NEW YORK SOCIETY OF
ADDICTION MEDICINE
April, 2015
www.nysam-asam.org
INSIDE THIS ISSUE:
President’s Column
1
NYSAM at ASAM 2015
1
NYSAM Public Policy 2015
2
PRESIDENT’S COLUMN -GREGORY C. BUNT, MD
privileged. As addiction physicians,
you have acquired a great professional
and social responsibility, and in this
regard I am deeply honored to serve as
your President of the Society.
UN Special Session on Drugs
Survey –info and link
3
NYSAM on Facebook
and Twitter
3
Summary Medical Marijuana 4
Public Policy continued ……. 5
Addiction Consultation
6-7
Calendar of Events
8
McLean NYSAM Event
8
NYSAM BOARD
Gregory C. Bunt, MD
President
Eric D. Collins, MD
President Elect
Jun David, MD
Treasurer
Sharon Stancliff, MD
Secretary
Norman Wetterau, MD
Immediate Past President
Michael Delman, MD
Member-At-Large
Merrill Herman, MD
Member-At-Large
Jeffrey Selzer, MD
Regional Director to ASAM
Dorothy Lennon, MD
Membership Committee
Chair
Edwin Salsitz, MD
Education & Program Committee Chair
Torin Finver, MD
Early Career Member
Timothy J. Wiegand, MD
Chair of Communications
Dear NYSAM Member,
NYSAM again welcomes you, one
of the most reputable addiction
physicians in New York State, to
the newsletter of our esteemed
Society. NYSAM’s mission, to
advance and develop the science
and clinical practice of Addiction
Medicine in New York State, will
be achieved by encouraging and
supporting premier addiction
physicians like you to become
established as experts and leaders in the prevention, diagnosis
and treatment of addictive disorders. Addictions are rapidly becoming the number one public
health problem and threat in New
York State and throughout the
nation, as evidenced by the epidemic in opiate overdoses, the
escalation in heroin addiction, the
ongoing development of dangerous synthetic drugs of abuse, and
the rise in marijuana abuse among
the youth, mentally-ill and under-
On behalf of the NYSAM Board of
Directors, I welcome and encourage
you to participate in networking and
committee work to further advance our
common cause and build the influence
of our leadership. Our 11th Annual
Statewide Conference, The Intersection of Science, Treatment and Policy) organized by Ed Salsitz, M.D.,
attracted more than 150 addiction
physicians and included and all day
Public Policy Forum involving the New
York State Medical Marijuana legislation and a review of the science and
evidence for marijuana as medicine as
well as sessions involving the treatment of marijuana dependence in
special populations including adolescents impacted by marijuana use disorders. Although several NYSAM members spoke at the conference experts
from around the state and more broadly
joined us in Manhattan for an outstanding two days. The conference has
been one of the high points of the year
and this year was no exception. Networking with other addiction treatment
professionals will strengthen ties with
disciplines and colleagues dedicated
to our common cause.
The New York Association of Alcoholism and Substance Abuse Providers
headed by John Coppola, is working
very closely with NYSAM in collaborative efforts in the areas of public
policy, continuing education and
strategic planning.
Furthermore,
NYSAM now has an associate membership category for non-physician
addiction professionals, accessible on
the ASAM website. Please invite your
non-physician addiction treatment
provider colleagues to join NYSAM,
and become part of our important
growing organization..
I’d also like to welcome Torin Finver,
MD, to the NYSAM Board of Directors.
Dr. Finver is the Fellowship Director
for the UAB Addictions Medicine
Fellowship Program, a faculty member
in the UAB School of Medicine and
Medical Director for several addictions
and detoxification programs in the
Buffalo area. Dr. Finver joins NYSAM
as the new Early Career position and
s a welcome addition to the NYSAM
Board.
Finally, I’d like to welcome Elisabeth
Kranson to her role with NYSAM.
Welcome Elisabeth!
NYSAM AT THE 46TH ASAM –INNOVATIONS IN
ADDICTION MEDICINE AND SCIENCE ANNUAL
CONFERENCE AUSTIN, TX 2015
Please join the New York Society of Addiction Medicine at the American Society of
Addiction Medicine Annual Medical Scientific Meeting April 23-26th in Austin, Texas. Key events and times for NYSAM members are below:
Scientific Plenary & Distinguished Scientist Lecture 8:30-10:00 4/23/2015
NYSAM meeting –Friday, 4/24/15 1:00pm —room 414 Fourth Floor
ASAM Annual Awards Luncheon (ticketed*) Governor Ballroom 12:30-2:30 4/24/15
NYSAM Newsletter Editor –Timothy J. Wiegand, MD, FACMT –[email protected]
NEW
YORK
SOCIETY
OF
ADDICTION
MEDICINE
Page 2
NYSAM Public Policy Forum: Marijuana: Problem and Opportunities in New York
State January 30, 2015 —-Norm Wetterau, Chair, Public Policy Committee
Almost 250 people attended, 100 more than last year’s public policy conference. A week
before the meeting, the American Academy of Pediatrics came out with their new policy
statement and technical paper on marijuana (Download both from their website). These
documents addressed some of the same issues that were addressed at our conference.
The AAP policy paper opposed legalization of marijuana, but felt that we need to explore
ways to decimalize possession of small amounts, and help young people receive treatment. Most of our speakers expressed similar views.
Norm Wetterau, MD,
FASAM, Chair of the
NYSAM Public Policy
Committee
NYSAM Public Policy Forum:
“Marijuana Symposium and
the Annual NYSAM Meeting
and Networking Reception
took place on Friday, January 30th, 2015 at the
Wyndam New Yorker Hotel
in Manhattan. The Marijuana symposium was held the
first day the NYSAM 11th
Annual Statewide Conference -”Intersection of Science, Treatment and Policy”
ASAM member Timothy Brennan, a pediatrician and child psychiatrist, reviewed the evidence showing the harm marijuana can cause children and teens. His review was extensive
and challenged some popular views that marijuana is harmless. Although some teens use
marijuana casually, 6.5% of high school seniors use it daily, and these figures would not
include those who had already dropped out of high school. He spent much of the talk discussing the effects on the brain. Adults who smoked cannabis regularly during adolescence
had impaired neural connectivity with fewer fibers in specific brain regions: the precuneus
which coordinates alertness and self- conscious awareness and the fimbria: an area of the
hippocampus that is important in learning and memory. There was also reduced functional
connectivity in the prefrontal networks responsible for executive function, including inhibitory control subcortical networks which process habits and routines. He had other slides
on IQ changes and neurocognitive testing, which showed similar results to nonusers, but
more areas of the brain had to be recruited to accomplish the same goal. Persistent users
showed neuropsychological declines across five different areas of mental function. In a
simpler slide, he showed that adolescents who had smoked more than 100 times left
school 5.8 times more often and entered college 3.3 times less often. Dr. Brennan noted
that many of these studies were done on strains of marijuana, which had less THC than
many of the strains used today. I feel that this and other data need to be publicized more
as our nation struggles with efforts to improve our schools and to be competitive in the
world.
ASAM member Marc Fishman followed up with a talk on treatment. Like Dr. Brennan’s
talk, his was full of examples and references. He presented evidence that treatment does
work, but not all teens will stop all marijuana use immediately. Engaging the teen in treatment is the most difficult, but not impossible task. Many of these teens use other drugs;
have mental health problems, or significant social problems. Several speakers then discussed the status of treatment availability in New York State. There is good treatment
available, but not for every teen that needs it.
Dr. Wetterau presented a view of marijuana from a primary care standpoint. He felt that
drug use is like a communicable pediatric disease. It spreads from teen to teen. In some
cases it goes away, in some remains the same, like continuing to smoke cigarettes or
smoke marijuana on weekends, but often it becomes much worse and causes many medical, educational and social problems. Continued page 4.
Email for NYSAM contact: [email protected] or [email protected].
NEW
YORK
SOCIETY
OF
ADDICTION
MEDICINE
Page 3
Survey for the upcoming UN Special Section on drugs
The United Nations General Assembly will hold a Special Session (UNGASS)
on drugs on April 19th -21st, 2016 (UNGASS 2016). This is the most significant
opportunity to hold a global and in-depth discussion on drugs in almost 20
years. The beneficial role civil society can play in the preparation for this meeting has been widely acknowledged by the United Nations.
With the support of the United Nations, the Vienna NGO Committee on Drugs
(VNGOC) and the New York NGO Committee on Drugs (NYNGOC) joined
forces to launch the Civil Society Task Force (CSTF) for the UNGASS 2016.
The CSTF is designed to secure civil society engagement and coordination in
order to effectively include NGO voices in the UNGASS. The VNGOC and the
NYNGOC have overseen the composition of the CSTF, aiming for an overall
balance in terms of both geography and approaches to drug policies and interventions.
This UNGASS 2016 Global Civil Society Survey is designed to provide an initial assessment on the civil society work in the field of drugs, as well as to
measure the awareness and level of knowledge and interest in participating
actively at the UNGASS 2016 initiative at the regional and global levels. The
results will provide an overview of (i) the work of NGOs active in the drug field,
(ii) areas of expertise, (iii) key priorities and concerns to be addressed as well
as (iv) best practices.
NYSAM Board member and
Medical Director for the
Harm Reduction Coalition
Sharon Stancliff –for more
information on the UN and
drug policy contact Dr.
Stancliff at:
[email protected]
Your experience is essential in the UNGASS preparatory process. Please complete the following survey, which will take no longer than 30 minutes of your
time, but will provide invaluable information for us to bring to global policy makers at the United Nations for the UNGASS preparation and beyond.
Your responses will be kept confidential and any identifying information is solely for the CSTF’s record keeping. Survey link: http://bit.ly/1J3NCHk
NEW
YORK SOCIETY OF ADDICTION MEDICINE
– SOCIAL MEDIA ‘CHECK US’ OUT’!
NYSAM is on the WEB,
TWITTER and FACEBOOK!
NYSAM has a website, Twitter
and Facebook account! Please
LIKE NYSAM on Facebook and
FOLLOW on Twitter! If anyone
is interested in assisting with
keeping the NYSAM website,
Twitter and Facebook accounts
updated with NYSAM news,
please contact Dr. Timothy J
Wiegand.
To follow NYSAM on Twitter,
twitter username is:
NYSAM@NYSAMAddiction,
Facebook, please search for
New York Society of Addiction Medicine, and LIKE,
please!!! NYSAM website is
www.NYSAM-ASAM.com.
New York Society of Addiction
Medicine on Facebook
and Twitter
Email for NYSAM contact: [email protected] or [email protected].
New York Society of Addiction Medicine
NYSAM
Page 4
Summary of New York Medical Marijuana Law and NYSAM Public Policy
Committee Critique —Norm Wetterau, MD, FASAM, Chair, NYSAM Public Policy
Committee
Update on Medical
Marijuana in New
York State —Norm
Wetterau, MD,
FASAM
NYSAM opposed the initial medical marijuana bill. It was wide open. The advisory committee would be
required by law to have representatives from the marijuana industry and people who use it, but the
committee would not have been required to have physicians. It is our opinion that the bill was crafted
by the marijuana industry. The governor gave the legislature a take it or leave it proposal which passed.
Although ASAM believes that all medical cannabinoid products should be approved by the FDA, this bill
is as good as it can get unless you have FDA approval.
The governor’s bill will not permit smoking as a delivery system. To smoke something for your health is
absurd. It can be given orally, Tran mucosal or by vaporizer. The marijuana must be tested in the laboratory so the doctor can order specific formulations and be assured that this is what the patient will get.
Dispensaries will be limited to 20.
The number of conditions that can be treated will be limited to:
Cancer, HIV, amyotrophic lateral sclerosis, Parkinson disease, multiple sclerosis, damage to the spinal
cord with objective neurological indication or intractable plasticity, epilepsy, inflammatory bowel disease, neuropathies, Huntington’s disease
The commissioner of health can recommend other conditions and this is a potential problem, since many
pro-marijuana groups want it approved for concussion and head injury. I am not sure how marijuana
will improve one’s memory after a head injury.
One of the best improvements over the previous bill was the elimination of the advisory committee. Initially this committee had to have members of the marijuana industry and people who used medical marijuana, but it did not have to include physicians. Now the commissioner of heath will seek out appropriate experts to advise him or her. The commission also hopes that data collected on usage in the approved diseases could have research value
Suppose things go badly. Under the bill the governor can unilaterally end the whole program. After 7
years, the program sunsets and has to end or be voted on again. If drugs such as Sativex(R) are on the
market, the program could easily be terminated.
Because of such widespread prescribing abuse in other states, this bill will make it a crime for a patient
to fraudulently seek medical marijuana. Doctors will have to avoid some of the practices of doctors in
California and other states. Doctors will not be able to have marijuana mills. First the doctor has to already be treating the patient for the chronic condition. Second the doctor has to take an approved
course on medical marijuana, and obtain a card to prescribe this, like a doctor who wants to prescribe
Suboxone(R). All prescriptions will be tracked by the state and part of ISTOP. If a doctor is recklessly and
inappropriately prescribing medical marijuana, he could be arrested and face felony charges.
NYSAM commends the governor for his position, and the health department, for their standing up so
far against the marijuana industry. NYSAM has offered to assist in the wording of package inserts, and in
the course doctors will have to take. We want to make sure that physicians who prescribe medical marijuana will know when a person develops an addiction, and will not prescribe to simply maintain an addiction. We are also concerned about polypharmacy, which is already a problem: opioids and benzodiazepines and medical marijuana, and then throw in stimulants to wake the person up. I think we already see enough of this.
Those with an interest in this area should contact Dr. Wetterau at [email protected]
New York Society of Addiction Medicine
Page 5
Public Policy Section –Continued from page 2
Norm Wetterau, MD, FASAM, Chair Public Policy Committee
In the past, SBIRT for teens alcohol and drug use has been proposed, but most physicians do not have the time or
expertise to do this. With the advent of the medical home and team care, other members of the team might help.
The Medical Home also has the concept of the medical neighborhood. Team members could connect hurting teens,
that are either at risk for drug use, or using drugs to community resources in the medical neighborhood. This might
be easier for early using teens to accept than referral to a formal treatment program. Such programs need to be
established and tested. All of these ideas are not currently evidence based, because they have not yet been formally tested. What is evidence based, however, are definite risk and protective factors for drug use. These are discussed in the MSSNY Youth at risk report which he helped author (MSSNY.org scroll down public health).
Sandeep Kendham JD, from the NY Legal Aid Societies Juvenile Rights Practice, gave a powerful presentation showing how being arrested caused great problem for teens. In New York State, 16 and 17 year olds are treated like
adults. Mr Kendham was not advocating legalization, but a program of education and treatment, depending on
what drugs were used, and how much. If at all possible this should be outside of the court system. He also discussed PINS, persons in need supervision. Here it is much better for a parent to be active in getting their teenager
help, than wait for the school or child welfare to refer them through a PINS petition. I know that the big argument is
between legalization and no legalization. I think that it might be more productive to look at models of decriminalization and access to treatment (Author opinion). This is also what the AAP position paper advocated.
Finally Allyn Taylor JD, JSD, discussed advertising and promotion of addicting substances. Although progress has
been made in restricting advertising of tobacco, the industry is always pushing the boundaries. Due to our constitutional protections, the government cannot outlaw all advertising. Since marijuana is still illegal nationally, there is
no constitutional protection for marijuana advertising, although that has not stopped it in marijuana states. ASAM
members in marijuana states might work to restrict advertising, which may be successful as long as marijuana is not
legal nationally.
If marijuana became legal nationally, then advertising would be constitutionally protected. I invited Dr. Taylor to
speak because I personally feel this is one of the biggest issues with legalization. If marijuana is legalized it will join
alcohol and tobacco in media promotion, more than it already is, and there will be little that can be done about this.
In theory, money from taxes on the product could be used for counter ads, but this usually does not happen with
alcohol or tobacco. The state finds other uses for the tax money, and the industry makes political contributions to
make sure their product is not too tightly regulated. ASAM members may not want to become involved in political
issues or have any position, but before saying that drug use is just a medical problem, we need to understand the
issues of marketing. Dr. Taylor showed us that advertising, and the media environment could have a great influence
on what we want to see as only a brain disease.
NYSAM plans to follow-up this conference with proposals for increasing treatment in our state, and for ticketing,
evaluation and treatment if needed, for possession of small amounts of marijuana rather than arrest. This is not
legalization in any way. We may also work with MSSNY in promoting prevention and the recommendations of the
MSSNY Youth At Risk Report.
For more information or to get involved contact ———Dr. Wetterau at [email protected]
Page 6
Consultation and Billing for the Treatment of Opioid Dependence and Withdrawal in Hospitalized Individuals –Use of Buprenorphine and Counseling On Top of Standard Consultation Codes –Opportunities
for the Addiction Specialist.
Timothy J. Wiegand MD, DABAM, FACMT, FAACT Chair of the NYSAM Communication Committee
Consultation and Billing
for the Treatment of
Opioid Dependence and
Withdrawal in Hospitalized I individuals–
Opportunities for the
Addiction Specialist.
Timothy J. Wiegand,
MD, FACMT, FAACT
Chair of the
Communications
Committee
Physicians trained in treating patients with substance use disorders are well-positioned to
offer important services to the hospitalized patients that suffer from the disease of addiction. Many of these scenarios represent not only significant opportunities to improve patient care, they also offer an opportunity for billing and revenue generation for the
‘addiction’ consultant. One example is the evaluation of patients with opioid dependence,
intravenous drug abuse and infections (e.g. abscess or endocarditis). In the Rochester, NY
area, as in most areas in the state of New York, many of these patients have been at least
exposed to buprenorphine (either through the illicit market via ‘self-treatment’ of withdrawal
while on the street or as part of a detoxification program. Some of them have had more
prolonged exposure during office or clinic based Medication Assisted Treatment). A recent
article in JAMA Internal Medicine reported that the identification of opioid-dependent patients while hospitalized for non-addiction related illness (not seeking addiction or detox as
the primary complaint) and induction and linkage to outpatient programs accompanied with
ongoing Medication Assisted Treatment (buprenorphine maintenance started in hospital
and continued to the outpatient setting) was associated with greater success (albeit still
fairly high dropout rates) compared to those that initiate treatment themselves by presenting to detox or other addiction treatment facilities (Liebschutz JM, et al).
Example – A 19 year-old male with several years of IVDU using heroin presents to the
hospital with fever and is found to have abscess in the antecubital fossa. The abscess is
incised and drained and IV antibiotics are started, however he remains febrile. There is
concern for possible endocarditis, as he is noted to have a murmur and his ESR is significantly elevated. There was surrounding cellulitis (from the abscess) as well. Addiction
Medicine is consulted for help with managing the patient’s anticipated withdrawal, and to
provide information about treatment programs and medications for opioid dependence that
would help “eliminate the Dilaudid™ he’s constantly asking for…” The patient is admitted
to the Observation Unit and seen by Addiction Medicine specialist the following morning.
He’s been getting short-acting opioids (hydromorphone) 2 mg intravenously every 4 hours
without exception. He notes his pain is, “10 out of 10” and he also complains of
“withdrawal” and insomnia. He has previous experience with use of Suboxone™ both “on
the street and in detox,” and he had been on maintenance with it for about 5 months, before losing insurance, and being forced to drop out of treatment due to inability to pay for
treatment and the prescription out of pocket. He notes that he “did OK on it,” and agrees
that it would be useful while in the hospital, and afterwards and he is willing to undergo
induction. Clonidine at 0.1 mg 1-2 every 4 hours along with diazepam 10 mg x 1 are ordered. These medications begin after the hydromorphone is discontinued, about 6 hours
after the initial consult was performed. The following morning the toxicology team assessed the patient (about 16 hours from the d/c of hydromorphone). His Clinical Opioid
Withdrawal Scale (COWS) is 15. His heart rate is 80 bpm. He is irritable and clearly in opioid w/d with mydriasis, rhinorrhea, nausea, anorexia, sweating and GI cramping. He reports that his anxiety is moderately well controlled with the clonidine and the diazepam.
He had slept for about 2 hours overnight (but received 0.2 mg clonidine every 4 hours and
an additional 50 mg hydroxyzine x 2).
Continued following page...
Page 7
Continued…. Consultation Opportunities for the Addiction Specialist –Hospitalized Patients.
The opioid (hydromorphone) has been dc’d for nearly 16 hours at this point. A 2/0.5 mg dose of Suboxone is
administered (ordered by addiction consultant attending with X-waiver) and administered while directly observed by resident (and Toxicology attending) after it is brought up from pharmacy. It takes 35 minutes to
interview, examine and assess the patient, and to discuss dosing and admin and review the contract. The
patient confirms a follow-up appointment for intake and evaluation for Chemical Dependency treatment. The
2/0.5 mg Suboxone™ dose was taken sublingual and an hour later the patient had moderate improvement in
his symptoms. A 4/1 mg dose was given, and on f/u phone call he has had dramatic improvement. The nurse
reports he denies w/d symptoms and notes that he is eating lunch and “very pleasant and appreciative.” The
maintenance dose is 8/2 mg SL BID and a one week Rx is given to the patient several days later after he
has confirmed negative tests for endocarditis and antibiotics sensitivities are back.
Billing/Charges/Revenue: His initial consult (initial visit 85 minutes CPT code: 99245 (diagnosis cellulitis,
fever, abscess, opioid dependence) the 99245 is used as he is technically ‘outpatient’ and the admit order
wasn’t in yet and he is seen in the ED). The charges are $650.00 for 99245 (CPT code) paid is $158.31. The
Hospital Day 2 charges (99233 –35 min subsequent visit) is charged at $305.00 and reimbursed at $ 157.96.
Additional charges include the medication administration during the buprenorphine induction (H0033) -oral
medication administration, direct observation –charge amount $248.00 is paid at $225.00. The Hospital Day
3 charges (99233 –subsequent visit level 3 35 min) is charged at $305.00 and reimbursed at $157.96. A
smoking cessation and tobacco use cessation counseling visit is added to this encounter. The cpt code is
99407 (intensive) for > 10 minutes counseling related to smoking and tobacco use cessation counseling:
charged: $85.00 and reimbursed $30.73. For this 3-day encounter the following charges and reimbursement
was billed/received: (99245, 2 x 99233, H0033 x 1, 99407 x 1).
Total charges: HD 1: $650, HD 2: $305.00 + 248.00, HD 3: $ 305.00 + $85.00
Total reimbursed: HD1: $158.31, HD 2: $157.96 + $225.00 and HD 3: $157.96 + $30.73.
Total charges: $1593.00
Total reimbursed: $729.96 for all consultation activities*
Reimbursement rate: 46%
Reference:
Liebschutz JM, Crooks D, Herman D, Anderson B, Tsui J, Meshesha LZ, Dossabhoy S, Stein M (2014). Buprenorphine treatment for hospitalized, opioid-dependent patients: a randomized clinical trial. JAMA Intern
med 174(8): 1369-76.
*Consultant was Board Certified Medical Toxicology and Addiction Medicine as well as Internal Medicine.
UPDATE ON MEMBERSHIP —Medical Student and Resident Membership and Rates—
Did you know that medical students may join ASAM and NYSAM at no cost. This does not require conference
attendance. The membership rate for residents is currently $36.
—-For more information about ASAM/NYSAM dues and membership please email NYSAM Membership
Committee Chair Dorothy R. Lennon, MD [email protected]
Page 8
NYSAM Calendar & Announcements