Renée Matthews

BETHESDA, MD. – Generalist chief residents who were trained in opioid risk management in immersion programs were more confident in dealing with the risks, showed improvement in their clinical practice skills, and were better prepared and more willing to pass on their knowledge to their trainees than were those who did not receive the training, data from a small study of chief residents show.

Such programs, known as Chief Resident Immersion Training (CRIT) programs, are one way of addressing the need for better physician training in opioid risk management, Dr. Daniel P. Alford said at the annual conference of the Association for Medical Education and Research in Substance Abuse.

Dr. Alford, of Boston University, and his colleagues initially targeted generalist chief residents specializing in internal medicine, family practice, and emergency medicine because providers in those specialties are increasingly prescribing opioids for chronic pain at a time when opioid abuse is becoming a public health problem. However, the access of chief residents to training in risk management is inadequate despite screening and monitoring recommendations from professional bodies.

The researchers expanded the course content in opioid risk management in the 2007 and 2008 CRIT programs in addiction medicine to include addiction-screening tools, controlled substance agreements, and monitoring strategies such as pill counts and urine drug testing. They conducted electronic surveys of the participants about their confidence in dealing with opioid risk management as well as their clinical and teaching practices at baseline (pre-CRIT) and 6 months after they had completed the program (post-CRIT).

The 43 chief residents were from 36 residency programs. Eighty-six percent specialized in internal medicine, 9% in family medicine, and 5% in emergency medicine. All of them completed the baseline survey; 1 did not complete the 6-month follow-up, and 2 of the remaining 42 did not provide complete responses for all of the questions. The changes in confidence, clinical practices, and teaching practices were rated on a 5-point Likert scale, and a P value of .05 was deemed significant.

The changes in confidence from baseline to post-CRIT in identifying substance abuse in chronic pain patients and in treating high-risk patients with chronic pain were significant. Confidence in identifying abuse went from 2.8 at baseline to 3.5 at 6 months (1 = not at all, 5 = very confident) and in treating high-risk patients, it went from 2.2 to 3.7 (P less than .0001 for both). One CR did not complete the post-CRIT confidence questions.

Future research should focus on the impact of the CRIT program on those who are trained by the chief residents, Dr. Alford said.

He and his colleagues had no financial disclosures. The study was funded by the National Institute on Drug Abuse.

BETHESDA, MD. – Generalist chief residents who were trained in opioid risk management in immersion programs were more confident in dealing with the risks, showed improvement in their clinical practice skills, and were better prepared and more willing to pass on their knowledge to their trainees than were those who did not receive the training, data from a small study of chief residents show.

Such programs, known as Chief Resident Immersion Training (CRIT) programs, are one way of addressing the need for better physician training in opioid risk management, Dr. Daniel P. Alford said at the annual conference of the Association for Medical Education and Research in Substance Abuse.

Dr. Alford, of Boston University, and his colleagues initially targeted generalist chief residents specializing in internal medicine, family practice, and emergency medicine because providers in those specialties are increasingly prescribing opioids for chronic pain at a time when opioid abuse is becoming a public health problem. However, the access of chief residents to training in risk management is inadequate despite screening and monitoring recommendations from professional bodies.

The researchers expanded the course content in opioid risk management in the 2007 and 2008 CRIT programs in addiction medicine to include addiction-screening tools, controlled substance agreements, and monitoring strategies such as pill counts and urine drug testing. They conducted electronic surveys of the participants about their confidence in dealing with opioid risk management as well as their clinical and teaching practices at baseline (pre-CRIT) and 6 months after they had completed the program (post-CRIT).

The 43 chief residents were from 36 residency programs. Eighty-six percent specialized in internal medicine, 9% in family medicine, and 5% in emergency medicine. All of them completed the baseline survey; 1 did not complete the 6-month follow-up, and 2 of the remaining 42 did not provide complete responses for all of the questions. The changes in confidence, clinical practices, and teaching practices were rated on a 5-point Likert scale, and a P value of .05 was deemed significant.

The changes in confidence from baseline to post-CRIT in identifying substance abuse in chronic pain patients and in treating high-risk patients with chronic pain were significant. Confidence in identifying abuse went from 2.8 at baseline to 3.5 at 6 months (1 = not at all, 5 = very confident) and in treating high-risk patients, it went from 2.2 to 3.7 (P less than .0001 for both). One CR did not complete the post-CRIT confidence questions.

Future research should focus on the impact of the CRIT program on those who are trained by the chief residents, Dr. Alford said.

He and his colleagues had no financial disclosures. The study was funded by the National Institute on Drug Abuse.

BETHESDA, MD. – Generalist chief residents who were trained in opioid risk management in immersion programs were more confident in dealing with the risks, showed improvement in their clinical practice skills, and were better prepared and more willing to pass on their knowledge to their trainees than were those who did not receive the training, data from a small study of chief residents show.

Such programs, known as Chief Resident Immersion Training (CRIT) programs, are one way of addressing the need for better physician training in opioid risk management, Dr. Daniel P. Alford said at the annual conference of the Association for Medical Education and Research in Substance Abuse.

Dr. Alford, of Boston University, and his colleagues initially targeted generalist chief residents specializing in internal medicine, family practice, and emergency medicine because providers in those specialties are increasingly prescribing opioids for chronic pain at a time when opioid abuse is becoming a public health problem. However, the access of chief residents to training in risk management is inadequate despite screening and monitoring recommendations from professional bodies.

The researchers expanded the course content in opioid risk management in the 2007 and 2008 CRIT programs in addiction medicine to include addiction-screening tools, controlled substance agreements, and monitoring strategies such as pill counts and urine drug testing. They conducted electronic surveys of the participants about their confidence in dealing with opioid risk management as well as their clinical and teaching practices at baseline (pre-CRIT) and 6 months after they had completed the program (post-CRIT).

The 43 chief residents were from 36 residency programs. Eighty-six percent specialized in internal medicine, 9% in family medicine, and 5% in emergency medicine. All of them completed the baseline survey; 1 did not complete the 6-month follow-up, and 2 of the remaining 42 did not provide complete responses for all of the questions. The changes in confidence, clinical practices, and teaching practices were rated on a 5-point Likert scale, and a P value of .05 was deemed significant.

The changes in confidence from baseline to post-CRIT in identifying substance abuse in chronic pain patients and in treating high-risk patients with chronic pain were significant. Confidence in identifying abuse went from 2.8 at baseline to 3.5 at 6 months (1 = not at all, 5 = very confident) and in treating high-risk patients, it went from 2.2 to 3.7 (P less than .0001 for both). One CR did not complete the post-CRIT confidence questions.

Future research should focus on the impact of the CRIT program on those who are trained by the chief residents, Dr. Alford said.

He and his colleagues had no financial disclosures. The study was funded by the National Institute on Drug Abuse.

BETHESDA, MD. — Generalist chief residents who were trained in opioid risk management in immersion programs were more confident in dealing with the risks, showed improvement in their clinical practice skills, and were better prepared and more willing to pass on their knowledge to their trainees, data from a small study of chief residents show.

Such programs, known as Chief Resident Immersion Training (CRIT) programs, are one way of addressing the need for better physician training in opioid risk management, Dr. Daniel P. Alford said at the annual conference of the Association for Medical Education and Research in Substance Abuse.

Dr. Alford, of Boston University, and his colleagues initially targeted generalist chief residents specializing in internal medicine, family practice, and emergency medicine because providers in those specialties are increasingly prescribing opioids for chronic pain at a time when opioid abuse is becoming a public health problem. However, the access of chief residents to training in risk management is inadequate despite screening and monitoring recommendations from professional bodies.

The researchers expanded the course content in opioid risk management in the 2007 and 2008 CRIT programs in addiction medicine to include addiction-screening tools, controlled substance agreements, and monitoring strategies such as pill counts and urine drug testing. They conducted electronic surveys of the participants about their confidence in dealing with opioid risk management as well as their clinical and teaching practices at baseline (pre-CRIT) and 6 months after they had completed the program (post-CRIT).

The 43 chief residents were from 36 residency programs. Eighty-six percent specialized in internal medicine, 9% in family medicine, and 5% in emergency medicine. All of them completed the baseline survey; 1 did not complete the 6-month follow-up, and 2 of the remaining 42 did not provide complete responses for all of the questions. The changes in confidence, clinical practices, and teaching practices were rated on a 5-point Likert scale, and a P value of .05 was deemed significant.

The changes in confidence from baseline to post-CRIT in identifying substance abuse in chronic pain patients and in treating high-risk patients with chronic pain were significant. Confidence in identifying abuse went from 2.8 at baseline to 3.5 at 6 months (1 = not at all, 5 = very confident) and in treating high-risk patients, it went from 2.2 to 3.7 (P less than .0001 for both). One CR did not complete the post-CRIT confidence questions.

In regard to changes in clinical practices, the differences were highly significant for the frequency of using a validated substance abuse screening tool (2.3 to 3.3 [1 = never, 3 = half of the time, 5 = always]; P less than .0001) and frequency using agreements or contracts and routine drug testing (2.9 to 3.5 and 2.3 to 3.3, respectively; P less than .001 for both). However, when it came to conducting routine pill counts, there was a nonsignificant decrease (2.3 to 2.2; P = .46). Dr. Alford said the decrease likely occurred because it is difficult to do a routine pill count during a brief primary care visit. “The count is often done with support staff—for example nursing—assistance, which is not universally available to physicians in training [or] chief residents,” he said.

Among the limitations of the study, Dr. Alford listed the absence of a nonintervention control group. He point out that the data were self-reported, which might have resulted in a social desirability bias.

Dr. Alford and his colleagues had no financial disclosures. The study was funded by the National Institute on Drug Abuse.

BETHESDA, MD. — Generalist chief residents who were trained in opioid risk management in immersion programs were more confident in dealing with the risks, showed improvement in their clinical practice skills, and were better prepared and more willing to pass on their knowledge to their trainees, data from a small study of chief residents show.

Such programs, known as Chief Resident Immersion Training (CRIT) programs, are one way of addressing the need for better physician training in opioid risk management, Dr. Daniel P. Alford said at the annual conference of the Association for Medical Education and Research in Substance Abuse.

Dr. Alford, of Boston University, and his colleagues initially targeted generalist chief residents specializing in internal medicine, family practice, and emergency medicine because providers in those specialties are increasingly prescribing opioids for chronic pain at a time when opioid abuse is becoming a public health problem. However, the access of chief residents to training in risk management is inadequate despite screening and monitoring recommendations from professional bodies.

The researchers expanded the course content in opioid risk management in the 2007 and 2008 CRIT programs in addiction medicine to include addiction-screening tools, controlled substance agreements, and monitoring strategies such as pill counts and urine drug testing. They conducted electronic surveys of the participants about their confidence in dealing with opioid risk management as well as their clinical and teaching practices at baseline (pre-CRIT) and 6 months after they had completed the program (post-CRIT).

The 43 chief residents were from 36 residency programs. Eighty-six percent specialized in internal medicine, 9% in family medicine, and 5% in emergency medicine. All of them completed the baseline survey; 1 did not complete the 6-month follow-up, and 2 of the remaining 42 did not provide complete responses for all of the questions. The changes in confidence, clinical practices, and teaching practices were rated on a 5-point Likert scale, and a P value of .05 was deemed significant.

The changes in confidence from baseline to post-CRIT in identifying substance abuse in chronic pain patients and in treating high-risk patients with chronic pain were significant. Confidence in identifying abuse went from 2.8 at baseline to 3.5 at 6 months (1 = not at all, 5 = very confident) and in treating high-risk patients, it went from 2.2 to 3.7 (P less than .0001 for both). One CR did not complete the post-CRIT confidence questions.

In regard to changes in clinical practices, the differences were highly significant for the frequency of using a validated substance abuse screening tool (2.3 to 3.3 [1 = never, 3 = half of the time, 5 = always]; P less than .0001) and frequency using agreements or contracts and routine drug testing (2.9 to 3.5 and 2.3 to 3.3, respectively; P less than .001 for both). However, when it came to conducting routine pill counts, there was a nonsignificant decrease (2.3 to 2.2; P = .46). Dr. Alford said the decrease likely occurred because it is difficult to do a routine pill count during a brief primary care visit. “The count is often done with support staff—for example nursing—assistance, which is not universally available to physicians in training [or] chief residents,” he said.

Among the limitations of the study, Dr. Alford listed the absence of a nonintervention control group. He point out that the data were self-reported, which might have resulted in a social desirability bias.

Dr. Alford and his colleagues had no financial disclosures. The study was funded by the National Institute on Drug Abuse.

BETHESDA, MD. — Generalist chief residents who were trained in opioid risk management in immersion programs were more confident in dealing with the risks, showed improvement in their clinical practice skills, and were better prepared and more willing to pass on their knowledge to their trainees, data from a small study of chief residents show.

Such programs, known as Chief Resident Immersion Training (CRIT) programs, are one way of addressing the need for better physician training in opioid risk management, Dr. Daniel P. Alford said at the annual conference of the Association for Medical Education and Research in Substance Abuse.

Dr. Alford, of Boston University, and his colleagues initially targeted generalist chief residents specializing in internal medicine, family practice, and emergency medicine because providers in those specialties are increasingly prescribing opioids for chronic pain at a time when opioid abuse is becoming a public health problem. However, the access of chief residents to training in risk management is inadequate despite screening and monitoring recommendations from professional bodies.

The researchers expanded the course content in opioid risk management in the 2007 and 2008 CRIT programs in addiction medicine to include addiction-screening tools, controlled substance agreements, and monitoring strategies such as pill counts and urine drug testing. They conducted electronic surveys of the participants about their confidence in dealing with opioid risk management as well as their clinical and teaching practices at baseline (pre-CRIT) and 6 months after they had completed the program (post-CRIT).

The 43 chief residents were from 36 residency programs. Eighty-six percent specialized in internal medicine, 9% in family medicine, and 5% in emergency medicine. All of them completed the baseline survey; 1 did not complete the 6-month follow-up, and 2 of the remaining 42 did not provide complete responses for all of the questions. The changes in confidence, clinical practices, and teaching practices were rated on a 5-point Likert scale, and a P value of .05 was deemed significant.

The changes in confidence from baseline to post-CRIT in identifying substance abuse in chronic pain patients and in treating high-risk patients with chronic pain were significant. Confidence in identifying abuse went from 2.8 at baseline to 3.5 at 6 months (1 = not at all, 5 = very confident) and in treating high-risk patients, it went from 2.2 to 3.7 (P less than .0001 for both). One CR did not complete the post-CRIT confidence questions.

In regard to changes in clinical practices, the differences were highly significant for the frequency of using a validated substance abuse screening tool (2.3 to 3.3 [1 = never, 3 = half of the time, 5 = always]; P less than .0001) and frequency using agreements or contracts and routine drug testing (2.9 to 3.5 and 2.3 to 3.3, respectively; P less than .001 for both). However, when it came to conducting routine pill counts, there was a nonsignificant decrease (2.3 to 2.2; P = .46). Dr. Alford said the decrease likely occurred because it is difficult to do a routine pill count during a brief primary care visit. “The count is often done with support staff—for example nursing—assistance, which is not universally available to physicians in training [or] chief residents,” he said.

Among the limitations of the study, Dr. Alford listed the absence of a nonintervention control group. He point out that the data were self-reported, which might have resulted in a social desirability bias.

Dr. Alford and his colleagues had no financial disclosures. The study was funded by the National Institute on Drug Abuse.

BETHESDA, MD. — Chemical dependence as a result of drug abuse occurs at the cellular level because of neurochemical dysregulation, and an evidence-based understanding of these chemical dynamics and of the circumstances that drive a person to abuse drugs could yield a more comprehensive and effective approach to treatment.

“Chemical dependence is a disease of the brain caused by genetic vulnerability as well as exposure to a drug, and possibly other environmental factors such as trauma and family influence,” said Carlton Erickson, Ph.D., a researcher in addiction science at the University of Texas at Austin, at the annual conference of the Association for Medical Education and Research in Substance Abuse.

Specifically, dependence occurs because of a neurochemical dysregulation of the mesolimbic dopamine system (MDS), which also is called the medial forebrain bundle or the pleasure or reward pathway because of dopamine's association with mood regulation, motivation, and reward, he said.

“We assume that a certain genetic propensity together with drug use can lead to dysregulation of the MDS neurotransmitter processes; that is, when people use a particular drug, it 'connects to' or 'matches' the transmitter system that is not normal” and disrupts the cellular-level functioning of the pathway. This connection occurs because drugs typically act on a single neurotransmitter system, and those systems are particularly vulnerable to the specific drugs.

Continued exposure of the MDS pathways to a drug leads to changes or adaptations in nerve function, which are known as neuroadaptations. These changes reach a threshold, leading to compulsive drug use over which the individual has impaired control, Dr. Erickson suggested. “The main symptom of chemical dependence is impaired control over the use of a drug, and the patient perceives this as a basic need for the drug.”

The mesolimbic dopamine system is a grouping of axons that extends from the brain's amygdaloid region to the frontal, prefrontal, and anterior cingulate cortexes that regulate feelings of pleasure. The different regions of the brain along the route of the MDS are governed by certain neurotransmitters, for example, dopamine (pleasure) in the ventral tegmental area, amygdala, hippocampus, and nucleus accumbens; serotonin (cravings) in the hypothalamus; and gamma-aminobutyric acid (GABA; sleepiness), also in the nucleus accumbens. Some addictive drugs such as cocaine, LSD, or benzodiazepines match up with and target certain neurotransmitters (dopamine, serotonin, and GABA, respectively), which might explain why some people have a drug or drugs of choice, Dr. Erickson said. “Multiple dysregulation could explain a person's codependence on several drugs,” he added.

Other pairings between addictive drugs and neurotransmitters include heroin and endorphins, nicotine and acetylcholine, alcohol and glutamate and substance P, and marijuana and endocannabinoids.

If chemical dependence occurs at the cellular level, then it would make sense that the treatment should also work at the cellular level, Dr. Erickson said. “Drug abuse is seen as a problem that needs to be solved through education, coercion, punishment, environmental change, or maturation, whereas chemical dependence should be treated by positively affecting the abnormal brain function—dysregulation—to reduce the need for the drug that is being abused,” Dr. Erickson said at the conference, which was sponsored by Brown Medical School.

Both abuse and dependence are serious conditions, and both need to be addressed, but they are not the same, he added. Drug abuse is volitional (person has control over drug use), but chemical dependence is an involuntary brain disease, so each requires a different treatment strategy.

Among the current options for initiating recovery are the traditional 12-step programs, which encourage abstinence; counseling for behavioral modification; cognitive-behavioral therapy (CBT) and primary care management; and medical treatment, which could include using detoxification medications or medications that enhance abstinence (at the cellular level), such as reward blockers, and anticraving medications such as methadone, buprenorphine, and vaccines.

One could argue, Dr. Erickson said, that behavioral therapies probably also change brain chemistry. “In other words, [during behavioral therapy] the MDS dysregulation begins to move back toward normal. It cannot be totally normalized, just “pushed back” toward normal, in much the same way that medications change brain chemistry.”

Although there are no direct brain imaging studies that show that this happens in dependence treatment, plenty of imaging research shows that psychotherapeutic methods such as CBT change brain function. Thus, “talk therapies” probably change brain function in a positive manner to help overcome dependence, he explained.

Disclosures: Dr. Erickson had no conflicts of interest to report.

BETHESDA, MD. — Chemical dependence as a result of drug abuse occurs at the cellular level because of neurochemical dysregulation, and an evidence-based understanding of these chemical dynamics and of the circumstances that drive a person to abuse drugs could yield a more comprehensive and effective approach to treatment.

“Chemical dependence is a disease of the brain caused by genetic vulnerability as well as exposure to a drug, and possibly other environmental factors such as trauma and family influence,” said Carlton Erickson, Ph.D., a researcher in addiction science at the University of Texas at Austin, at the annual conference of the Association for Medical Education and Research in Substance Abuse.

Specifically, dependence occurs because of a neurochemical dysregulation of the mesolimbic dopamine system (MDS), which also is called the medial forebrain bundle or the pleasure or reward pathway because of dopamine's association with mood regulation, motivation, and reward, he said.

“We assume that a certain genetic propensity together with drug use can lead to dysregulation of the MDS neurotransmitter processes; that is, when people use a particular drug, it 'connects to' or 'matches' the transmitter system that is not normal” and disrupts the cellular-level functioning of the pathway. This connection occurs because drugs typically act on a single neurotransmitter system, and those systems are particularly vulnerable to the specific drugs.

Continued exposure of the MDS pathways to a drug leads to changes or adaptations in nerve function, which are known as neuroadaptations. These changes reach a threshold, leading to compulsive drug use over which the individual has impaired control, Dr. Erickson suggested. “The main symptom of chemical dependence is impaired control over the use of a drug, and the patient perceives this as a basic need for the drug.”

The mesolimbic dopamine system is a grouping of axons that extends from the brain's amygdaloid region to the frontal, prefrontal, and anterior cingulate cortexes that regulate feelings of pleasure. The different regions of the brain along the route of the MDS are governed by certain neurotransmitters, for example, dopamine (pleasure) in the ventral tegmental area, amygdala, hippocampus, and nucleus accumbens; serotonin (cravings) in the hypothalamus; and gamma-aminobutyric acid (GABA; sleepiness), also in the nucleus accumbens. Some addictive drugs such as cocaine, LSD, or benzodiazepines match up with and target certain neurotransmitters (dopamine, serotonin, and GABA, respectively), which might explain why some people have a drug or drugs of choice, Dr. Erickson said. “Multiple dysregulation could explain a person's codependence on several drugs,” he added.

Other pairings between addictive drugs and neurotransmitters include heroin and endorphins, nicotine and acetylcholine, alcohol and glutamate and substance P, and marijuana and endocannabinoids.

If chemical dependence occurs at the cellular level, then it would make sense that the treatment should also work at the cellular level, Dr. Erickson said. “Drug abuse is seen as a problem that needs to be solved through education, coercion, punishment, environmental change, or maturation, whereas chemical dependence should be treated by positively affecting the abnormal brain function—dysregulation—to reduce the need for the drug that is being abused,” Dr. Erickson said at the conference, which was sponsored by Brown Medical School.

Both abuse and dependence are serious conditions, and both need to be addressed, but they are not the same, he added. Drug abuse is volitional (person has control over drug use), but chemical dependence is an involuntary brain disease, so each requires a different treatment strategy.

Among the current options for initiating recovery are the traditional 12-step programs, which encourage abstinence; counseling for behavioral modification; cognitive-behavioral therapy (CBT) and primary care management; and medical treatment, which could include using detoxification medications or medications that enhance abstinence (at the cellular level), such as reward blockers, and anticraving medications such as methadone, buprenorphine, and vaccines.

One could argue, Dr. Erickson said, that behavioral therapies probably also change brain chemistry. “In other words, [during behavioral therapy] the MDS dysregulation begins to move back toward normal. It cannot be totally normalized, just “pushed back” toward normal, in much the same way that medications change brain chemistry.”

Although there are no direct brain imaging studies that show that this happens in dependence treatment, plenty of imaging research shows that psychotherapeutic methods such as CBT change brain function. Thus, “talk therapies” probably change brain function in a positive manner to help overcome dependence, he explained.

Disclosures: Dr. Erickson had no conflicts of interest to report.

BETHESDA, MD. — Chemical dependence as a result of drug abuse occurs at the cellular level because of neurochemical dysregulation, and an evidence-based understanding of these chemical dynamics and of the circumstances that drive a person to abuse drugs could yield a more comprehensive and effective approach to treatment.

“Chemical dependence is a disease of the brain caused by genetic vulnerability as well as exposure to a drug, and possibly other environmental factors such as trauma and family influence,” said Carlton Erickson, Ph.D., a researcher in addiction science at the University of Texas at Austin, at the annual conference of the Association for Medical Education and Research in Substance Abuse.

Specifically, dependence occurs because of a neurochemical dysregulation of the mesolimbic dopamine system (MDS), which also is called the medial forebrain bundle or the pleasure or reward pathway because of dopamine's association with mood regulation, motivation, and reward, he said.

“We assume that a certain genetic propensity together with drug use can lead to dysregulation of the MDS neurotransmitter processes; that is, when people use a particular drug, it 'connects to' or 'matches' the transmitter system that is not normal” and disrupts the cellular-level functioning of the pathway. This connection occurs because drugs typically act on a single neurotransmitter system, and those systems are particularly vulnerable to the specific drugs.

Continued exposure of the MDS pathways to a drug leads to changes or adaptations in nerve function, which are known as neuroadaptations. These changes reach a threshold, leading to compulsive drug use over which the individual has impaired control, Dr. Erickson suggested. “The main symptom of chemical dependence is impaired control over the use of a drug, and the patient perceives this as a basic need for the drug.”

The mesolimbic dopamine system is a grouping of axons that extends from the brain's amygdaloid region to the frontal, prefrontal, and anterior cingulate cortexes that regulate feelings of pleasure. The different regions of the brain along the route of the MDS are governed by certain neurotransmitters, for example, dopamine (pleasure) in the ventral tegmental area, amygdala, hippocampus, and nucleus accumbens; serotonin (cravings) in the hypothalamus; and gamma-aminobutyric acid (GABA; sleepiness), also in the nucleus accumbens. Some addictive drugs such as cocaine, LSD, or benzodiazepines match up with and target certain neurotransmitters (dopamine, serotonin, and GABA, respectively), which might explain why some people have a drug or drugs of choice, Dr. Erickson said. “Multiple dysregulation could explain a person's codependence on several drugs,” he added.

Other pairings between addictive drugs and neurotransmitters include heroin and endorphins, nicotine and acetylcholine, alcohol and glutamate and substance P, and marijuana and endocannabinoids.

If chemical dependence occurs at the cellular level, then it would make sense that the treatment should also work at the cellular level, Dr. Erickson said. “Drug abuse is seen as a problem that needs to be solved through education, coercion, punishment, environmental change, or maturation, whereas chemical dependence should be treated by positively affecting the abnormal brain function—dysregulation—to reduce the need for the drug that is being abused,” Dr. Erickson said at the conference, which was sponsored by Brown Medical School.

Both abuse and dependence are serious conditions, and both need to be addressed, but they are not the same, he added. Drug abuse is volitional (person has control over drug use), but chemical dependence is an involuntary brain disease, so each requires a different treatment strategy.

Among the current options for initiating recovery are the traditional 12-step programs, which encourage abstinence; counseling for behavioral modification; cognitive-behavioral therapy (CBT) and primary care management; and medical treatment, which could include using detoxification medications or medications that enhance abstinence (at the cellular level), such as reward blockers, and anticraving medications such as methadone, buprenorphine, and vaccines.

One could argue, Dr. Erickson said, that behavioral therapies probably also change brain chemistry. “In other words, [during behavioral therapy] the MDS dysregulation begins to move back toward normal. It cannot be totally normalized, just “pushed back” toward normal, in much the same way that medications change brain chemistry.”

Although there are no direct brain imaging studies that show that this happens in dependence treatment, plenty of imaging research shows that psychotherapeutic methods such as CBT change brain function. Thus, “talk therapies” probably change brain function in a positive manner to help overcome dependence, he explained.

Disclosures: Dr. Erickson had no conflicts of interest to report.

BETHESDA, MD. — The current economic downturn has had a substantial impact on the prevalence and treatment of addiction in the United States, according to preliminary findings of data gathered from treatment program administrators.

Stress as a result of job loss or being in a family affected by job loss has led to an increased demand for addiction treatment services, which are themselves under siege due to lower funding, fewere counselors, and the ripple effects of hiring freezes, Paul Roman, Ph.D., said at the annual meeting of the Association of Medical Education and Research in Substance Abuse, sponsored by Brown Medical School.

Dr. Roman and Amanda J. Abraham, Ph.D., both of the University of Georgia, Athens, collected data during face-to-face and follow-up telephone interviews with treatment program administrators in the Clinical Trial Program (198), privately run programs (345), and atthe National Institute of Alcohol Abuse and Alcoholism (350).

The administrators reported a mean reduction of 13% in overall budget, 22% in grant funding, 17% in Medicaid income, and 12% in insurance payments. The dip in grant allocations alone correlated with an increase in uncollectible revenues, a decrease in staff and treatment slots, and the implementation of hiring freezes, he said.

Staff losses and hiring freezes cut across the management, counselor, and support staff categories: 14% of interviewees reported cuts at management level, 21% reported counselor losses, and 25% support staff losses. One-third of those interviewed said there had been hiring freezes across all three staff categories. Commensurate with these staff cuts, particularly at the counselor level, was a reduction in the number of treatment slots, which was reported by 12% of the interviewees. At the same time, there was a mean overall increase of 18% in patients.

“The American substance abuse treatment system is under considerable economic stress,” Dr. Roman said. Smaller, nonprofit, nonhospital-associated programs have been hardest hit, as have programs with a higher percentage of Medicaid patients, a lower percentage of counselors with master's degrees, and more injection drug users and unemployed patients.

Regionally, almost half of the programs in the Pacific coast region were stressed, compared with 23% in the South Atlantic, 15% in the East North Central, and 8% in the Mid-Atlantic regions.

Dr. Roman said programs might capitalize on four “great opportunities” to bolster their bottom lines and treatment services: the growth of substance abuse problems in the elderly, the fact that Baby Boomers are aging into the high prevalence years of substance abuse, the implementation of parity for substance and alcohol use disorder treatment, and health care reform.

He emphasized, however, that leadership will be critical if providers are to join together to take advantage of these factors. “The most successful treatment programs … engage in concrete, measurable, identifiable, systemic strategic planning,” he said. Programs should therefore consider how they could attract clients to and keep them in treatment, work to shed the chronic disease stigma associated with substance abuse, and tap new sources of referral, such as the workplace.

Disclosures: Dr. Roman said he had no financial disclosures to make. The study was funded by National Institute of Drug Abuse and the NIAAA.

BETHESDA, MD. — The current economic downturn has had a substantial impact on the prevalence and treatment of addiction in the United States, according to preliminary findings of data gathered from treatment program administrators.

Stress as a result of job loss or being in a family affected by job loss has led to an increased demand for addiction treatment services, which are themselves under siege due to lower funding, fewere counselors, and the ripple effects of hiring freezes, Paul Roman, Ph.D., said at the annual meeting of the Association of Medical Education and Research in Substance Abuse, sponsored by Brown Medical School.

Dr. Roman and Amanda J. Abraham, Ph.D., both of the University of Georgia, Athens, collected data during face-to-face and follow-up telephone interviews with treatment program administrators in the Clinical Trial Program (198), privately run programs (345), and atthe National Institute of Alcohol Abuse and Alcoholism (350).

The administrators reported a mean reduction of 13% in overall budget, 22% in grant funding, 17% in Medicaid income, and 12% in insurance payments. The dip in grant allocations alone correlated with an increase in uncollectible revenues, a decrease in staff and treatment slots, and the implementation of hiring freezes, he said.

Staff losses and hiring freezes cut across the management, counselor, and support staff categories: 14% of interviewees reported cuts at management level, 21% reported counselor losses, and 25% support staff losses. One-third of those interviewed said there had been hiring freezes across all three staff categories. Commensurate with these staff cuts, particularly at the counselor level, was a reduction in the number of treatment slots, which was reported by 12% of the interviewees. At the same time, there was a mean overall increase of 18% in patients.

“The American substance abuse treatment system is under considerable economic stress,” Dr. Roman said. Smaller, nonprofit, nonhospital-associated programs have been hardest hit, as have programs with a higher percentage of Medicaid patients, a lower percentage of counselors with master's degrees, and more injection drug users and unemployed patients.

Regionally, almost half of the programs in the Pacific coast region were stressed, compared with 23% in the South Atlantic, 15% in the East North Central, and 8% in the Mid-Atlantic regions.

Dr. Roman said programs might capitalize on four “great opportunities” to bolster their bottom lines and treatment services: the growth of substance abuse problems in the elderly, the fact that Baby Boomers are aging into the high prevalence years of substance abuse, the implementation of parity for substance and alcohol use disorder treatment, and health care reform.

He emphasized, however, that leadership will be critical if providers are to join together to take advantage of these factors. “The most successful treatment programs … engage in concrete, measurable, identifiable, systemic strategic planning,” he said. Programs should therefore consider how they could attract clients to and keep them in treatment, work to shed the chronic disease stigma associated with substance abuse, and tap new sources of referral, such as the workplace.

Disclosures: Dr. Roman said he had no financial disclosures to make. The study was funded by National Institute of Drug Abuse and the NIAAA.

BETHESDA, MD. — The current economic downturn has had a substantial impact on the prevalence and treatment of addiction in the United States, according to preliminary findings of data gathered from treatment program administrators.

Stress as a result of job loss or being in a family affected by job loss has led to an increased demand for addiction treatment services, which are themselves under siege due to lower funding, fewere counselors, and the ripple effects of hiring freezes, Paul Roman, Ph.D., said at the annual meeting of the Association of Medical Education and Research in Substance Abuse, sponsored by Brown Medical School.

Dr. Roman and Amanda J. Abraham, Ph.D., both of the University of Georgia, Athens, collected data during face-to-face and follow-up telephone interviews with treatment program administrators in the Clinical Trial Program (198), privately run programs (345), and atthe National Institute of Alcohol Abuse and Alcoholism (350).

The administrators reported a mean reduction of 13% in overall budget, 22% in grant funding, 17% in Medicaid income, and 12% in insurance payments. The dip in grant allocations alone correlated with an increase in uncollectible revenues, a decrease in staff and treatment slots, and the implementation of hiring freezes, he said.

Staff losses and hiring freezes cut across the management, counselor, and support staff categories: 14% of interviewees reported cuts at management level, 21% reported counselor losses, and 25% support staff losses. One-third of those interviewed said there had been hiring freezes across all three staff categories. Commensurate with these staff cuts, particularly at the counselor level, was a reduction in the number of treatment slots, which was reported by 12% of the interviewees. At the same time, there was a mean overall increase of 18% in patients.

“The American substance abuse treatment system is under considerable economic stress,” Dr. Roman said. Smaller, nonprofit, nonhospital-associated programs have been hardest hit, as have programs with a higher percentage of Medicaid patients, a lower percentage of counselors with master's degrees, and more injection drug users and unemployed patients.

Regionally, almost half of the programs in the Pacific coast region were stressed, compared with 23% in the South Atlantic, 15% in the East North Central, and 8% in the Mid-Atlantic regions.

Dr. Roman said programs might capitalize on four “great opportunities” to bolster their bottom lines and treatment services: the growth of substance abuse problems in the elderly, the fact that Baby Boomers are aging into the high prevalence years of substance abuse, the implementation of parity for substance and alcohol use disorder treatment, and health care reform.

He emphasized, however, that leadership will be critical if providers are to join together to take advantage of these factors. “The most successful treatment programs … engage in concrete, measurable, identifiable, systemic strategic planning,” he said. Programs should therefore consider how they could attract clients to and keep them in treatment, work to shed the chronic disease stigma associated with substance abuse, and tap new sources of referral, such as the workplace.

Disclosures: Dr. Roman said he had no financial disclosures to make. The study was funded by National Institute of Drug Abuse and the NIAAA.

BETHESDA, MD. – Chemical dependence as a result of drug abuse occurs at the cellular level because of neurochemical dysregulation, and an evidence-based understanding of these chemical dynamics and of the circumstances that drive a person to abuse drugs could yield a more comprehensive and effective approach to treatment.

“Chemical dependence is a disease of the brain caused by genetic vulnerability as well as exposure to a drug, and possibly other environmental factors such as trauma and family influence,” said Carlton Erickson, Ph.D., a researcher in addiction science at the University of Texas at Austin, at the annual conference of the Association for Medical Education and Research in Substance Abuse.

Specifically, dependence occurs because of a neurochemical dysregulation of the mesolimbic dopamine system (MDS), which also is called the medial forebrain bundle or the pleasure or reward pathway because of dopamine's association with mood regulation, motivation, and reward, he said.

“We assume that a certain genetic propensity together with drug use can lead to dysregulation of the MDS neurotransmitter processes, that is, when people use a particular drug, it 'connects to' or 'matches' the transmitter system that is not normal” and disrupts the cellular-level functioning of the pathway, Dr. Erickson said, adding that this connection occurs because drugs typically act on a single neurotransmitter system, and those systems are particularly vulnerable to the specific drugs.

Continued exposure of the MDS pathways to a drug leads to changes or adaptations in nerve function, which are known as neuroadaptations, and when these changes reach a threshold, it leads to compulsive drug use over which the individual has impaired control, he suggested.

“The main symptom of chemical dependence is impaired control over the use of a drug, and the patient perceives this as a basic need for the drug,” he emphasized.

The mesolimbic dopamine system is a grouping of axons that extends from the brain's amygdaloid region to the frontal, prefrontal, and anterior cingulate cortexes that regulate feelings of pleasure. The different regions of the brain along the route of the MDS are governed by certain neurotransmitters, for example, dopamine (pleasure) in the ventral tegmental area, amygdala, hippocampus, and nucleus accumbens; serotonin (cravings) in the hypothalamus; and gamma-aminobutyric acid (GABA; sleepiness), also in the nucleus accumbens. Some addictive drugs such as cocaine, LSD, or benzodiazepines match up with and target certain neurotransmitters (dopamine, serotonin, and GABA, respectively), which might explain why some people have a drug or drugs of choice. “Multiple dysregulation could explain a person's codependence on several drugs,” Dr. Erickson suggested.

Other pairings between addictive drugs and neurotransmitters include heroin and endorphins, nicotine and acetylcholine, alcohol and glutamate and substance P, and marijuana and endocannabinoids.

If chemical dependence occurs at the cellular level, then it would make sense that the treatment should also work at the cellular level, Dr. Erickson said. “Drug abuse is seen as a problem that needs to be solved through education, coercion, punishment, environmental change, or maturation, whereas chemical dependence should be treated by positively affecting the abnormal brain function–dysregulation–to reduce the need for the drug that is being abused,” Dr. Erickson said at the conference, which was also sponsored by Brown Medical School.

Abuse and dependence are serious conditions and both need to be addressed, but they are not the same, he added. Drug abuse is volitional (person has control over use), but chemical dependence is an involuntary brain disease, so each requires a different treatment strategy.

Among the current options for initiating recovery are the traditional 12-step programs, which encourage abstinence; counseling for behavioral modification; cognitive-behavioral therapy (CBT) and primary care management; and medical treatment, which could include the use of detoxification medications or medications that enhance abstinence (at the cellular level), such as reward blockers, and anticraving medications such as methadone, buprenorphine, and vaccines.

One could argue, Dr. Erickson said, that behavioral therapies probably also change brain chemistry. “In other words, [during behavioral therapy] the MDS dysregulation begins to move back toward normal. It cannot be totally normalized, just “pushed back” toward normal, in much the same way that medications change brain chemistry.”

Although there are no direct brain imaging studies that show that this happens in dependence treatment, plenty of imaging research shows that psychotherapeutic methods such as CBT change brain function. Thus, “talk therapies” probably change brain function in a positive manner to help overcome dependence, said Dr. Erickson, who had no disclosures to make.

BETHESDA, MD. – Chemical dependence as a result of drug abuse occurs at the cellular level because of neurochemical dysregulation, and an evidence-based understanding of these chemical dynamics and of the circumstances that drive a person to abuse drugs could yield a more comprehensive and effective approach to treatment.

“Chemical dependence is a disease of the brain caused by genetic vulnerability as well as exposure to a drug, and possibly other environmental factors such as trauma and family influence,” said Carlton Erickson, Ph.D., a researcher in addiction science at the University of Texas at Austin, at the annual conference of the Association for Medical Education and Research in Substance Abuse.

Specifically, dependence occurs because of a neurochemical dysregulation of the mesolimbic dopamine system (MDS), which also is called the medial forebrain bundle or the pleasure or reward pathway because of dopamine's association with mood regulation, motivation, and reward, he said.

“We assume that a certain genetic propensity together with drug use can lead to dysregulation of the MDS neurotransmitter processes, that is, when people use a particular drug, it 'connects to' or 'matches' the transmitter system that is not normal” and disrupts the cellular-level functioning of the pathway, Dr. Erickson said, adding that this connection occurs because drugs typically act on a single neurotransmitter system, and those systems are particularly vulnerable to the specific drugs.

Continued exposure of the MDS pathways to a drug leads to changes or adaptations in nerve function, which are known as neuroadaptations, and when these changes reach a threshold, it leads to compulsive drug use over which the individual has impaired control, he suggested.

“The main symptom of chemical dependence is impaired control over the use of a drug, and the patient perceives this as a basic need for the drug,” he emphasized.

The mesolimbic dopamine system is a grouping of axons that extends from the brain's amygdaloid region to the frontal, prefrontal, and anterior cingulate cortexes that regulate feelings of pleasure. The different regions of the brain along the route of the MDS are governed by certain neurotransmitters, for example, dopamine (pleasure) in the ventral tegmental area, amygdala, hippocampus, and nucleus accumbens; serotonin (cravings) in the hypothalamus; and gamma-aminobutyric acid (GABA; sleepiness), also in the nucleus accumbens. Some addictive drugs such as cocaine, LSD, or benzodiazepines match up with and target certain neurotransmitters (dopamine, serotonin, and GABA, respectively), which might explain why some people have a drug or drugs of choice. “Multiple dysregulation could explain a person's codependence on several drugs,” Dr. Erickson suggested.

Other pairings between addictive drugs and neurotransmitters include heroin and endorphins, nicotine and acetylcholine, alcohol and glutamate and substance P, and marijuana and endocannabinoids.

If chemical dependence occurs at the cellular level, then it would make sense that the treatment should also work at the cellular level, Dr. Erickson said. “Drug abuse is seen as a problem that needs to be solved through education, coercion, punishment, environmental change, or maturation, whereas chemical dependence should be treated by positively affecting the abnormal brain function–dysregulation–to reduce the need for the drug that is being abused,” Dr. Erickson said at the conference, which was also sponsored by Brown Medical School.

Abuse and dependence are serious conditions and both need to be addressed, but they are not the same, he added. Drug abuse is volitional (person has control over use), but chemical dependence is an involuntary brain disease, so each requires a different treatment strategy.

Among the current options for initiating recovery are the traditional 12-step programs, which encourage abstinence; counseling for behavioral modification; cognitive-behavioral therapy (CBT) and primary care management; and medical treatment, which could include the use of detoxification medications or medications that enhance abstinence (at the cellular level), such as reward blockers, and anticraving medications such as methadone, buprenorphine, and vaccines.

One could argue, Dr. Erickson said, that behavioral therapies probably also change brain chemistry. “In other words, [during behavioral therapy] the MDS dysregulation begins to move back toward normal. It cannot be totally normalized, just “pushed back” toward normal, in much the same way that medications change brain chemistry.”

Although there are no direct brain imaging studies that show that this happens in dependence treatment, plenty of imaging research shows that psychotherapeutic methods such as CBT change brain function. Thus, “talk therapies” probably change brain function in a positive manner to help overcome dependence, said Dr. Erickson, who had no disclosures to make.

BETHESDA, MD. – Chemical dependence as a result of drug abuse occurs at the cellular level because of neurochemical dysregulation, and an evidence-based understanding of these chemical dynamics and of the circumstances that drive a person to abuse drugs could yield a more comprehensive and effective approach to treatment.

“Chemical dependence is a disease of the brain caused by genetic vulnerability as well as exposure to a drug, and possibly other environmental factors such as trauma and family influence,” said Carlton Erickson, Ph.D., a researcher in addiction science at the University of Texas at Austin, at the annual conference of the Association for Medical Education and Research in Substance Abuse.

Specifically, dependence occurs because of a neurochemical dysregulation of the mesolimbic dopamine system (MDS), which also is called the medial forebrain bundle or the pleasure or reward pathway because of dopamine's association with mood regulation, motivation, and reward, he said.

“We assume that a certain genetic propensity together with drug use can lead to dysregulation of the MDS neurotransmitter processes, that is, when people use a particular drug, it 'connects to' or 'matches' the transmitter system that is not normal” and disrupts the cellular-level functioning of the pathway, Dr. Erickson said, adding that this connection occurs because drugs typically act on a single neurotransmitter system, and those systems are particularly vulnerable to the specific drugs.

Continued exposure of the MDS pathways to a drug leads to changes or adaptations in nerve function, which are known as neuroadaptations, and when these changes reach a threshold, it leads to compulsive drug use over which the individual has impaired control, he suggested.

“The main symptom of chemical dependence is impaired control over the use of a drug, and the patient perceives this as a basic need for the drug,” he emphasized.

The mesolimbic dopamine system is a grouping of axons that extends from the brain's amygdaloid region to the frontal, prefrontal, and anterior cingulate cortexes that regulate feelings of pleasure. The different regions of the brain along the route of the MDS are governed by certain neurotransmitters, for example, dopamine (pleasure) in the ventral tegmental area, amygdala, hippocampus, and nucleus accumbens; serotonin (cravings) in the hypothalamus; and gamma-aminobutyric acid (GABA; sleepiness), also in the nucleus accumbens. Some addictive drugs such as cocaine, LSD, or benzodiazepines match up with and target certain neurotransmitters (dopamine, serotonin, and GABA, respectively), which might explain why some people have a drug or drugs of choice. “Multiple dysregulation could explain a person's codependence on several drugs,” Dr. Erickson suggested.

Other pairings between addictive drugs and neurotransmitters include heroin and endorphins, nicotine and acetylcholine, alcohol and glutamate and substance P, and marijuana and endocannabinoids.

If chemical dependence occurs at the cellular level, then it would make sense that the treatment should also work at the cellular level, Dr. Erickson said. “Drug abuse is seen as a problem that needs to be solved through education, coercion, punishment, environmental change, or maturation, whereas chemical dependence should be treated by positively affecting the abnormal brain function–dysregulation–to reduce the need for the drug that is being abused,” Dr. Erickson said at the conference, which was also sponsored by Brown Medical School.

Abuse and dependence are serious conditions and both need to be addressed, but they are not the same, he added. Drug abuse is volitional (person has control over use), but chemical dependence is an involuntary brain disease, so each requires a different treatment strategy.

Among the current options for initiating recovery are the traditional 12-step programs, which encourage abstinence; counseling for behavioral modification; cognitive-behavioral therapy (CBT) and primary care management; and medical treatment, which could include the use of detoxification medications or medications that enhance abstinence (at the cellular level), such as reward blockers, and anticraving medications such as methadone, buprenorphine, and vaccines.

One could argue, Dr. Erickson said, that behavioral therapies probably also change brain chemistry. “In other words, [during behavioral therapy] the MDS dysregulation begins to move back toward normal. It cannot be totally normalized, just “pushed back” toward normal, in much the same way that medications change brain chemistry.”

Although there are no direct brain imaging studies that show that this happens in dependence treatment, plenty of imaging research shows that psychotherapeutic methods such as CBT change brain function. Thus, “talk therapies” probably change brain function in a positive manner to help overcome dependence, said Dr. Erickson, who had no disclosures to make.

BETHESDA, MD. — Current trends in the increase in the number of Americans aged 65 years and older could have significant implications for managing substance abuse in this population.

By 2030, 20% of the population in the United States will be older than 65 years (currently, that percentage is 13) and in 2 years' time, the first wave of Baby Boomers will be eligible for Social Security. Both trends will place pressure on substance abuse prevention and treatment, Frederic C. Blow, Ph.D., said at the annual meeting of the Association for Medical Education and Research in Substance Abuse. The conference was jointly sponsored by Brown Medical School.

“The number of adults with substance abuse disorders is projected to double from [an annual average of] 2.8 million in 2002–2006 to 5.7 million in 2020,” he said. Elderly adults who abuse alcohol or drugs are more likely to have mental health comorbidities, especially depression, cognitive loss, or anxiety or sleep disorders, as well as other comorbidities such as heart disease, diabetes, or conditions that require treatment for pain.

Dr. Blow of the University of Michigan, Ann Arbor, said aging-related changes make older adults more vulnerable to the adverse effects of alcohol, so that even moderate amounts of alcohol can be riskier for elderly drinkers.

“They are three times more likely to develop a mental disorder with a lifetime diagnosis of alcohol abuse, with common dual diagnoses, including depression [20%-30%], cognitive loss [10%-40%], and anxiety disorders [10%-20%],” said Dr. Blow, who also noted an association between alcohol abuse and suicide.

When it comes to screening for alcohol abuse problems, one should ask direct questions, though in doing so it is preferable to frame the question so that it is linked to a medical condition and avoid using stigmatizing terms such as alcoholic, Dr. Blow advised.

“Every person over 60 should be screened for alcohol and prescription drug abuse as part of the regular physical examination—and screen or rescreen if certain physical symptoms are present or if the older person is undergoing major life transitions,” he added.

Among the tools that can be used for screening and assessing alcohol use in the elderly are the Alcohol-Related Problems Survey and its shorter version, the shARPS; the Computerized Alcohol-Related Problems Survey, which combines screening assessment with health education; and two that are “elder-specific”—the Michigan Alcoholism Screening Test–Geriatric Version and the Short Michigan Alcohol Screening Instrument–Geriatric Version.

In regard to drinking limits, older men should have no more than one drink a day on average, and older women should have less than one a day, Dr. Blow said.

Brief interventions focusing on physician lifestyle guidance or in-home motivational enhancement have both been found to reduce alcohol use in at-risk older adults and alcohol-related harm, and as a result, health care use. When it comes to treatment, however, age-appropriate treatment models are essential. “The current bias toward institution-based services conflicts with expressed preferences and needs of older persons,” said Dr. Blow.

Dr. Blow said that he had no financial disclosures.

BETHESDA, MD. — Current trends in the increase in the number of Americans aged 65 years and older could have significant implications for managing substance abuse in this population.

By 2030, 20% of the population in the United States will be older than 65 years (currently, that percentage is 13) and in 2 years' time, the first wave of Baby Boomers will be eligible for Social Security. Both trends will place pressure on substance abuse prevention and treatment, Frederic C. Blow, Ph.D., said at the annual meeting of the Association for Medical Education and Research in Substance Abuse. The conference was jointly sponsored by Brown Medical School.

“The number of adults with substance abuse disorders is projected to double from [an annual average of] 2.8 million in 2002–2006 to 5.7 million in 2020,” he said. Elderly adults who abuse alcohol or drugs are more likely to have mental health comorbidities, especially depression, cognitive loss, or anxiety or sleep disorders, as well as other comorbidities such as heart disease, diabetes, or conditions that require treatment for pain.

Dr. Blow of the University of Michigan, Ann Arbor, said aging-related changes make older adults more vulnerable to the adverse effects of alcohol, so that even moderate amounts of alcohol can be riskier for elderly drinkers.

“They are three times more likely to develop a mental disorder with a lifetime diagnosis of alcohol abuse, with common dual diagnoses, including depression [20%-30%], cognitive loss [10%-40%], and anxiety disorders [10%-20%],” said Dr. Blow, who also noted an association between alcohol abuse and suicide.

When it comes to screening for alcohol abuse problems, one should ask direct questions, though in doing so it is preferable to frame the question so that it is linked to a medical condition and avoid using stigmatizing terms such as alcoholic, Dr. Blow advised.

“Every person over 60 should be screened for alcohol and prescription drug abuse as part of the regular physical examination—and screen or rescreen if certain physical symptoms are present or if the older person is undergoing major life transitions,” he added.

Among the tools that can be used for screening and assessing alcohol use in the elderly are the Alcohol-Related Problems Survey and its shorter version, the shARPS; the Computerized Alcohol-Related Problems Survey, which combines screening assessment with health education; and two that are “elder-specific”—the Michigan Alcoholism Screening Test–Geriatric Version and the Short Michigan Alcohol Screening Instrument–Geriatric Version.

In regard to drinking limits, older men should have no more than one drink a day on average, and older women should have less than one a day, Dr. Blow said.

Brief interventions focusing on physician lifestyle guidance or in-home motivational enhancement have both been found to reduce alcohol use in at-risk older adults and alcohol-related harm, and as a result, health care use. When it comes to treatment, however, age-appropriate treatment models are essential. “The current bias toward institution-based services conflicts with expressed preferences and needs of older persons,” said Dr. Blow.

Dr. Blow said that he had no financial disclosures.

BETHESDA, MD. — Current trends in the increase in the number of Americans aged 65 years and older could have significant implications for managing substance abuse in this population.

By 2030, 20% of the population in the United States will be older than 65 years (currently, that percentage is 13) and in 2 years' time, the first wave of Baby Boomers will be eligible for Social Security. Both trends will place pressure on substance abuse prevention and treatment, Frederic C. Blow, Ph.D., said at the annual meeting of the Association for Medical Education and Research in Substance Abuse. The conference was jointly sponsored by Brown Medical School.

“The number of adults with substance abuse disorders is projected to double from [an annual average of] 2.8 million in 2002–2006 to 5.7 million in 2020,” he said. Elderly adults who abuse alcohol or drugs are more likely to have mental health comorbidities, especially depression, cognitive loss, or anxiety or sleep disorders, as well as other comorbidities such as heart disease, diabetes, or conditions that require treatment for pain.

Dr. Blow of the University of Michigan, Ann Arbor, said aging-related changes make older adults more vulnerable to the adverse effects of alcohol, so that even moderate amounts of alcohol can be riskier for elderly drinkers.

“They are three times more likely to develop a mental disorder with a lifetime diagnosis of alcohol abuse, with common dual diagnoses, including depression [20%-30%], cognitive loss [10%-40%], and anxiety disorders [10%-20%],” said Dr. Blow, who also noted an association between alcohol abuse and suicide.

When it comes to screening for alcohol abuse problems, one should ask direct questions, though in doing so it is preferable to frame the question so that it is linked to a medical condition and avoid using stigmatizing terms such as alcoholic, Dr. Blow advised.

“Every person over 60 should be screened for alcohol and prescription drug abuse as part of the regular physical examination—and screen or rescreen if certain physical symptoms are present or if the older person is undergoing major life transitions,” he added.

Among the tools that can be used for screening and assessing alcohol use in the elderly are the Alcohol-Related Problems Survey and its shorter version, the shARPS; the Computerized Alcohol-Related Problems Survey, which combines screening assessment with health education; and two that are “elder-specific”—the Michigan Alcoholism Screening Test–Geriatric Version and the Short Michigan Alcohol Screening Instrument–Geriatric Version.

In regard to drinking limits, older men should have no more than one drink a day on average, and older women should have less than one a day, Dr. Blow said.

Brief interventions focusing on physician lifestyle guidance or in-home motivational enhancement have both been found to reduce alcohol use in at-risk older adults and alcohol-related harm, and as a result, health care use. When it comes to treatment, however, age-appropriate treatment models are essential. “The current bias toward institution-based services conflicts with expressed preferences and needs of older persons,” said Dr. Blow.

Dr. Blow said that he had no financial disclosures.

BETHESDA, MD. — Current trends in the increase in the number of Americans aged 65 years and older could have significant implications for managing substance abuse in this population.

By 2030, 20% of the population in the United States will be older than 65 years (currently, 13%), and in 2 years' time, the first wave of Baby Boomers will be eligible for Social Security. Both trends will place pressure on retirement and health care systems in general, and on substance abuse prevention and treatment in particular, Frederic C. Blow, Ph.D., said at the annual meeting of the Association for Medical Education and Research in Substance Abuse. The conference was jointly sponsored by Brown Medical School.

“The number of adults with substance abuse disorders is projected to double from [an annual average of] 2.8 million in 2002–2006 to 5.7 million in 2020,” he said. In addition, elderly adults who abuse alcohol or drugs are more likely to have mental health comorbidities, especially depression, cognitive loss, or anxiety or sleep disorders, as well as other comorbidities such as heart disease, diabetes, or conditions that require treatment for pain, all of which add another level of complexity in managing substance abuse in this population.

The most common addictions among older adults are to nicotine, alcohol, psychoactive prescription drugs, and other illegal drugs, such as marijuana, cocaine, and narcotics. Estimates suggest that about 19% of older Americans might be affected by combined alcohol and medication abuse, which is more prevalent among men and those aged 50–64 years.

Aging-related changes make older adults more vulnerable to the adverse effects of alcohol, so even moderate amounts of alcohol can be riskier for elderly drinkers, said Dr. Blow, of the University of Michigan, Ann Arbor.

“They are three times more likely to develop a mental disorder with a lifetime diagnosis of alcohol abuse, with common dual diagnoses, including depression [20%–30%], cognitive loss [10%–40%], and anxiety disorders [10%–20%],” said Dr. Blow, who also noted an association between alcohol abuse and suicide. Moreover, “patients with a history of problem alcohol use … exhibit more behavioral disturbances, including agitation, irritability, and disinhibition,” which increases caregiver distress and therefore caregiver burden.

When it comes to screening for alcohol abuse problems, one should ask direct questions, though in doing so, it is preferable to frame the question so that it is linked to a medical condition and avoid using stigmatizing terms such as alcoholic, Dr. Blow advised. Patients also should be warned that some conditions can be caused or worsened by alcohol use. For example, one or more drinks a day could aggravate or cause gastritis, ulcers, and liver or pancreas conditions; two or more daily might affect depression, gout, insomnia, memory problems; and three or more a day could affect hypertension, stroke, diabetes, gastrointestinal diseases, and some cancers.

“Every person over 60 should be screened for alcohol and prescription drug abuse as part of the regular physical examination—and screen or rescreen if certain physical symptoms are present or if the older person is undergoing major life transitions,” he added.

Among the tools that can be used for screening and assessing alcohol use in the elderly are the Alcohol-Related Problems Survey and its shorter version, the shARPS; the Computerized Alcohol-Related Problems Survey, which combines screening assessment with health education; AUDIT-C, which screens for alcohol consumption; and two that are “elder-specific”—the Michigan Alcoholism Screening Test–Geriatric Version and the Short Michigan Alcohol Screening Instrument–Geriatric Version.

In regard to drinking limits, older men should have no more than one drink a day on average, and older women should have less than one drink a day, Dr. Blow said. The cut-off for binge drinking in the elderly is four or more drinks in a drinking day for men, and three or more in a drinking day for women.

Brief interventions focusing on physician lifestyle guidance or in-home motivational enhancement have both been found to reduce alcohol use in at-risk older adults and alcohol-related harm, and as a result, health care use.

However, when it comes to treatment, age-appropriate treatment models are essential. “The current bias toward institution-based services conflicts with expressed preferences and needs of older persons,” said Dr. Blow, noting that home and community-based settings are in fact preferable for older adults, as are mixed-age treatment settings when individualized psychotherapeutic approaches are included.

Compared with their younger counterparts, older at-risk adults have greater attendance at therapy sessions, better medication adherence, and lower relapse rates, he said.

Dr. Blow said he had no financial disclosures.

BETHESDA, MD. — Current trends in the increase in the number of Americans aged 65 years and older could have significant implications for managing substance abuse in this population.

By 2030, 20% of the population in the United States will be older than 65 years (currently, 13%), and in 2 years' time, the first wave of Baby Boomers will be eligible for Social Security. Both trends will place pressure on retirement and health care systems in general, and on substance abuse prevention and treatment in particular, Frederic C. Blow, Ph.D., said at the annual meeting of the Association for Medical Education and Research in Substance Abuse. The conference was jointly sponsored by Brown Medical School.

“The number of adults with substance abuse disorders is projected to double from [an annual average of] 2.8 million in 2002–2006 to 5.7 million in 2020,” he said. In addition, elderly adults who abuse alcohol or drugs are more likely to have mental health comorbidities, especially depression, cognitive loss, or anxiety or sleep disorders, as well as other comorbidities such as heart disease, diabetes, or conditions that require treatment for pain, all of which add another level of complexity in managing substance abuse in this population.

The most common addictions among older adults are to nicotine, alcohol, psychoactive prescription drugs, and other illegal drugs, such as marijuana, cocaine, and narcotics. Estimates suggest that about 19% of older Americans might be affected by combined alcohol and medication abuse, which is more prevalent among men and those aged 50–64 years.

Aging-related changes make older adults more vulnerable to the adverse effects of alcohol, so even moderate amounts of alcohol can be riskier for elderly drinkers, said Dr. Blow, of the University of Michigan, Ann Arbor.

“They are three times more likely to develop a mental disorder with a lifetime diagnosis of alcohol abuse, with common dual diagnoses, including depression [20%–30%], cognitive loss [10%–40%], and anxiety disorders [10%–20%],” said Dr. Blow, who also noted an association between alcohol abuse and suicide. Moreover, “patients with a history of problem alcohol use … exhibit more behavioral disturbances, including agitation, irritability, and disinhibition,” which increases caregiver distress and therefore caregiver burden.

When it comes to screening for alcohol abuse problems, one should ask direct questions, though in doing so, it is preferable to frame the question so that it is linked to a medical condition and avoid using stigmatizing terms such as alcoholic, Dr. Blow advised. Patients also should be warned that some conditions can be caused or worsened by alcohol use. For example, one or more drinks a day could aggravate or cause gastritis, ulcers, and liver or pancreas conditions; two or more daily might affect depression, gout, insomnia, memory problems; and three or more a day could affect hypertension, stroke, diabetes, gastrointestinal diseases, and some cancers.

“Every person over 60 should be screened for alcohol and prescription drug abuse as part of the regular physical examination—and screen or rescreen if certain physical symptoms are present or if the older person is undergoing major life transitions,” he added.

Among the tools that can be used for screening and assessing alcohol use in the elderly are the Alcohol-Related Problems Survey and its shorter version, the shARPS; the Computerized Alcohol-Related Problems Survey, which combines screening assessment with health education; AUDIT-C, which screens for alcohol consumption; and two that are “elder-specific”—the Michigan Alcoholism Screening Test–Geriatric Version and the Short Michigan Alcohol Screening Instrument–Geriatric Version.

In regard to drinking limits, older men should have no more than one drink a day on average, and older women should have less than one drink a day, Dr. Blow said. The cut-off for binge drinking in the elderly is four or more drinks in a drinking day for men, and three or more in a drinking day for women.

Brief interventions focusing on physician lifestyle guidance or in-home motivational enhancement have both been found to reduce alcohol use in at-risk older adults and alcohol-related harm, and as a result, health care use.

However, when it comes to treatment, age-appropriate treatment models are essential. “The current bias toward institution-based services conflicts with expressed preferences and needs of older persons,” said Dr. Blow, noting that home and community-based settings are in fact preferable for older adults, as are mixed-age treatment settings when individualized psychotherapeutic approaches are included.

Compared with their younger counterparts, older at-risk adults have greater attendance at therapy sessions, better medication adherence, and lower relapse rates, he said.

Dr. Blow said he had no financial disclosures.

BETHESDA, MD. — Current trends in the increase in the number of Americans aged 65 years and older could have significant implications for managing substance abuse in this population.

By 2030, 20% of the population in the United States will be older than 65 years (currently, 13%), and in 2 years' time, the first wave of Baby Boomers will be eligible for Social Security. Both trends will place pressure on retirement and health care systems in general, and on substance abuse prevention and treatment in particular, Frederic C. Blow, Ph.D., said at the annual meeting of the Association for Medical Education and Research in Substance Abuse. The conference was jointly sponsored by Brown Medical School.

“The number of adults with substance abuse disorders is projected to double from [an annual average of] 2.8 million in 2002–2006 to 5.7 million in 2020,” he said. In addition, elderly adults who abuse alcohol or drugs are more likely to have mental health comorbidities, especially depression, cognitive loss, or anxiety or sleep disorders, as well as other comorbidities such as heart disease, diabetes, or conditions that require treatment for pain, all of which add another level of complexity in managing substance abuse in this population.

The most common addictions among older adults are to nicotine, alcohol, psychoactive prescription drugs, and other illegal drugs, such as marijuana, cocaine, and narcotics. Estimates suggest that about 19% of older Americans might be affected by combined alcohol and medication abuse, which is more prevalent among men and those aged 50–64 years.

Aging-related changes make older adults more vulnerable to the adverse effects of alcohol, so even moderate amounts of alcohol can be riskier for elderly drinkers, said Dr. Blow, of the University of Michigan, Ann Arbor.

“They are three times more likely to develop a mental disorder with a lifetime diagnosis of alcohol abuse, with common dual diagnoses, including depression [20%–30%], cognitive loss [10%–40%], and anxiety disorders [10%–20%],” said Dr. Blow, who also noted an association between alcohol abuse and suicide. Moreover, “patients with a history of problem alcohol use … exhibit more behavioral disturbances, including agitation, irritability, and disinhibition,” which increases caregiver distress and therefore caregiver burden.

When it comes to screening for alcohol abuse problems, one should ask direct questions, though in doing so, it is preferable to frame the question so that it is linked to a medical condition and avoid using stigmatizing terms such as alcoholic, Dr. Blow advised. Patients also should be warned that some conditions can be caused or worsened by alcohol use. For example, one or more drinks a day could aggravate or cause gastritis, ulcers, and liver or pancreas conditions; two or more daily might affect depression, gout, insomnia, memory problems; and three or more a day could affect hypertension, stroke, diabetes, gastrointestinal diseases, and some cancers.

“Every person over 60 should be screened for alcohol and prescription drug abuse as part of the regular physical examination—and screen or rescreen if certain physical symptoms are present or if the older person is undergoing major life transitions,” he added.

Among the tools that can be used for screening and assessing alcohol use in the elderly are the Alcohol-Related Problems Survey and its shorter version, the shARPS; the Computerized Alcohol-Related Problems Survey, which combines screening assessment with health education; AUDIT-C, which screens for alcohol consumption; and two that are “elder-specific”—the Michigan Alcoholism Screening Test–Geriatric Version and the Short Michigan Alcohol Screening Instrument–Geriatric Version.

In regard to drinking limits, older men should have no more than one drink a day on average, and older women should have less than one drink a day, Dr. Blow said. The cut-off for binge drinking in the elderly is four or more drinks in a drinking day for men, and three or more in a drinking day for women.

Brief interventions focusing on physician lifestyle guidance or in-home motivational enhancement have both been found to reduce alcohol use in at-risk older adults and alcohol-related harm, and as a result, health care use.

However, when it comes to treatment, age-appropriate treatment models are essential. “The current bias toward institution-based services conflicts with expressed preferences and needs of older persons,” said Dr. Blow, noting that home and community-based settings are in fact preferable for older adults, as are mixed-age treatment settings when individualized psychotherapeutic approaches are included.

Compared with their younger counterparts, older at-risk adults have greater attendance at therapy sessions, better medication adherence, and lower relapse rates, he said.

Dr. Blow said he had no financial disclosures.

BETHESDA, MD. — The current economic downturn has had a substantial impact on the prevalence and treatment of addiction in the United States, according to preliminary findings, Paul Roman, Ph.D., said at the annual meeting of the Association of Medical Education and Research in Substance Abuse, which was sponsored by Brown Medical School.

Dr. Roman and Amanda J. Abraham, Ph.D., both of the University of Georgia, Atlanta, collected data during interviews with treatment program administrators in the Clinical Trial Program (198), privately run programs (345), and the National Institute of Alcohol Abuse and Alcoholism (350).

The administrators reported a mean reduction of 13% in overall budget, 22% in grant funding, 17% in Medicaid income, and 12% in insurance payments. The dip in grant allocations alone correlated with an increase in uncollectible revenues, a decrease in staff and treatment slots, and the implementation of hiring freezes, he said.

Staff losses and hiring freezes cut across the management, counselor, and support staff categories: 14% of interviewees reported cuts at management level, 27% reported counselor losses, and 25% support staff losses. One-third of those interviewed said there had been hiring freezes across all three staff categories. Commensurate with these staff cuts, particularly at the counselor level, was a reduction in the number of treatment slots, which was reported by 12% of the interviewees. At the same time, there was a mean overall increase of 18% in patients.

Dr. Roman had no financial disclosures. The study was funded by National Institute of Drug Abuse and the NIAAA.

BETHESDA, MD. — The current economic downturn has had a substantial impact on the prevalence and treatment of addiction in the United States, according to preliminary findings, Paul Roman, Ph.D., said at the annual meeting of the Association of Medical Education and Research in Substance Abuse, which was sponsored by Brown Medical School.

Dr. Roman and Amanda J. Abraham, Ph.D., both of the University of Georgia, Atlanta, collected data during interviews with treatment program administrators in the Clinical Trial Program (198), privately run programs (345), and the National Institute of Alcohol Abuse and Alcoholism (350).

The administrators reported a mean reduction of 13% in overall budget, 22% in grant funding, 17% in Medicaid income, and 12% in insurance payments. The dip in grant allocations alone correlated with an increase in uncollectible revenues, a decrease in staff and treatment slots, and the implementation of hiring freezes, he said.

Staff losses and hiring freezes cut across the management, counselor, and support staff categories: 14% of interviewees reported cuts at management level, 27% reported counselor losses, and 25% support staff losses. One-third of those interviewed said there had been hiring freezes across all three staff categories. Commensurate with these staff cuts, particularly at the counselor level, was a reduction in the number of treatment slots, which was reported by 12% of the interviewees. At the same time, there was a mean overall increase of 18% in patients.

Dr. Roman had no financial disclosures. The study was funded by National Institute of Drug Abuse and the NIAAA.

BETHESDA, MD. — The current economic downturn has had a substantial impact on the prevalence and treatment of addiction in the United States, according to preliminary findings, Paul Roman, Ph.D., said at the annual meeting of the Association of Medical Education and Research in Substance Abuse, which was sponsored by Brown Medical School.

Dr. Roman and Amanda J. Abraham, Ph.D., both of the University of Georgia, Atlanta, collected data during interviews with treatment program administrators in the Clinical Trial Program (198), privately run programs (345), and the National Institute of Alcohol Abuse and Alcoholism (350).

The administrators reported a mean reduction of 13% in overall budget, 22% in grant funding, 17% in Medicaid income, and 12% in insurance payments. The dip in grant allocations alone correlated with an increase in uncollectible revenues, a decrease in staff and treatment slots, and the implementation of hiring freezes, he said.

Staff losses and hiring freezes cut across the management, counselor, and support staff categories: 14% of interviewees reported cuts at management level, 27% reported counselor losses, and 25% support staff losses. One-third of those interviewed said there had been hiring freezes across all three staff categories. Commensurate with these staff cuts, particularly at the counselor level, was a reduction in the number of treatment slots, which was reported by 12% of the interviewees. At the same time, there was a mean overall increase of 18% in patients.

Dr. Roman had no financial disclosures. The study was funded by National Institute of Drug Abuse and the NIAAA.

BETHESDA, MD. – The current economic downturn has had a substantial impact on the prevalence and treatment of addiction in the United States, according to preliminary findings of data gathered from treatment program administrators.

Stress as a result of job loss or being in a family affected by job loss has led to an increased demand for addiction treatment services, which are themselves under siege because of a drop in funding, cuts in management and counselor slots, and the ripple effects of hiring freezes, Paul Roman, Ph.D., said at the annual meeting of the Association for Medical Education and Research in Substance Abuse, which was sponsored by Brown Medical School.

Dr. Roman and Amanda J. Abraham, Ph.D., both of the University of Georgia, Atlanta, collected data during face-to-face and follow-up telephone interviews with treatment program administrators in the Clinical Trial Program (198), privately run programs (345), and the National Institute of Alcohol Abuse and Alcoholism (350).

The administrators reported a mean reduction of 12.6% in overall budget, 21.8% in grant funding, 16.9% in Medicaid income, and 12.4% in insurance payments.

The dip in grant allocations alone correlated with an increase in uncollectible revenues, a decrease in staff and treatment slots, and the implementation of hiring freezes, he said.

Staff losses and hiring freezes cut across the management, counselor, and support staff categories: 14.1% of interviewees reported cuts at management level, 27.1% reported counselor losses, and 24.6% support staff losses.

One-third of those interviewed said there had been hiring freezes across all three staff categories.

Commensurate with these staff cuts, particularly at the counselor level, was a reduction in the number of treatment slots, which was reported by 11.9% of the interviewees.

At the same time, there was a mean overall increase of 18.2% in patients.

“The American substance abuse treatment system is under considerable economic stress,” Dr. Roman said. Smaller, nonprofit, nonhospital-associated programs have been hardest hit, as have programs with a higher percentage of Medicaid patients, a lower percentage of counselors with master's degrees, and more injection drug users and unemployed patients.

From a regional perspective, almost half of the programs in the Pacific coast region were stressed, compared with 23.1% in the South Atlantic, 15.4% in the East North Central, and 7.7% in the Mid-Atlantic regions.

Dr. Roman said programs might capitalize on four “great opportunities” to bolster their bottom lines and treatment services: the growth of substance abuse problems in the elderly, the fact that Baby Boomers are aging into the high prevalence years of substance abuse, the implementation of parity for substance and alcohol use disorder treatment, and health care reform.

He emphasized, however, that leadership will be critical if providers are to join together to take advantage of these factors. “The most successful treatment programs … engage in concrete, measurable, identifiable, systemic strategic planning,” he said. Programs should therefore consider how they could attract clients to and keep them in treatment, work to shed the chronic disease stigma associated with substance abuse, and tap new sources of referral, such as the workplace.

Dr. Roman said he had no financial disclosures to make. The study was funded by National Institute of Drug Abuse and the NIAAA.

BETHESDA, MD. – The current economic downturn has had a substantial impact on the prevalence and treatment of addiction in the United States, according to preliminary findings of data gathered from treatment program administrators.

Stress as a result of job loss or being in a family affected by job loss has led to an increased demand for addiction treatment services, which are themselves under siege because of a drop in funding, cuts in management and counselor slots, and the ripple effects of hiring freezes, Paul Roman, Ph.D., said at the annual meeting of the Association for Medical Education and Research in Substance Abuse, which was sponsored by Brown Medical School.

Dr. Roman and Amanda J. Abraham, Ph.D., both of the University of Georgia, Atlanta, collected data during face-to-face and follow-up telephone interviews with treatment program administrators in the Clinical Trial Program (198), privately run programs (345), and the National Institute of Alcohol Abuse and Alcoholism (350).

The administrators reported a mean reduction of 12.6% in overall budget, 21.8% in grant funding, 16.9% in Medicaid income, and 12.4% in insurance payments.

The dip in grant allocations alone correlated with an increase in uncollectible revenues, a decrease in staff and treatment slots, and the implementation of hiring freezes, he said.

Staff losses and hiring freezes cut across the management, counselor, and support staff categories: 14.1% of interviewees reported cuts at management level, 27.1% reported counselor losses, and 24.6% support staff losses.

One-third of those interviewed said there had been hiring freezes across all three staff categories.

Commensurate with these staff cuts, particularly at the counselor level, was a reduction in the number of treatment slots, which was reported by 11.9% of the interviewees.

At the same time, there was a mean overall increase of 18.2% in patients.

“The American substance abuse treatment system is under considerable economic stress,” Dr. Roman said. Smaller, nonprofit, nonhospital-associated programs have been hardest hit, as have programs with a higher percentage of Medicaid patients, a lower percentage of counselors with master's degrees, and more injection drug users and unemployed patients.

From a regional perspective, almost half of the programs in the Pacific coast region were stressed, compared with 23.1% in the South Atlantic, 15.4% in the East North Central, and 7.7% in the Mid-Atlantic regions.

Dr. Roman said programs might capitalize on four “great opportunities” to bolster their bottom lines and treatment services: the growth of substance abuse problems in the elderly, the fact that Baby Boomers are aging into the high prevalence years of substance abuse, the implementation of parity for substance and alcohol use disorder treatment, and health care reform.

He emphasized, however, that leadership will be critical if providers are to join together to take advantage of these factors. “The most successful treatment programs … engage in concrete, measurable, identifiable, systemic strategic planning,” he said. Programs should therefore consider how they could attract clients to and keep them in treatment, work to shed the chronic disease stigma associated with substance abuse, and tap new sources of referral, such as the workplace.

Dr. Roman said he had no financial disclosures to make. The study was funded by National Institute of Drug Abuse and the NIAAA.

BETHESDA, MD. – The current economic downturn has had a substantial impact on the prevalence and treatment of addiction in the United States, according to preliminary findings of data gathered from treatment program administrators.

Stress as a result of job loss or being in a family affected by job loss has led to an increased demand for addiction treatment services, which are themselves under siege because of a drop in funding, cuts in management and counselor slots, and the ripple effects of hiring freezes, Paul Roman, Ph.D., said at the annual meeting of the Association for Medical Education and Research in Substance Abuse, which was sponsored by Brown Medical School.

Dr. Roman and Amanda J. Abraham, Ph.D., both of the University of Georgia, Atlanta, collected data during face-to-face and follow-up telephone interviews with treatment program administrators in the Clinical Trial Program (198), privately run programs (345), and the National Institute of Alcohol Abuse and Alcoholism (350).

The administrators reported a mean reduction of 12.6% in overall budget, 21.8% in grant funding, 16.9% in Medicaid income, and 12.4% in insurance payments.

The dip in grant allocations alone correlated with an increase in uncollectible revenues, a decrease in staff and treatment slots, and the implementation of hiring freezes, he said.

Staff losses and hiring freezes cut across the management, counselor, and support staff categories: 14.1% of interviewees reported cuts at management level, 27.1% reported counselor losses, and 24.6% support staff losses.

One-third of those interviewed said there had been hiring freezes across all three staff categories.

Commensurate with these staff cuts, particularly at the counselor level, was a reduction in the number of treatment slots, which was reported by 11.9% of the interviewees.

At the same time, there was a mean overall increase of 18.2% in patients.

“The American substance abuse treatment system is under considerable economic stress,” Dr. Roman said. Smaller, nonprofit, nonhospital-associated programs have been hardest hit, as have programs with a higher percentage of Medicaid patients, a lower percentage of counselors with master's degrees, and more injection drug users and unemployed patients.

From a regional perspective, almost half of the programs in the Pacific coast region were stressed, compared with 23.1% in the South Atlantic, 15.4% in the East North Central, and 7.7% in the Mid-Atlantic regions.

Dr. Roman said programs might capitalize on four “great opportunities” to bolster their bottom lines and treatment services: the growth of substance abuse problems in the elderly, the fact that Baby Boomers are aging into the high prevalence years of substance abuse, the implementation of parity for substance and alcohol use disorder treatment, and health care reform.

He emphasized, however, that leadership will be critical if providers are to join together to take advantage of these factors. “The most successful treatment programs … engage in concrete, measurable, identifiable, systemic strategic planning,” he said. Programs should therefore consider how they could attract clients to and keep them in treatment, work to shed the chronic disease stigma associated with substance abuse, and tap new sources of referral, such as the workplace.

Dr. Roman said he had no financial disclosures to make. The study was funded by National Institute of Drug Abuse and the NIAAA.

BETHESDA, MD. – Screening, brief intervention, and referral to treatment programs in large-volume general medical settings captured a range of patients at risk for alcohol, tobacco, and other drug use disorders that otherwise might not have been detected, findings in an evaluation of data from a cohort of centers that implemented the program show.

Emergency/trauma centers, in particular, are effective as screening, brief intervention, and referral to treatment (SBIRT) venues, because they serve high proportions of at-risk individuals, Francis K. Del Boca, Ph.D., reported at the annual conference of the Association for Medical Education and Research in Substance Abuse.

Forty-five percent of patients who screened positive for tobacco or at-risk alcohol use also reported using an illicit drug, said Dr. Del Boca of the University of Connecticut Health Center in Farmington. She noted that those who screened positive “often had ancillary physical, medical, and mental health issues that required consideration in the treatment referral process” and that being able to do so at an earlier stage could have an impact on patient outcomes.

The centers in the current analysis were based in California, Illinois, New Mexico, Pennsylvania, Texas, Washington State, and Cook Inlet in Alaska–together referred to as cohort 1 in the analysis. The cohort members had received funding from the Substance Abuse and Mental Health Services Administration in 2003 to set up SBIRT services in several diverse settings.

Other centers have since received funding as well, but the current analysis was based on data from the first cohort.

The researchers sought to establish the effectiveness, availability, and efficiency of the program by reviewing documents from the centers and conducting site visits that included interviewing and observing program providers and administrators.

There were three service delivery models–in-house generalist, in-house specialist, or contracted specialist–and when the researchers broke down the services into the categories of prescreening, screening, brief intervention (BI), or brief treatment (BT), the contracted specialist model seemed to work well across all of the categories, especially for screening, BI, and BT.

Providers in the hospital-outpatient setting recommended screening and feedback to 87% of patients, but BI, BT, and referral to treatment (RT) to only 8%, 3%, and 3% of patients, respectively. Likewise, federally qualified community health center providers recommended screening to most patients (85%), but their rates for BI, BT, and RT were also notably lower–11%, 3%, and 1%, respectively. By comparison, although only 70% of emergency/trauma patients were recommended for screening and feedback, the corresponding percentages for BI, BT, and RT recommendations were 18, 5, and 8. In the hospital-inpatient setting, only 65% of patients were recommended for screening, but the rates for BI, BT, and RT were 23%, 6%, and 7%.

The researchers found that the SBIRT programs could be implemented successfully and that both patients and medical staff found the programs acceptable. In fact, most patients were willing to participate in SBIRT after screening, with 86% proceeding to BI, 93% to BT, and 93% to RT.

Over time, most SBIRT facilitators found that the programs needed to be adapted to real-world settings, and the researchers noted a migration from early service delivery models, settings, and implementation models, Dr. Del Boca said. Delivery models migrated from full-length screening to shorter prescreening; traditional substance abuse treatment to on-site delivery of treatment; and from a focus on alcohol and drug risk factors to a focus on tobacco, comorbid psychiatric disorders, and other health risk factors.

In addition, hospital and emergency/trauma settings supplanted clinic settings, and a shift was seen away from the early in-house generalist model to contracted specialist model.

The effects of these migrations resulted in an overall shift in program emphasis from treatment to prevention, from alcoholism to heavy drinking, addiction to recreational drug use, disease conditions to risk factors, and from a focus on the individual to a broader public health perspective, said Thomas Babor, Ph.D., also of University of Connecticut Health Center, and who copresented with Dr. Del Boca at the meeting, which was also sponsored by Brown Medical School.

Another presenter, Jeremy Bray, Ph.D., of the nonprofit research and development organization, RTI International, reported on the costs and financing of SBIRT. Among the components that the researchers examined were the cost per patient of screening, and the cost of a BI or BT in a medical care setting, compared with a specialty care setting.

In regard to screening, they found that support activities took as much time as–or sometimes more time than–services activities, with the total screen and service time ranging from about 4 to 14 minutes at a per patient cost of $1.50 to $6.00. For BI, service and support activities took about the same amount of time–from 12 to 22 minutes, with cost ranging from $4.50 to $9.00.

However, service time for BT was considerably longer, compared with the support time, with total time ranging from 40 to 52 minutes, and translating into total labor costs ranging from $16.50 to $22.50.

Dr. Del Boca, Dr. Babor, and Dr. Bray had no financial disclosures. The study was funded by the Center for Substance Abuse Treatment.

BETHESDA, MD. – Screening, brief intervention, and referral to treatment programs in large-volume general medical settings captured a range of patients at risk for alcohol, tobacco, and other drug use disorders that otherwise might not have been detected, findings in an evaluation of data from a cohort of centers that implemented the program show.

Emergency/trauma centers, in particular, are effective as screening, brief intervention, and referral to treatment (SBIRT) venues, because they serve high proportions of at-risk individuals, Francis K. Del Boca, Ph.D., reported at the annual conference of the Association for Medical Education and Research in Substance Abuse.

Forty-five percent of patients who screened positive for tobacco or at-risk alcohol use also reported using an illicit drug, said Dr. Del Boca of the University of Connecticut Health Center in Farmington. She noted that those who screened positive “often had ancillary physical, medical, and mental health issues that required consideration in the treatment referral process” and that being able to do so at an earlier stage could have an impact on patient outcomes.

The centers in the current analysis were based in California, Illinois, New Mexico, Pennsylvania, Texas, Washington State, and Cook Inlet in Alaska–together referred to as cohort 1 in the analysis. The cohort members had received funding from the Substance Abuse and Mental Health Services Administration in 2003 to set up SBIRT services in several diverse settings.

Other centers have since received funding as well, but the current analysis was based on data from the first cohort.

The researchers sought to establish the effectiveness, availability, and efficiency of the program by reviewing documents from the centers and conducting site visits that included interviewing and observing program providers and administrators.

There were three service delivery models–in-house generalist, in-house specialist, or contracted specialist–and when the researchers broke down the services into the categories of prescreening, screening, brief intervention (BI), or brief treatment (BT), the contracted specialist model seemed to work well across all of the categories, especially for screening, BI, and BT.

Providers in the hospital-outpatient setting recommended screening and feedback to 87% of patients, but BI, BT, and referral to treatment (RT) to only 8%, 3%, and 3% of patients, respectively. Likewise, federally qualified community health center providers recommended screening to most patients (85%), but their rates for BI, BT, and RT were also notably lower–11%, 3%, and 1%, respectively. By comparison, although only 70% of emergency/trauma patients were recommended for screening and feedback, the corresponding percentages for BI, BT, and RT recommendations were 18, 5, and 8. In the hospital-inpatient setting, only 65% of patients were recommended for screening, but the rates for BI, BT, and RT were 23%, 6%, and 7%.

The researchers found that the SBIRT programs could be implemented successfully and that both patients and medical staff found the programs acceptable. In fact, most patients were willing to participate in SBIRT after screening, with 86% proceeding to BI, 93% to BT, and 93% to RT.

Over time, most SBIRT facilitators found that the programs needed to be adapted to real-world settings, and the researchers noted a migration from early service delivery models, settings, and implementation models, Dr. Del Boca said. Delivery models migrated from full-length screening to shorter prescreening; traditional substance abuse treatment to on-site delivery of treatment; and from a focus on alcohol and drug risk factors to a focus on tobacco, comorbid psychiatric disorders, and other health risk factors.

In addition, hospital and emergency/trauma settings supplanted clinic settings, and a shift was seen away from the early in-house generalist model to contracted specialist model.

The effects of these migrations resulted in an overall shift in program emphasis from treatment to prevention, from alcoholism to heavy drinking, addiction to recreational drug use, disease conditions to risk factors, and from a focus on the individual to a broader public health perspective, said Thomas Babor, Ph.D., also of University of Connecticut Health Center, and who copresented with Dr. Del Boca at the meeting, which was also sponsored by Brown Medical School.

Another presenter, Jeremy Bray, Ph.D., of the nonprofit research and development organization, RTI International, reported on the costs and financing of SBIRT. Among the components that the researchers examined were the cost per patient of screening, and the cost of a BI or BT in a medical care setting, compared with a specialty care setting.

In regard to screening, they found that support activities took as much time as–or sometimes more time than–services activities, with the total screen and service time ranging from about 4 to 14 minutes at a per patient cost of $1.50 to $6.00. For BI, service and support activities took about the same amount of time–from 12 to 22 minutes, with cost ranging from $4.50 to $9.00.

However, service time for BT was considerably longer, compared with the support time, with total time ranging from 40 to 52 minutes, and translating into total labor costs ranging from $16.50 to $22.50.

Dr. Del Boca, Dr. Babor, and Dr. Bray had no financial disclosures. The study was funded by the Center for Substance Abuse Treatment.

BETHESDA, MD. – Screening, brief intervention, and referral to treatment programs in large-volume general medical settings captured a range of patients at risk for alcohol, tobacco, and other drug use disorders that otherwise might not have been detected, findings in an evaluation of data from a cohort of centers that implemented the program show.

Emergency/trauma centers, in particular, are effective as screening, brief intervention, and referral to treatment (SBIRT) venues, because they serve high proportions of at-risk individuals, Francis K. Del Boca, Ph.D., reported at the annual conference of the Association for Medical Education and Research in Substance Abuse.

Forty-five percent of patients who screened positive for tobacco or at-risk alcohol use also reported using an illicit drug, said Dr. Del Boca of the University of Connecticut Health Center in Farmington. She noted that those who screened positive “often had ancillary physical, medical, and mental health issues that required consideration in the treatment referral process” and that being able to do so at an earlier stage could have an impact on patient outcomes.

The centers in the current analysis were based in California, Illinois, New Mexico, Pennsylvania, Texas, Washington State, and Cook Inlet in Alaska–together referred to as cohort 1 in the analysis. The cohort members had received funding from the Substance Abuse and Mental Health Services Administration in 2003 to set up SBIRT services in several diverse settings.

Other centers have since received funding as well, but the current analysis was based on data from the first cohort.

The researchers sought to establish the effectiveness, availability, and efficiency of the program by reviewing documents from the centers and conducting site visits that included interviewing and observing program providers and administrators.

There were three service delivery models–in-house generalist, in-house specialist, or contracted specialist–and when the researchers broke down the services into the categories of prescreening, screening, brief intervention (BI), or brief treatment (BT), the contracted specialist model seemed to work well across all of the categories, especially for screening, BI, and BT.

Providers in the hospital-outpatient setting recommended screening and feedback to 87% of patients, but BI, BT, and referral to treatment (RT) to only 8%, 3%, and 3% of patients, respectively. Likewise, federally qualified community health center providers recommended screening to most patients (85%), but their rates for BI, BT, and RT were also notably lower–11%, 3%, and 1%, respectively. By comparison, although only 70% of emergency/trauma patients were recommended for screening and feedback, the corresponding percentages for BI, BT, and RT recommendations were 18, 5, and 8. In the hospital-inpatient setting, only 65% of patients were recommended for screening, but the rates for BI, BT, and RT were 23%, 6%, and 7%.

The researchers found that the SBIRT programs could be implemented successfully and that both patients and medical staff found the programs acceptable. In fact, most patients were willing to participate in SBIRT after screening, with 86% proceeding to BI, 93% to BT, and 93% to RT.

Over time, most SBIRT facilitators found that the programs needed to be adapted to real-world settings, and the researchers noted a migration from early service delivery models, settings, and implementation models, Dr. Del Boca said. Delivery models migrated from full-length screening to shorter prescreening; traditional substance abuse treatment to on-site delivery of treatment; and from a focus on alcohol and drug risk factors to a focus on tobacco, comorbid psychiatric disorders, and other health risk factors.

In addition, hospital and emergency/trauma settings supplanted clinic settings, and a shift was seen away from the early in-house generalist model to contracted specialist model.

The effects of these migrations resulted in an overall shift in program emphasis from treatment to prevention, from alcoholism to heavy drinking, addiction to recreational drug use, disease conditions to risk factors, and from a focus on the individual to a broader public health perspective, said Thomas Babor, Ph.D., also of University of Connecticut Health Center, and who copresented with Dr. Del Boca at the meeting, which was also sponsored by Brown Medical School.

Another presenter, Jeremy Bray, Ph.D., of the nonprofit research and development organization, RTI International, reported on the costs and financing of SBIRT. Among the components that the researchers examined were the cost per patient of screening, and the cost of a BI or BT in a medical care setting, compared with a specialty care setting.

In regard to screening, they found that support activities took as much time as–or sometimes more time than–services activities, with the total screen and service time ranging from about 4 to 14 minutes at a per patient cost of $1.50 to $6.00. For BI, service and support activities took about the same amount of time–from 12 to 22 minutes, with cost ranging from $4.50 to $9.00.

However, service time for BT was considerably longer, compared with the support time, with total time ranging from 40 to 52 minutes, and translating into total labor costs ranging from $16.50 to $22.50.

Dr. Del Boca, Dr. Babor, and Dr. Bray had no financial disclosures. The study was funded by the Center for Substance Abuse Treatment.