Illicit use of opiates is the fastest growing substance use problem in the United States, and the main reason for seeking addiction treatment services for illicit drug use throughout the world. It is associated with significant morbidity and mortality related to human immunodeficiency virus, hepatitis C, and overdose. Treatment for opiate addiction requires long-term management. Behavioral interventions alone have extremely poor outcomes, with more than 80% of patients returning to drug use. Similarly poor results are seen with medication-assisted detoxification. This article provides a topical review of the three medications approved by the Food and Drug Administration for long-term treatment of opiate dependence: the opioid-agonist methadone, the partial opioid-agonist buprenorphine, and the opioid-antagonist naltrexone. Basic mechanisms of action and treatment outcomes are described for each medication. Results indicate that maintenance medication provides the best opportunity for patients to achieve recovery from opiate addiction. Extensive literature and systematic reviews show that maintenance treatment with either methadone or buprenorphine is associated with retention in treatment, reduction in illicit opiate use, decreased craving, and improved social function. Oral naltrexone is ineffective in treating opiate addiction, but recent studies using extended-release naltrexone injections have shown promise. Although no direct comparisons between extended-release naltrexone injections and either methadone or buprenorphine exist, indirect comparison of retention shows inferior outcome compared with methadone and buprenorphine. Further work is needed to directly compare each medication and determine individual factors that can assist in medication selection. Until such time, selection of medication should be based on informed choice following a discussion of outcomes, risks, and benefits of each medication.

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Maintenance Medication for Opiate Addiction: The Foundation of Recovery

Results:Of25073surgeonssampled,7197(28.7%)completed the survey. Of these, 1112 (15.4%) had a score on the Alcohol Use Disorders IdentificationTest, versionC, consistent with alcohol abuse or dependence. The point prevalenceforalcoholabuseordependenceformalesurgeonswas13.9%andforfemalesurgeonswas25.6%.Surgeons reporting a major medical error in the previous 3 months were more likely to have alcohol abuse or dependence(oddsratio,1.45;P.001).Surgeonswhowere burnedout(oddsratio,1.25;P=.01)anddepressed(odds ratio, 1.48; P.001) were more likely to have alcohol abuse or dependence. The emotional exhaustion and depersonalization domains of burnout were strongly associated with alcohol abuse or dependence. Male sex, havingchildren,andworkingfortheDepartmentofVeterans Affairs were associated with a lower likelihood of alcohol abuse or dependence. Conclusions: Alcohol abuse and dependence is a significant problem in US surgeons. Organizational approaches for the early identification of problematic alcohol consumption followed by intervention and treatment where indicated should be strongly supported.

https://jamanetwork.com/journals/jamasurgery/articlepdf/1107783/siz110029_168_174.pdf

Prevalence of alcohol use disorders among American surgeons

Objective To evaluate the effectiveness of US state physician health programmes in treating physicians with substance use disorders.

Design Five year, longitudinal, cohort study.

Setting Purposive sample of 16 state physician health programmes in the United States.

Participants 904 physicians consecutively admitted to one of the 16 programmes from September 1995 to September 2001.

Main outcome measures Completion of the programme, continued alcohol and drug misuse (regular urine tests), and occupational status at five years.

Results 155 of 802 physicians (19.3%) with known outcomes failed the programme, usually early during treatment. Of the 647 (80.7%) who completed treatment and resumed practice under supervision and monitoring, alcohol or drug misuse was detected by urine testing in 126 (19%) over five years; 33 (26%) of these had a repeat positive test result. At five year follow-up, 631 (78.7%) physicians were licensed and working, 87 (10.8%) had their licences revoked, 28 (3.5%) had retired, 30 (3.7%) had died, and 26 (3.2%) had unknown status.

Conclusion About three quarters of US physicians with substance use disorders managed in this subset of physician health programmes had favourable outcomes at five years. Such programmes seem to provide an appropriate combination of treatment, support, and sanctions to manage addiction among physicians effectively.

https://www.bmj.com/content/bmj/337/bmj.a2038.full.pdf

Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States

Alcohol drinking is an established risk factor for several malignancies, and it is a potentially modifiable risk factor for cancer. The Cancer Prevention Committee of the American Society of Clinical Oncology (ASCO) believes that a proactive stance by the Society to minimize excessive exposure to alcohol has important implications for cancer prevention. In addition, the role of alcohol drinking on outcomes in patients with cancer is in its formative stages, and ASCO can play a key role by generating a research agenda. Also, ASCO could provide needed leadership in the cancer community on this issue. In the issuance of this statement, ASCO joins a growing number of international organizations by establishing a platform to support effective public health strategies in this area. The goals of this statement are to:• Promote public education about the risks between alcohol abuse and certain types of cancer;• Support policy efforts to reduce the risk of cancer through evidence-based strategies that prevent exce...

https://ascopubs.org/doi/pdfdirect/10.1200/JCO.2017.76.1155

Alcohol and Cancer: A Statement of the American Society of Clinical Oncology

How are addicted physicians treated? A national survey of physician health programs

Context Substance use disorders among physicians are important and persistent problems. Considerable debate exists over whether use of major opioids, especially among anesthesiologists, is associated with a higher relapse rate compared with alcohol and nonopioids. Moreover, the risk factors for relapse with current treatment and monitoring strategies are unknown. Objective To test the hypothesis that chemically dependent health care professionals using a major opioid (eg, fentanyl, sufentanil, morphine, meperidine) as drug of choice are at higher risk of relapse. Design, Setting, and Participants Retrospective cohort study of 292 health care professionals enrolled in the Washington Physicians Health Program, an independent posttreatment monitoring program, followed up between January 1, 1991, and December 31, 2001. Main Outcome Measure Factors associated with relapse, defined as the resumption of substance use after initial diagnosis and completion of primary treatment for chemical dependency. Results Twenty-five percent (74 of 292 individuals) had at least 1 relapse. A family history of a substance use disorder increased the risk of relapse (hazard ratio [HR], 2.29; 95% confidence interval [CI], 1.44-3.64). The use of a major opioid increased the risk of relapse significantly in the presence of a coexisting psychiatric disorder (HR, 5.79; 95% CI, 2.89-11.42) but not in the absence of a coexisting psychiatric disorder (HR, 0.85; 95% CI, 0.33-2.17). The presence of all 3 factors— major opioid use, dual diagnosis, and family history—markedly increased the risk of relapse (HR, 13.25; 95% CI, 5.22-33.59). The risk of subsequent relapses increased after the first relapse (HR, 1.69; 95% CI, 1.13-2.53). Conclusions The risk of relapse with substance use was increased in health care professionals who used a major opioid or had a coexisting psychiatric illness or a family history of a substance use disorder. The presence of more than 1 of these risk factors and previous relapse further increased the likelihood of relapse. These observations should be considered in monitoring the recovery of health care professionals.

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Lynn Hankes

Papers

Risk factors for relapse in health care professionals with substance use disorders.