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by Richard G. Soper, MD, JD, MS, FASAM, ABAM Diplomate | Aug 11, 2014
The July/August 2014 of ASAM’s official journal, Journal of Addiction Medicine contains a superb review article, Science and Electronic Cigarettes: Current Data, Future Needs.
The current model of the e-cigarette was invented and taken to market by Chinese pharmacist Hon Lik in 2003, entering the United States market in 2007 (Maron, 2014).
The FDA first attempted to regulate the e-cigarettes as drug-delivery devices, defined under federal law as items “intended to affect the structure or any function of the body.” However, e-cigarette company NJOY sued the agency, arguing that the nicotine-containing devices were similar to tobacco products- which had not been under FDA regulation. A federal appeals court ruled in December 2010 that the agency lacked authority over e-cigs, finding they offer only the recreational benefits of a regular cigarette. That legal decision allowed sales of e-cigarettes to proceed but did not address the safety of the products (Maron, 2014). President Obama signed the Family Smoking Prevention and Tobacco Control Act in 2009. In the spring of this year, the FDA proposed extending the act to include e-cigarettes, pipe tobacco, cigars, hookah water pipes, nicotine gels, and dissolvable forms of nicotine.
As of this date, the FDA does not regulate recreational nicotine products. Manufacturers have no requirement for consumer protection. Thus, there are no warning labels, no child resistant packaging and significant media advertising. Television advertisements for cigarettes have been banned in our country since 1971, but in the past few years supposedly healthier, battery-powered alternatives are seen in numerous prime-time programs. Electronic cigarettes had significant air time during the 2014 Super Bowl and are frequent products of late-night talk show advertising (Maron, 2014).
While e-cigarettes are being marketed as healthy options for nicotine use, the scientific data, although limited, does not validate this position. Long-term consequences of electronic cigarette use have not been determined. “The increased use of e-cigarettes by teens is deeply troubling,” said CDC Director Tom Frieden, MD, in a press release. “Nicotine is a highly addictive drug. Many teens who start with e-cigarettes may be condemned to struggling with a lifelong addiction to nicotine and conventional cigarettes.”
Concern has been raised about manufacturers catering to the teenage demographic in the hopes of snaring young users. Online kits provide flavors including cherry, vanilla, grape, cola and so on. Some states have gone about regulating e-cigarettes themselves, while awaiting further action by the FDA.
Proponents of e-cigarettes claim that the user is limiting the risks for harm by inhaling vapor, not smoke. “This illusive ‘safety’ of ENDS can be enticing to consumers; however, the chemicals used in electronic cigarettes have not been fully disclosed, and there are no adequate data on their emissions,” explains the WHO website. A study presented at the 2013 European Respiratory Annual Congress found significant airway resistance and decreased oxygen saturation among study subjects who used the e-cigarettes.
The electronic cigarette has four ingredients; nicotine, propylene glycol, vegetable glycerin and flavoring (Electronic Cigarette Consumer Reviews, 2014). Tobacco is not included. Some concerns have been raised not only about the potential effects of inhaling otherwise “safe” ingredients, but about the heating device itself and the solution in the e-cigarette. Several studies have suggested the vapors of e-cigarettes can contain microscopic particulate matter, tin, chromium, nickel and other heavy metals, which can cause pulmonary pathology (Kleinstreuer, 2013).
With an e-cigarette, the user inhales vaporized liquid nicotine instead of the tobacco smoke that would be inhaled from a conventional cigarette. This is the alternative that is touted as “healthy” or less harmful (Trimarchi, 2014).
The process of smoking an e-cigarette is called “vaping”. Nicotine addiction, as most other addictions, is cue driven. The activity of using an e-cigarette is a powerful cue as it mimics the activity of regular smoking (Pepper, 2014).
The unregulated and unrestricted availability of highly concentrated ENDS, has led to increased exposure and potentially significant nicotine toxicity. This is confirmed by the National Poison Data System, which has reported triple the number of childhood exposures to nicotine in 2013 compared with 2012.
Nicotine is a plant derived parasympathomimetic alkaloid. Nicotine is essentially a highly agonist of the nicotinic acetylcholine receptors. Nicotine stimulates the reticular activating system in addition to stimulating a dopamine release. Emerging research also links nicotine to impairment of the immune system (Bassett, 2014).
With dosage increase of nicotine, cardiovascular effects can occur, including tachycardia and hypertension, gastrointestinal disturbance and at toxic levels neuromuscular blockade and CNS toxicity (Kuschner, 2011).
As physicians and healthcare professionals, especially addiction medicine specialists, what are our reactions and responses to our patients, community members, colleagues, family when we are asked about electronic cigarettes?
It seems reasonable that we continue to advise any current non-tobacco user to not start and not consider trying any of the currently available methods of using nicotine. As we also advise our patients regarding opiates, benzodiazepines, alcohol and other risk behaviors.
Considering a current patient that uses nicotine, who's considering cessation, how do we respond? Is this an opportunity to discuss life change with our patient? When a patient inquires about my opinion regarding e-cigarettes, it is an opportunity to begin discussing a goal of nicotine cessation and developing a treatment strategy.
A recent survey of North Carolina physicians published in PLOS ONE measured physicians’ attitudes toward e-cigarettes use by adult smokers.
“Even in the absence of evidence regarding the health impact of e-cigarettes and other vaping devices, a third of physicians we surveyed are recommending e-cigarettes to their patients to help quit smoking”, said Leah Ranney, PhD, one of the authors of the survey. “Yet, e-cigarettes are not approved by the FDA for smoking cessation.”
Clinically, with each patient encounter, I remember, first do no harm…
Recently we added to our patient intake forms these questions-
With any patient encounter I want to maintain the patient’s respect and trust in my providing guidance to healthy life choices. One of my goals is to assist with the patient attaining their full potential.
Treat Addiction, Save Lives
Jessica K Pepper, S. L. (2014). Effects of Advertisements on Smokers' Interest in Trying e-Cigarettes: the Roles of Product Comparison and Visual Cues. Tobacco Control.
Maria Trimarchi, S. C. (2014). How Stuff Works. Retrieved August 8, 2014, from http://health.howstuffworks.com/wellness/smoking-cessation/10-facts-about-e-cigarettes.htm#page=0
Maron, D. F. (2014, May 1). Smoke Screen: Are E-Cigarettes Safe? Scientific American.
Robert A. Bassett, D. (2014, May 27). Medscape Multispecialty. Retrieved August 8, 2014, from Medscape: http://www.medscape.com/viewarticle/825199
Ware G Kuschner, S. R. (2011). Electronic Cigarettes and Thirdhand Tobacco Smoke: Two Emerging Health Care Challenges for the Primary Care Provider. International Journal of General Medicine, 115-120.
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by Martha Bebinger
The first time Jeremy Wurzburg left a heroin treatment program, he planned to begin Narcotics Anonymous and do all the right things to stay off drugs. But one week later, the skinny, pale young man was hanging out with a guy who was also in early recovery, experiencing what Wurzburg, now 21, has come to realize is a typical turning point for recovering addicts: two guys sitting casually in a car, poised to use drugs again.
"We're not sure whether we're going to use or not," he says, "and someone makes like a half joke – 'We could just go out and drink right now,' or something. And the other one is like, 'Yeah let's do that. Sounds good.' "
From that first drink, Wurzburg was quickly back to heroin, his drug of choice. Most recovery programs don't — and maybe can't — prepare freshly discharged patients to fight that urge on their own, he says.
High Relapse Rate In First Year Of Recovery
"Once I got out of treatment into the real world, it was a big shock," Wurzburg says.
Of patients addicted to heroin who are able to quit their habit, 40 to 60 percent relapse within the first year — often within the first weeks of finishing a treatment program, studies show.
Wurzburg is now in a new program aimed at young adults. It's a one-year pilot project run by Gosnold, a network of addiction treatment services on Cape Cod.
As part of the program, Wurzburg agreed to live in a household that doesn't allow the use of drugs or alcohol. He agreed to attend daily 12-step group meetings and to get individual counseling. Perhaps most importantly, Wurzburg now has help daily — sometimes hourly — from a recovery coach.
Coaches in the Gosnold program get much more involved in the lives of the people they're mentoring than the typical sponsor in a Narcotics Anonymous program would.
The recovery coaches show patients "how to manage their emotions," says Wurzburg's coach, Kristoph Pydynkowski — "how to fill out job applications, how to go to meetings, how to take care of themselves, how to go back to school." Pydynkowski, who also calls himself a "cheerleader, a beacon of hope," quit using heroin seven years ago.
Much More Than A Sponsor
Pydynkowski ticks off the list of things he and Wurzburg now do together: visits with Wurzburg's parents, a reunion in Los Angeles with Wurzburg's twin brother, fishing and 6:15 a.m. trips to a coffee shop before attending NA meetings. Pydynkowski helps each of the 10 patients he manages create and follow a weekly recovery treatment plan.
Ray Tamasi, the director at Gosnold, says this aggressively supportive approach is paying off. His evidence? A comparison of medical records collected during the year before the program's inception to records collected in the year after its start. The comparison is striking. Fifty-four young adults (ages 18 to 28) who participated in the coaching program saw an 83 percent reduction in admissions to rehabilitation facilities during their year of intensive coaching. Emergency room admissions also dropped — from 16 in the year before the program, down to one during the year of coaching.
Coaching Costs Save States Money
Because fewer people had to be readmitted to rehab centers, Tamasi says, the program saved the state an estimated 37 percent in total outlay.
"Think about the cost/benefit," he says, "if at 19, you're cycling in and out of treatment, but there's an alternative — going back to school and living life."
The program makes sense economically, he says, "and it makes sense simply from the value we place on the human life."
As Vermont expands addiction treatment services, it is also coming to grips with one of the most difficult and emotional aspects of the problem: pregnant women addicted to opiates.
And it may make more sense to state legislators than simply increasing the number of beds in recovery facilities, he says, "because you can't just keep people in beds all the time. They have to come out at some point."
Gov. Deval Patrick's administration is ready to spend $20 million on two dozen initiatives aimed at curbing a surge in addiction to heroin and other opiates in Massachusetts. A task force report recommended more peer support and home-based counseling. Health insurers and state Medicaid leaders have said they will look into funding for recovery coaches, but there is right now no plan in place.
New York and Tennessee pay for peer coaches to help treat addiction through Medicaid — something Massachusetts is taking a look at. The use of coaches is built on the idea that addiction is a disease that patients will deal for life, a disease that will be treated by primary doctors in a general medical setting, not just in rehabilitation facilities.
Pydynkowski is teaching his patients to treat addiction as they would hypertension or diabetes.
It's just like taking insulin, he says, "watching my diet, getting my blood work drawn, going to different appointments, walking on the treadmill — making sure I'm taking care of myself."
This story is part of a reporting partnership among NPR, WBUR and Kaiser Health News.
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A new, lifesaving product aimed at reducing the death toll from heroin abuse—developed by a professor at the University of Kentucky College of Pharmacy—is in its final round of clinical trials and has received Fast Track designation by the Food and Drug Administration.
The product, a nasal spray application of the anti-opioid drug naloxone, was developed by Daniel Wermeling, UK professor of pharmacy practice and science, through his startup company AntiOp Inc. Naloxone is the standard treatment for suspected opioid overdose, already in use by emergency rooms and emergency medical technicians across the country. Opioids are the class of pain-killing drugs that are related to morphine, including prescription drugs such as hydrocodone and oxycodone, as well as illegal drugs such as heroin.
"The goal is to make the medication available to patients at high risk of opioid overdose, and to caregivers, including family members, who may lack specialized medical training," Wermeling said. "The treatment could be given in anticipation of EMS arrival, advancing the continuum of care and ultimately saving lives."
Nationwide, deaths from opioid overdose are on the rise, according to data from the Centers for Disease Control and Prevention. Kentucky, long troubled by widespread abuse of prescription opioids, has seen a dramatic rise in deaths from heroin overdose in recent years. In autopsies from 2013, the state medical examiner attributed 230 deaths to heroin overdose, an increase of more than 60 percent from the previous year.
"Too many Kentucky families have experienced the tragedy of seeing a loved one's life cut short by a drug overdose," Capilouto said. "The epidemic of opioid abuse in our state presents an enormous and urgent challenge, not only for health care providers and law enforcement, but also for us here at the University of Kentucky. Dr. Wermeling's project is putting a powerful new tool into the hands of those on the front line of the fight against heroin, both here in Kentucky and beyond. This type of innovation embodies the three main components of the university's mission—education, research and, above all, service."
UK College of Pharmacy Dean Timothy S. Tracy said Wermeling's work also provides an illustration of "bench-to-bedside" research in action.
"Dr. Wermeling's project is a great example of how UK College of Pharmacy faculty are working each and every day to create healthier Kentucky communities," Tracy said. "Dr. Wermeling and his collaborative team of research colleagues saw a problem facing families in Kentucky and across the nation and developed an innovative solution. That type of translational approach is important to our college, this university, and, of course, the future of our Commonwealth."
The Fast Track program of the FDA is designed to expedite the development and review of new drugs that are intended to treat serious or life-threatening conditions and that demonstrate the potential to address unmet medical needs. Fast Track-designated drugs ordinarily qualify for priority review, thereby expediting the FDA review process.
"As an educator, pharmacist, researcher and entrepreneur, being able to work on this naloxone project has been a dream come true," Wermeling said. "I often tell my students and colleagues that this project has allowed me to use all of the skills I have learned over the years. It has been the ultimate problem-solving project, requiring me to utilize my pharmacological skills, my drug delivery knowledge, my business and marketing skills—all at the same time.
"At the end of the day, however, this project has always been about people. It has always been about utilizing the knowledge and skills that we have to improve patient care."
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Just a reminder if you ever are feeling down.
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by ASAM Staff | Jul 28, 2014
ASAM, the largest American medical professional society dedicated to the treatment and prevention of addiction, has examined the medical and recreational use of marijuana and the public health consequences of both. In neither case does the Society find sufficient evidence to support the notion that any perceived public health benefits of using the illicit drug outweigh the dangers to marijuana users and to their communities.
According to the National Institute on Drug Abuse, marijuana is an intoxicating drug that impairs memory, motor function, and, when smoked, short-term and long-term respiratory health. And, for nearly one in ten habitual users, marijuana is addictive and can lead to chronic brain disease.
“Addiction is a chronic brain disease that can affect people at any age. In fact, the younger one initiates alcohol or drug use, the greater the likelihood that he or she has addictive disease,” says Dr. Gitlow. “The addicted brain doesn’t care if the substance is alcohol or marijuana; both can be very dangerous, particularly to the naïve user.”
ASAM rejects the Times’ position that marijuana has been treated in the same manner as alcohol, and that its long-held illegality is akin to Prohibition. As Dr. Gitlow says, the paper’s alcohol/Prohibition analogy is poor on several levels: “At the start of Prohibition, alcohol consumption per capita was twice what it was at the end of Prohibition, proving Prohibition reduced the public's alcohol intake. Likewise, the rate of alcohol-associated illness dropped. Prohibition was eventually a political failure, but it was an impressive success from a public health stand point.”
ASAM supports public policies that provide prevention and treatment for the chronic brain disease of substance addiction that affects 23 million Americans. Dr. Gitlow cautions that “this requires, however, that substances of abuse are not made more easily available or made to seem less dangerous than they really are.”
ASAM encourages The New York Times to re-examine its official editorial stance and to start building public awareness for addiction as a chronic brain disease that has proven methods for prevention and treatment, whether the addictive substance is alcohol, nicotine, marijuana or prescription opioids.
ASAM looks forward to partnering with The New York Times and other leading media and public education outlets to advance science-based policies that deter unhealthy substance use of all types and promote access to medical and behavioral treatment for those who need it.
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There are approximately 6 million people in the US living with paralysis - the loss of muscle function caused by nerve damage. Now, researchers from the Salk Institute of Biological Studies in La Jolla, CA, have identified a small molecule that they say could trigger nerve repair in humans, paving the way for new treatments for paralysis.
Read the full story here: http://www.medicalnewstoday.com/articles/280691.php
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CHERI CHENG - Update Date: Jul 18, 2014 03:02 PM EDT
Even though marijuana is known for creating a relaxing state of mind, in some rare situations, smoking the drug can lead to paranoia. In a new study, researchers from Britain set out
"The study very convincingly shows that cannabis [marijuana] can cause short-term paranoia in some people," study leader Daniel Freeman, professor of clinical psychology at the University of Oxford in England, said in a university news release reported by Philly. "But more importantly it shines a light on the way our mind encourages paranoia. Paranoia is likely to occur when we are worried, think negatively about ourselves, and experience unsettling changes in our perceptions."
For this study, the team recruited 121 participants between the ages of 21 and 50. All of them had reported using marijuana at least once prior to the study. The researchers administered THC via an injection, which had the strength of one strong joint, to two-thirds of the participants. The remaining one-third received an injection of a placebo drug.
The researchers found that about 50 percent of the people who received the THC injection had paranoid thoughts whereas only 30 percent of the people from the placebo group did. THC was the direct cause of the paranoia in roughly one out of five people. People's paranoid thoughts diminished as the THC left their bloodstream. The researchers noted that other factors did contribute to people's risk of developing paranoia after their injection. People who dealt with low self-esteem, anxiety or worrying were more likely to become paranoid.
"Paranoia is excessive thinking that other people are trying to harm us. It's very common because in our day-to-day lives we have to weigh up whether to trust or mistrust, and when we get it wrong - that's paranoia. Many people have a few paranoid thoughts, and a few people have many paranoid thoughts," Freeman said according to Medical Xpress. "The study identifies a number of highly plausible ways in which our mind promotes paranoid fears. Worry skews our view of the world and makes us focus on perceived threat. Thinking we are inferior means we feel vulnerable to harm. Just small differences in our perception can make us feel that something strange and even frightening is going on."
The study was published in the journal, Schizophrenia Bulletin.
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