ignore early warning signs of an impending relapse, such as when the individual begins to opt out of continued counseling or attendance at Alcoholics Anonymous meetings.

The length of the programs may be almost as important as the fact that they can be punitive, because studies suggest that recovery from drug addiction and alcoholism is not really stable for 5 years, said William White, a senior research consultant with Chestnut Health Systems, Bloomington, Ill.

Treatment for the general population tends to be done on an “ER model,” with the active phase of treatment being only a few months or less, Mr. White said. Some of the experts suggested that major problems in the alcohol/drug abuse treatment industry are being illuminated.

Eighty percent of drug/alcohol treatment programs in this country receive almost all their recompense from the government, and get less than 12% of their revenues from private insurance. Government funding “has taken market forces out of the field,” said A. Thomas McLellan, Ph.D., a professor in the department of psychiatry at the University of Pennsylvania, and director of the Treatment Research Institute, Philadelphia.

He sees many problems in the field, including the fact that most programs have nothing to offer but group therapy and do not take an evidence-based approach. “If this was another industry, things would change,” he said.

In a survey of 175 programs, 12% closed over a 13-month period, Dr. McLellan said. Moreover, counselor turnover in all of the programs was roughly 50% a year, and many of the directors—17% of whom had no college education—had less than 1 year on the job. Fifty-four percent of the programs had no physician on staff.

The expert group has received a $100,000 grant from the Robert Wood Johnson Foundation, funds it has been spending to get organized and obtain information from the state physician health programs about how they manage their recovering doctors.

“What we're after right now is evidence” of what is done and how it works, Dr. DuPont said. “We are optimistic that this effort is going to be helpful.”

SAN DIEGO — Drug abuse treatment has a fairly dismal success rate among most groups, with one notable exception: physicians.

Now, a group of experts wants to find out what it is about doctors or the assistance they receive that is so helpful so that the lessons learned can be applied to treatment for others.

“It's easy to say that physicians are different from other addicts, but our [theoretical] model is that this is a biological disease,” said Dr. Robert L. DuPont at a presentation made by this group of experts at the annual conference of the American Society of Addiction Medicine.

The trigger for this study effort was an article published in the Journal of the American Medical Association last year. The article reported on a study that looked at relapse in 292 physicians in Washington state who had successfully gone through drug or alcohol treatment and were involved in a physician monitoring program.

The aim of the study was to see whether it was true that physicians who abused opiates—especially anesthesiologists—relapsed more often than did physicians who abused primarily other drugs or alcohol.

The study found that opiate abusers did not relapse more frequently, except when they also had a coexisting psychiatric disorder. But the relevant part of the study for the expert group was that only 25% of the physicians had any relapse, said Dr. DuPont, a former director of the National Institute on Drug Abuse who is now in private practice in Rockville, Md.

In contrast, it is estimated that most nonphysicians receive treatment for relapse in the first year after initial treatment. Some reports suggest physician success rates may be even higher than 70%–75%, the experts said.

The experts expect that one of the obvious reasons that physicians tend to do well is because they have a lot of “recovery capital,” that is, they are educated and have a lot to lose. Another probable reason is that their families tend to be strongly involved in the process.

But it is also true that physicians tend to get enrolled in physician health monitoring programs that last a long time, insist on complete abstinence, conduct drug testing, and do not ignore early warning signs of an impending relapse, such as when the individual begins to opt out of continued counseling or attendance at Alcoholics Anonymous meetings.

The length of the programs may be almost as important as the fact that they can be punitive, because studies suggest that recovery from drug addiction and alcoholism is not really stable for 5 years, said William White, a senior research consultant with Chestnut Health Systems, Bloomington, Ill.

Treatment for the general population tends to be done on an “ER model,” with the active phase of treatment being only a few months or less, Mr. White said. Some of the experts suggested that major problems in the alcohol/drug abuse treatment industry are being illuminated.

Eighty percent of drug/alcohol treatment programs in this country receive almost all their recompense from the government, and get less than 12% of their revenues from private insurance. Government funding “has taken market forces out of the field,” said A. Thomas McLellan, Ph.D., a professor in the department of psychiatry at the University of Pennsylvania, and director of the Treatment Research Institute, Philadelphia.

He sees many problems in the field, including the fact that most programs have nothing to offer but group therapy and do not take an evidence-based approach. “If this was another industry, things would change,” he said.

In a survey of 175 programs, 12% closed over a 13-month period, Dr. McLellan said. Moreover, counselor turnover in all of the programs was roughly 50% a year, and many of the directors—17% of whom had no college education—had less than 1 year on the job. Fifty-four percent of the programs had no physician on staff.

The expert group has received a $100,000 grant from the Robert Wood Johnson Foundation, funds it has been spending to get organized and obtain information from the state physician health programs about how they manage their recovering doctors.

“What we're after right now is evidence” of what is done and how it works, Dr. DuPont said. “We are optimistic that this effort is going to be helpful.”

SOUTH LAKE TAHOE, CALIF. — Bedside ultrasound should be used in the emergency department for patients with undifferentiated hypotension, Dr. John S. Rose said at an emergency medicine conference sponsored by the University of California, Davis.

The device can help identify three major physical causes of hypotension: fluid in the peritoneal cavity, fluid around the heart or gross cardiac abnormalities, and an abdominal aortic aneurysm, said Dr. Rose of the department of emergency medicine at UC Davis Medical Center, Sacramento.

“Ultrasound really will change your practice, not just in the trauma setting,” said Dr. Rose who described some hypothetical situations in which ultrasound might be used. They included a 24-year-old female who might have a ruptured ectopic pregnancy, a cancer patient undergoing treatment who could have pericardial effusion, and a 60-year-old patient with a systolic blood pressure of 70 mm Hg who might have an aortic aneurysm.

Because unexplained hypotension is potentially life threatening, one doesn't usually use restraint in ordering tests and studies in these cases, Dr. Rose said. And often there is no time to trundle the patient off to some other department for imaging studies.

“We do a lot of empiric things when they come in sick, so why not add [an ultrasound exam] on top of it?” he said.

“You can still do a comprehensive evaluation. The purpose behind the exam is just to think about the three reversible causes that you can find with ultrasound.”

Dr. Rose's proposed exam consists of three ultrasound views: a right upper quadrant view, the same as is used for a focused assessment with sonography for trauma, or FAST, examination; a cardiac assessment with a subxiphoid or parasternal long axis view; and an abdominal view.

The right upper quadrant view—which looks for fluid in the peritoneal cavity, in Morison's pouch between the liver and kidney—is not always sensitive in a trauma patient with limited bleeding. But it will be in the patient who has lost enough blood from the circulatory system to be hypotensive, and evidence bears this out, Dr. Rose said.

The cardiac assessment, which Dr. Rose calls a “limited echo,” is practical because it does not require extensive expertise, he said. It is a procedure that could be taught to an emergency physician in half an hour. One is simply looking to see that the heart is beating vigorously, that the left ventricle appears to be filling, and that there is no pericardial effusion.

The abdominal view follows the aorta all the way down, from substernum to the bifurcation, he said. As with the intraperitoneal findings, evidence shows that most abdominal aortic aneurysms associated with hypotension are apparent on ultrasound, and they are almost never missed in the emergency department.

Each of these assessments can be accomplished extremely quickly, and none needs a special transducer, he added.

“If you find free fluid, an effusion, or an [abdominal aortic aneurysm], I guarantee you are going to change the course on that patient,” Dr. Rose said. “You are going to do something different. This is not just for 'I'd like to know.'”

SOUTH LAKE TAHOE, CALIF. — Bedside ultrasound should be used in the emergency department for patients with undifferentiated hypotension, Dr. John S. Rose said at an emergency medicine conference sponsored by the University of California, Davis.

The device can help identify three major physical causes of hypotension: fluid in the peritoneal cavity, fluid around the heart or gross cardiac abnormalities, and an abdominal aortic aneurysm, said Dr. Rose of the department of emergency medicine at UC Davis Medical Center, Sacramento.

“Ultrasound really will change your practice, not just in the trauma setting,” said Dr. Rose who described some hypothetical situations in which ultrasound might be used. They included a 24-year-old female who might have a ruptured ectopic pregnancy, a cancer patient undergoing treatment who could have pericardial effusion, and a 60-year-old patient with a systolic blood pressure of 70 mm Hg who might have an aortic aneurysm.

Because unexplained hypotension is potentially life threatening, one doesn't usually use restraint in ordering tests and studies in these cases, Dr. Rose said. And often there is no time to trundle the patient off to some other department for imaging studies.

“We do a lot of empiric things when they come in sick, so why not add [an ultrasound exam] on top of it?” he said.

“You can still do a comprehensive evaluation. The purpose behind the exam is just to think about the three reversible causes that you can find with ultrasound.”

Dr. Rose's proposed exam consists of three ultrasound views: a right upper quadrant view, the same as is used for a focused assessment with sonography for trauma, or FAST, examination; a cardiac assessment with a subxiphoid or parasternal long axis view; and an abdominal view.

The right upper quadrant view—which looks for fluid in the peritoneal cavity, in Morison's pouch between the liver and kidney—is not always sensitive in a trauma patient with limited bleeding. But it will be in the patient who has lost enough blood from the circulatory system to be hypotensive, and evidence bears this out, Dr. Rose said.

The cardiac assessment, which Dr. Rose calls a “limited echo,” is practical because it does not require extensive expertise, he said. It is a procedure that could be taught to an emergency physician in half an hour. One is simply looking to see that the heart is beating vigorously, that the left ventricle appears to be filling, and that there is no pericardial effusion.

The abdominal view follows the aorta all the way down, from substernum to the bifurcation, he said. As with the intraperitoneal findings, evidence shows that most abdominal aortic aneurysms associated with hypotension are apparent on ultrasound, and they are almost never missed in the emergency department.

Each of these assessments can be accomplished extremely quickly, and none needs a special transducer, he added.

“If you find free fluid, an effusion, or an [abdominal aortic aneurysm], I guarantee you are going to change the course on that patient,” Dr. Rose said. “You are going to do something different. This is not just for 'I'd like to know.'”

SOUTH LAKE TAHOE, CALIF. — Bedside ultrasound should be used in the emergency department for patients with undifferentiated hypotension, Dr. John S. Rose said at an emergency medicine conference sponsored by the University of California, Davis.

The device can help identify three major physical causes of hypotension: fluid in the peritoneal cavity, fluid around the heart or gross cardiac abnormalities, and an abdominal aortic aneurysm, said Dr. Rose of the department of emergency medicine at UC Davis Medical Center, Sacramento.

“Ultrasound really will change your practice, not just in the trauma setting,” said Dr. Rose who described some hypothetical situations in which ultrasound might be used. They included a 24-year-old female who might have a ruptured ectopic pregnancy, a cancer patient undergoing treatment who could have pericardial effusion, and a 60-year-old patient with a systolic blood pressure of 70 mm Hg who might have an aortic aneurysm.

Because unexplained hypotension is potentially life threatening, one doesn't usually use restraint in ordering tests and studies in these cases, Dr. Rose said. And often there is no time to trundle the patient off to some other department for imaging studies.

“We do a lot of empiric things when they come in sick, so why not add [an ultrasound exam] on top of it?” he said.

“You can still do a comprehensive evaluation. The purpose behind the exam is just to think about the three reversible causes that you can find with ultrasound.”

Dr. Rose's proposed exam consists of three ultrasound views: a right upper quadrant view, the same as is used for a focused assessment with sonography for trauma, or FAST, examination; a cardiac assessment with a subxiphoid or parasternal long axis view; and an abdominal view.

The right upper quadrant view—which looks for fluid in the peritoneal cavity, in Morison's pouch between the liver and kidney—is not always sensitive in a trauma patient with limited bleeding. But it will be in the patient who has lost enough blood from the circulatory system to be hypotensive, and evidence bears this out, Dr. Rose said.

The cardiac assessment, which Dr. Rose calls a “limited echo,” is practical because it does not require extensive expertise, he said. It is a procedure that could be taught to an emergency physician in half an hour. One is simply looking to see that the heart is beating vigorously, that the left ventricle appears to be filling, and that there is no pericardial effusion.

The abdominal view follows the aorta all the way down, from substernum to the bifurcation, he said. As with the intraperitoneal findings, evidence shows that most abdominal aortic aneurysms associated with hypotension are apparent on ultrasound, and they are almost never missed in the emergency department.

Each of these assessments can be accomplished extremely quickly, and none needs a special transducer, he added.

“If you find free fluid, an effusion, or an [abdominal aortic aneurysm], I guarantee you are going to change the course on that patient,” Dr. Rose said. “You are going to do something different. This is not just for 'I'd like to know.'”

SAN DIEGO – Drug abuse treatment has a fairly dismal success rate among most groups, with one notable exception: physicians.

Now, a group of experts wants to find out what it is about doctors or the assistance they receive that is so helpful so that the lessons learned can be applied to treatment for others.

“It's easy to say that physicians are different from other addicts, but our [theoretical] model is that this is a biological disease,” said Dr. Robert L. DuPont at a presentation made by this group of experts at the annual conference of the American Society of Addiction Medicine.

The trigger for this study effort was an article published in the Journal of the American Medical Association last year. The article reported on a study that looked at relapse in 292 physicians in Washington state who had successfully gone through drug or alcohol treatment and were involved in a physician monitoring program.

The aim of the study was to see whether it was true that physicians who abused opiates–especially anesthesiologists–relapsed more often than did physicians who abused primarily other drugs or alcohol.

The study found that opiate abusers did not relapse more frequently, except when they also had a coexisting psychiatric disorder. But the relevant part of the study for the expert group was that only 25% of the physicians had any relapse, said Dr. DuPont, a former director of the National Institute on Drug Abuse who is now in private practice in Rockville, Md.

In contrast, most nonphysicians receive treatment for relapse in the first year after initial treatment.

Some reports suggest physician success rates may be even higher than 70%–75%, the experts said. The experts suspect that one of the obvious reasons that physicians tend to do well is because they have a lot of “recovery capital,” that is, they are educated and have a lot to lose. Another probable reason is that their families tend to be strongly involved in the process.

But it is also true that physicians tend to get enrolled in physician health monitoring programs that last a long time, insist on complete abstinence, conduct drug testing, and do not ignore early warning signs of an impending relapse, such as when the individual begins to opt out of continued counseling or attendance at Alcoholics Anonymous meetings.

The length of the programs may be almost as important as the fact that they can be punitive, because studies suggest that recovery from drug addiction and alcoholism is not really stable for 5 years, said William White, a senior research consultant with Chestnut Health Systems, Bloomington, Ill.

Treatment for the general population tends to be done on an “ER model,” with the active phase of treatment being only a few months or less, Mr. White said.

Some of the experts suggested that major problems in the alcohol/drug abuse treatment industry are being illuminated.

Eighty percent of drug/alcohol treatment programs in this country receive almost all their recompense from the government, and get less than 12% of their revenues from private insurance. Government funding “has taken market forces out of the field,” said A. Thomas McLellan, Ph.D., a professor in the department of psychiatry at the University of Pennsylvania, and director of the Treatment Research Institute, Philadelphia.

He sees many problems in the field, including the fact that most programs have nothing to offer but group therapy and do not take an evidence-based approach. “If this was another industry, things would change,” he said.

In a survey of 175 programs, 12% closed over 13 months, Dr. McLellan said. Moreover, counselor turnover in all of the programs was roughly 50% a year, and many of the directors–17% of whom had no college education–had less than 1 year on the job. Fifty-four percent of the programs had no physician on staff.

The expert group so far has received a $100,000 grant from the Robert Wood Johnson Foundation, money it has been spending to get organized and obtain information from the state physician health programs about how they manage their recovering doctors.

“What we're after right now is evidence” of what is done and how it works, Dr. DuPont said. “We are optimistic that this effort is going to be helpful.”

SAN DIEGO – Drug abuse treatment has a fairly dismal success rate among most groups, with one notable exception: physicians.

Now, a group of experts wants to find out what it is about doctors or the assistance they receive that is so helpful so that the lessons learned can be applied to treatment for others.

“It's easy to say that physicians are different from other addicts, but our [theoretical] model is that this is a biological disease,” said Dr. Robert L. DuPont at a presentation made by this group of experts at the annual conference of the American Society of Addiction Medicine.

The trigger for this study effort was an article published in the Journal of the American Medical Association last year. The article reported on a study that looked at relapse in 292 physicians in Washington state who had successfully gone through drug or alcohol treatment and were involved in a physician monitoring program.

The aim of the study was to see whether it was true that physicians who abused opiates–especially anesthesiologists–relapsed more often than did physicians who abused primarily other drugs or alcohol.

The study found that opiate abusers did not relapse more frequently, except when they also had a coexisting psychiatric disorder. But the relevant part of the study for the expert group was that only 25% of the physicians had any relapse, said Dr. DuPont, a former director of the National Institute on Drug Abuse who is now in private practice in Rockville, Md.

In contrast, most nonphysicians receive treatment for relapse in the first year after initial treatment.

Some reports suggest physician success rates may be even higher than 70%–75%, the experts said. The experts suspect that one of the obvious reasons that physicians tend to do well is because they have a lot of “recovery capital,” that is, they are educated and have a lot to lose. Another probable reason is that their families tend to be strongly involved in the process.

But it is also true that physicians tend to get enrolled in physician health monitoring programs that last a long time, insist on complete abstinence, conduct drug testing, and do not ignore early warning signs of an impending relapse, such as when the individual begins to opt out of continued counseling or attendance at Alcoholics Anonymous meetings.

The length of the programs may be almost as important as the fact that they can be punitive, because studies suggest that recovery from drug addiction and alcoholism is not really stable for 5 years, said William White, a senior research consultant with Chestnut Health Systems, Bloomington, Ill.

Treatment for the general population tends to be done on an “ER model,” with the active phase of treatment being only a few months or less, Mr. White said.

Some of the experts suggested that major problems in the alcohol/drug abuse treatment industry are being illuminated.

Eighty percent of drug/alcohol treatment programs in this country receive almost all their recompense from the government, and get less than 12% of their revenues from private insurance. Government funding “has taken market forces out of the field,” said A. Thomas McLellan, Ph.D., a professor in the department of psychiatry at the University of Pennsylvania, and director of the Treatment Research Institute, Philadelphia.

He sees many problems in the field, including the fact that most programs have nothing to offer but group therapy and do not take an evidence-based approach. “If this was another industry, things would change,” he said.

In a survey of 175 programs, 12% closed over 13 months, Dr. McLellan said. Moreover, counselor turnover in all of the programs was roughly 50% a year, and many of the directors–17% of whom had no college education–had less than 1 year on the job. Fifty-four percent of the programs had no physician on staff.

The expert group so far has received a $100,000 grant from the Robert Wood Johnson Foundation, money it has been spending to get organized and obtain information from the state physician health programs about how they manage their recovering doctors.

“What we're after right now is evidence” of what is done and how it works, Dr. DuPont said. “We are optimistic that this effort is going to be helpful.”

SAN DIEGO – Drug abuse treatment has a fairly dismal success rate among most groups, with one notable exception: physicians.

Now, a group of experts wants to find out what it is about doctors or the assistance they receive that is so helpful so that the lessons learned can be applied to treatment for others.

“It's easy to say that physicians are different from other addicts, but our [theoretical] model is that this is a biological disease,” said Dr. Robert L. DuPont at a presentation made by this group of experts at the annual conference of the American Society of Addiction Medicine.

The trigger for this study effort was an article published in the Journal of the American Medical Association last year. The article reported on a study that looked at relapse in 292 physicians in Washington state who had successfully gone through drug or alcohol treatment and were involved in a physician monitoring program.

The aim of the study was to see whether it was true that physicians who abused opiates–especially anesthesiologists–relapsed more often than did physicians who abused primarily other drugs or alcohol.

The study found that opiate abusers did not relapse more frequently, except when they also had a coexisting psychiatric disorder. But the relevant part of the study for the expert group was that only 25% of the physicians had any relapse, said Dr. DuPont, a former director of the National Institute on Drug Abuse who is now in private practice in Rockville, Md.

In contrast, most nonphysicians receive treatment for relapse in the first year after initial treatment.

Some reports suggest physician success rates may be even higher than 70%–75%, the experts said. The experts suspect that one of the obvious reasons that physicians tend to do well is because they have a lot of “recovery capital,” that is, they are educated and have a lot to lose. Another probable reason is that their families tend to be strongly involved in the process.

But it is also true that physicians tend to get enrolled in physician health monitoring programs that last a long time, insist on complete abstinence, conduct drug testing, and do not ignore early warning signs of an impending relapse, such as when the individual begins to opt out of continued counseling or attendance at Alcoholics Anonymous meetings.

The length of the programs may be almost as important as the fact that they can be punitive, because studies suggest that recovery from drug addiction and alcoholism is not really stable for 5 years, said William White, a senior research consultant with Chestnut Health Systems, Bloomington, Ill.

Treatment for the general population tends to be done on an “ER model,” with the active phase of treatment being only a few months or less, Mr. White said.

Some of the experts suggested that major problems in the alcohol/drug abuse treatment industry are being illuminated.

Eighty percent of drug/alcohol treatment programs in this country receive almost all their recompense from the government, and get less than 12% of their revenues from private insurance. Government funding “has taken market forces out of the field,” said A. Thomas McLellan, Ph.D., a professor in the department of psychiatry at the University of Pennsylvania, and director of the Treatment Research Institute, Philadelphia.

He sees many problems in the field, including the fact that most programs have nothing to offer but group therapy and do not take an evidence-based approach. “If this was another industry, things would change,” he said.

In a survey of 175 programs, 12% closed over 13 months, Dr. McLellan said. Moreover, counselor turnover in all of the programs was roughly 50% a year, and many of the directors–17% of whom had no college education–had less than 1 year on the job. Fifty-four percent of the programs had no physician on staff.

The expert group so far has received a $100,000 grant from the Robert Wood Johnson Foundation, money it has been spending to get organized and obtain information from the state physician health programs about how they manage their recovering doctors.

“What we're after right now is evidence” of what is done and how it works, Dr. DuPont said. “We are optimistic that this effort is going to be helpful.”

SAN DIEGO – Methamphetamine abuse may injure the brain, according to new evidence and the experience of clinicians who treat recovering users.

For some, the damage could be permanent. For many, there is an impairment that may be temporary but that interferes with their ability to attend to the short-term treatment most drug abusers get.

“They're just in a fog,” said Dr. Jerome D. Dirkers, medical director of the Montana Chemical Dependency Center, Butte, in an interview at the annual conference of the American Society of Addiction Medicine. “When you try to engage them in treatment, you find they just can't comprehend. If [the user's brain] is not fried, it is at least parboiled.”

In Montana, methamphetamine is the illicit drug most commonly abused by persons coming into treatment, and has been for some time. But Dr. Dirkers has also practiced in South Carolina, where cocaine abuse is more prevalent.

“This [impairment] is something fairly unique to the methamphetamine abuser,” he said.

When the mental fog is temporary, it appears to last about 3–4 months, said Frank J. Vocci Jr., Ph.D., director of the division of pharmacotherapies and medical consequences of drug abuse at the National Institute on Drug Abuse.

“I call it a temporal mismatch, because just when they need their mental faculties–during treatment–they don't have them,” he said in an interview.

A laboratory study of rats given amphetamine three times per week for 5 weeks has shown that amphetamine can induce cognitive deficits. And that study suggested that one of the specific deficits is an inability to make extradimensional set shifts, a cognitive deficit that is also seen in schizophrenia, Dr. Vocci said.

One researcher who has most prominently begun to investigate the effects of methamphetamine abuse on the human brain is Sara L. Simon, Ph.D., a researcher at the integrated substance abuse program (ISAP) of the Neuropsychiatric Institute at the University of California, Los Angeles.

In one of her early studies, Dr. Simon administered a battery of cognitive function tests to recently abstinent abusers and compared them with controls. She reported that there were measurable deficits in the abusers, but that they were specific and perhaps subtle.

In her report, she noted that before her investigation, human studies had looked only at the administration of amphetamine and cognitive functioning, not at its long-term use.

Those studies found, not surprisingly, that amphetamine improved function–probably by increasing focus and concentration–and therefore the notion that amphetamine actually abetted mental function tended to prevail.

Dr. Simon described several of the deficits seen–including problems with word recall and some kinds of abstract reasoning–as being similar to those seen in normal aging (Am. J. Addict. 2000;9:222–31).

Dr. Dirkers noted that methamphetamine abusers in treatment do often seem to function mentally as if they are older than their years.

“They look as though they ought to be functionally well because they are young,” he said. “But they have deficits you would see in someone in their 80s.”

In another of Dr. Simon's studies, PET and structural MRI showed that long-term abusers had severe gray-matter deficits in specific cortical regions, had white-matter hypertrophy that was somewhat greater in the right hemisphere, and had on average 8% less volume in the hippocampus than did controls (J. Neurosci. 2004;24:6028–36).

In a subsequent study using the same technology and complicated functional testing, she reported that abstinent, former abusers have trouble with cognitive vigilance and sustained attention.

Finally, Dr. Simon has compared episodic memory function in abusers who had gone through a drug treatment program and had relapsed, remained abstinent, or continued to use the whole time. Those who relapsed had worse memory than did those who were abstinent, and significantly worse memory than did those who had continued using (J. Subst. Abuse Treat. 2004;27:59–66).

According to a poster presented at the conference, at least some former methamphetamine abusers appear to be aware that their mental faculties are impaired or diminished.

The poster detailed a study reviewing the records of 422 abusers who were followed for 3–5 years after treatment.

Of these abusers, 38% reported having memory, thinking, or concentration problems at some time. Of those who reported such problems, 67% said they were currently experiencing them, said Maureen Hillhouse, Ph.D., who is also a researcher at ISAP.

It is not clear whether this apparent impairment reported by methamphetamine abusers definitely affects treatment outcome. Although some researchers have suggested that methamphetamine abusers have a higher treatment drop-out rate and a higher relapse rate, compared with those who abuse primarily other drugs, other observers have not found evidence of worse outcomes.

A 2004 report from the state of Colorado looked at treatment outcomes from methamphetamine abusers compared with abusers of alcohol and other drugs, and found that on several measures, methamphetamine abusers tended to do about as well as everyone else.

Nevertheless, all the experts interviewed at the meeting said they were convinced that this was an issue that needed to be addressed in treatment.

“Treatment really needs to be designed to accommodate these cognitive deficits we see in meth users,” Dr. Hillhouse said.

Dr. Vocci suggested that some form of pharmacotherapy might be helpful. Some candidate agents have been suggested, including modafinil, the wakefulness drug, which some studies have reported improves the very types of cognition apparently affected by methamphetamine abuse, he noted.

“I would say that the cognitive impairment [in methamphetamine abusers] is universal,” Dr. Dirkers said. “That's why it is such a bad drug. The effects are malignant.”

SAN DIEGO – Methamphetamine abuse may injure the brain, according to new evidence and the experience of clinicians who treat recovering users.

For some, the damage could be permanent. For many, there is an impairment that may be temporary but that interferes with their ability to attend to the short-term treatment most drug abusers get.

“They're just in a fog,” said Dr. Jerome D. Dirkers, medical director of the Montana Chemical Dependency Center, Butte, in an interview at the annual conference of the American Society of Addiction Medicine. “When you try to engage them in treatment, you find they just can't comprehend. If [the user's brain] is not fried, it is at least parboiled.”

In Montana, methamphetamine is the illicit drug most commonly abused by persons coming into treatment, and has been for some time. But Dr. Dirkers has also practiced in South Carolina, where cocaine abuse is more prevalent.

“This [impairment] is something fairly unique to the methamphetamine abuser,” he said.

When the mental fog is temporary, it appears to last about 3–4 months, said Frank J. Vocci Jr., Ph.D., director of the division of pharmacotherapies and medical consequences of drug abuse at the National Institute on Drug Abuse.

“I call it a temporal mismatch, because just when they need their mental faculties–during treatment–they don't have them,” he said in an interview.

A laboratory study of rats given amphetamine three times per week for 5 weeks has shown that amphetamine can induce cognitive deficits. And that study suggested that one of the specific deficits is an inability to make extradimensional set shifts, a cognitive deficit that is also seen in schizophrenia, Dr. Vocci said.

One researcher who has most prominently begun to investigate the effects of methamphetamine abuse on the human brain is Sara L. Simon, Ph.D., a researcher at the integrated substance abuse program (ISAP) of the Neuropsychiatric Institute at the University of California, Los Angeles.

In one of her early studies, Dr. Simon administered a battery of cognitive function tests to recently abstinent abusers and compared them with controls. She reported that there were measurable deficits in the abusers, but that they were specific and perhaps subtle.

In her report, she noted that before her investigation, human studies had looked only at the administration of amphetamine and cognitive functioning, not at its long-term use.

Those studies found, not surprisingly, that amphetamine improved function–probably by increasing focus and concentration–and therefore the notion that amphetamine actually abetted mental function tended to prevail.

Dr. Simon described several of the deficits seen–including problems with word recall and some kinds of abstract reasoning–as being similar to those seen in normal aging (Am. J. Addict. 2000;9:222–31).

Dr. Dirkers noted that methamphetamine abusers in treatment do often seem to function mentally as if they are older than their years.

“They look as though they ought to be functionally well because they are young,” he said. “But they have deficits you would see in someone in their 80s.”

In another of Dr. Simon's studies, PET and structural MRI showed that long-term abusers had severe gray-matter deficits in specific cortical regions, had white-matter hypertrophy that was somewhat greater in the right hemisphere, and had on average 8% less volume in the hippocampus than did controls (J. Neurosci. 2004;24:6028–36).

In a subsequent study using the same technology and complicated functional testing, she reported that abstinent, former abusers have trouble with cognitive vigilance and sustained attention.

Finally, Dr. Simon has compared episodic memory function in abusers who had gone through a drug treatment program and had relapsed, remained abstinent, or continued to use the whole time. Those who relapsed had worse memory than did those who were abstinent, and significantly worse memory than did those who had continued using (J. Subst. Abuse Treat. 2004;27:59–66).

According to a poster presented at the conference, at least some former methamphetamine abusers appear to be aware that their mental faculties are impaired or diminished.

The poster detailed a study reviewing the records of 422 abusers who were followed for 3–5 years after treatment.

Of these abusers, 38% reported having memory, thinking, or concentration problems at some time. Of those who reported such problems, 67% said they were currently experiencing them, said Maureen Hillhouse, Ph.D., who is also a researcher at ISAP.

It is not clear whether this apparent impairment reported by methamphetamine abusers definitely affects treatment outcome. Although some researchers have suggested that methamphetamine abusers have a higher treatment drop-out rate and a higher relapse rate, compared with those who abuse primarily other drugs, other observers have not found evidence of worse outcomes.

A 2004 report from the state of Colorado looked at treatment outcomes from methamphetamine abusers compared with abusers of alcohol and other drugs, and found that on several measures, methamphetamine abusers tended to do about as well as everyone else.

Nevertheless, all the experts interviewed at the meeting said they were convinced that this was an issue that needed to be addressed in treatment.

“Treatment really needs to be designed to accommodate these cognitive deficits we see in meth users,” Dr. Hillhouse said.

Dr. Vocci suggested that some form of pharmacotherapy might be helpful. Some candidate agents have been suggested, including modafinil, the wakefulness drug, which some studies have reported improves the very types of cognition apparently affected by methamphetamine abuse, he noted.

“I would say that the cognitive impairment [in methamphetamine abusers] is universal,” Dr. Dirkers said. “That's why it is such a bad drug. The effects are malignant.”

SAN DIEGO – Methamphetamine abuse may injure the brain, according to new evidence and the experience of clinicians who treat recovering users.

For some, the damage could be permanent. For many, there is an impairment that may be temporary but that interferes with their ability to attend to the short-term treatment most drug abusers get.

“They're just in a fog,” said Dr. Jerome D. Dirkers, medical director of the Montana Chemical Dependency Center, Butte, in an interview at the annual conference of the American Society of Addiction Medicine. “When you try to engage them in treatment, you find they just can't comprehend. If [the user's brain] is not fried, it is at least parboiled.”

In Montana, methamphetamine is the illicit drug most commonly abused by persons coming into treatment, and has been for some time. But Dr. Dirkers has also practiced in South Carolina, where cocaine abuse is more prevalent.

“This [impairment] is something fairly unique to the methamphetamine abuser,” he said.

When the mental fog is temporary, it appears to last about 3–4 months, said Frank J. Vocci Jr., Ph.D., director of the division of pharmacotherapies and medical consequences of drug abuse at the National Institute on Drug Abuse.

“I call it a temporal mismatch, because just when they need their mental faculties–during treatment–they don't have them,” he said in an interview.

A laboratory study of rats given amphetamine three times per week for 5 weeks has shown that amphetamine can induce cognitive deficits. And that study suggested that one of the specific deficits is an inability to make extradimensional set shifts, a cognitive deficit that is also seen in schizophrenia, Dr. Vocci said.

One researcher who has most prominently begun to investigate the effects of methamphetamine abuse on the human brain is Sara L. Simon, Ph.D., a researcher at the integrated substance abuse program (ISAP) of the Neuropsychiatric Institute at the University of California, Los Angeles.

In one of her early studies, Dr. Simon administered a battery of cognitive function tests to recently abstinent abusers and compared them with controls. She reported that there were measurable deficits in the abusers, but that they were specific and perhaps subtle.

In her report, she noted that before her investigation, human studies had looked only at the administration of amphetamine and cognitive functioning, not at its long-term use.

Those studies found, not surprisingly, that amphetamine improved function–probably by increasing focus and concentration–and therefore the notion that amphetamine actually abetted mental function tended to prevail.

Dr. Simon described several of the deficits seen–including problems with word recall and some kinds of abstract reasoning–as being similar to those seen in normal aging (Am. J. Addict. 2000;9:222–31).

Dr. Dirkers noted that methamphetamine abusers in treatment do often seem to function mentally as if they are older than their years.

“They look as though they ought to be functionally well because they are young,” he said. “But they have deficits you would see in someone in their 80s.”

In another of Dr. Simon's studies, PET and structural MRI showed that long-term abusers had severe gray-matter deficits in specific cortical regions, had white-matter hypertrophy that was somewhat greater in the right hemisphere, and had on average 8% less volume in the hippocampus than did controls (J. Neurosci. 2004;24:6028–36).

In a subsequent study using the same technology and complicated functional testing, she reported that abstinent, former abusers have trouble with cognitive vigilance and sustained attention.

Finally, Dr. Simon has compared episodic memory function in abusers who had gone through a drug treatment program and had relapsed, remained abstinent, or continued to use the whole time. Those who relapsed had worse memory than did those who were abstinent, and significantly worse memory than did those who had continued using (J. Subst. Abuse Treat. 2004;27:59–66).

According to a poster presented at the conference, at least some former methamphetamine abusers appear to be aware that their mental faculties are impaired or diminished.

The poster detailed a study reviewing the records of 422 abusers who were followed for 3–5 years after treatment.

Of these abusers, 38% reported having memory, thinking, or concentration problems at some time. Of those who reported such problems, 67% said they were currently experiencing them, said Maureen Hillhouse, Ph.D., who is also a researcher at ISAP.

It is not clear whether this apparent impairment reported by methamphetamine abusers definitely affects treatment outcome. Although some researchers have suggested that methamphetamine abusers have a higher treatment drop-out rate and a higher relapse rate, compared with those who abuse primarily other drugs, other observers have not found evidence of worse outcomes.

A 2004 report from the state of Colorado looked at treatment outcomes from methamphetamine abusers compared with abusers of alcohol and other drugs, and found that on several measures, methamphetamine abusers tended to do about as well as everyone else.

Nevertheless, all the experts interviewed at the meeting said they were convinced that this was an issue that needed to be addressed in treatment.

“Treatment really needs to be designed to accommodate these cognitive deficits we see in meth users,” Dr. Hillhouse said.

Dr. Vocci suggested that some form of pharmacotherapy might be helpful. Some candidate agents have been suggested, including modafinil, the wakefulness drug, which some studies have reported improves the very types of cognition apparently affected by methamphetamine abuse, he noted.

“I would say that the cognitive impairment [in methamphetamine abusers] is universal,” Dr. Dirkers said. “That's why it is such a bad drug. The effects are malignant.”