Showing papers on "Addiction medicine published in 2013"

Physician education in addiction medicine.

Abstract: Substance use disorders contribute substantially to the global burden of disease,1 with hospitals and medical clinics often clogged with the primary and secondary sequelae of these conditions in the United States.2 Yet many in the medical community fail to diagnose and treat substance use disorders, in part because of the failure to educate physicians about addiction medicine. The last several decades have advanced our understanding of the biology of addiction, which has led to the recognition that drug and alcohol addiction are chronic and relapsing diseases of the brain resulting from various drug effects on the brain’s reward and control circuitries. These effects involve neuroadaptations that follow chronic drug exposure and ultimately serve to impair the function of brain regions involved with motivation and self-control.3 Research has also delineated the dynamic interplay between drugs and their molecular targets, thereby helping to identify specific neuroadaptations that are unique to the individual drug types (eg, alcohol, nicotine, cocaine, heroin), and how the expression of the resultant maladaptive behaviors is altered by environmental factors. Advances in genetic research have also enabled the identification of gene variants that affect vulnerability to addictive disorders, and how some genes can influence the response to treatment, which introduces the possibility of applying personalized medicine principles to the treatment of addiction.4 A recent report highlighted that most individuals with addiction in the United States do not receive any treatment from a physician. Improved understanding of the neurobiology underlying addictive behaviors and the effects of psychoactive substances at the neuropeptide, neurotransmitter, and receptor levels has contributed to the development of medications that can significantly improve outcomes among individuals with substance use disorder. Particularly effective among medications are those for treatment of opioid addiction (opioid agonist and antagonist medications). Effective medications also exist for treatment of nicotine and alcohol addiction. Although there are currently no approved medications for treatment of addiction to stimulant drugs (eg, cocaine and methamphetamines), marijuana, or sedative/hypnotic drugs (eg, benzodiazepine, barbiturates), behavioral interventions exist that have proven to be effective at reducing their use. These include interventions by health care professionals and psychosocial interventions that leverage specialized treatment programs.5 These advances make the traditional view of addiction primarily a moral issue—an outdated model. New therapies have the potential to create a momentous shift in society, whereby addiction is seen primarily as a health issue amenable to prevention and treatment, through the application of evidence-based tools. However, this shift has yet to be fully realized, with advances in this area often not implemented in the medical setting. A substantial literature describes the implementation gaps in addiction medicine. For instance, a recent audit of health care among US adults found that quality of care varied substantially according to medical condition and that, in the case of alcohol addiction, the percentage of recommended care received was approximately 10%. Interventions for smoking cessation were similarly low.6 Collectively, the underutilization of proven interventions contributes to major human and social costs that manifest in the form of disease, lost productivity, and crime, as well as substantial healthcare expenditures resulting directly from the health effects of substance use (eg, lung cancer) or indirectly from behaviors associated with substance use (eg, syringe sharing with subsequent human immunodeficiency virus [HIV] or hepatitis infections). For instance, many clinical trials have proven the benefits of opioid agonist treatment in reducing heroin use and HIV-risk behavior, resulting in methadone being placed on the World Health Organization’s list of essential medicines. Despite this evidence, methodone is underused by some treatment programs in the United States and, in some countries, this drug is unavailable or illegal, thus contributing to major missed opportunities to reduce heroin use and HIV epidemics.7 Moreover, failure of the health care system to effectively address substance abuse interferes with the medical outcomes of many other frequent comorbid diseases (eg, chronic obstructive pulmonary disease, HIV, hepatitis, chronic pain). An example of how an inadequate understanding of addiction negatively affects medical practice is illustrated by the improper use of opioid medications, both underprescribing and overprescribing. This deficiency in medical training contributes to improper management of pain and to the epidemic of opioid analgesic addiction in the United States. The failure to effectively respond to a health issue—with enormous health and social costs—brings about the question of “Why.” One key explanation, which remains poorly understood even among individuals in the medical community, is failure of medical education systems to train physicians in addiction medicine. Despite the enormous burden of disease attributable to addiction in North America, there have traditionally been exceptionally few opportunities for physicians to obtain advanced skills in this area outside of addiction psychiatry. The result has been predictable. A recent report8 highlighted that most individuals with addiction in the United States do not receive any treatment from a physician. Rather, much as in Canada, US addiction care is often provided by unskilled laypersons—that is, individuals without the mental health or medical training required to effectively deliver evidence-based interventions. The report’s toughest criticism is saved for the medical community, stating that “most medical professionals who should be providing addiction treatment are not sufficiently trained to diagnose or treat it.”8 Research by this same group has also reported that 94% of US physicians “failed to include substance abuse among the five diagnoses they offered” when presented with symptoms of alcohol abuse. Calling the lack of physician training a “monumental lost opportunity,” the report describes a “failure of the medical profession at every level—in medical school, residency training, continuing education and in practice—to confront the nation’s number one disease.”9 With the burden of disease contributed by substance use disorders, and with major taxpayer investments in criminal justice approaches (eg, incarceration for nonviolent drug offenses) that fail to acknowledge that addiction is a disease of the brain, the onus is on the medical community to take steps to better treat patients and protect public health. In this context, the American Board of Addiction Medicine (ABAM) and the ABAM Foundation have been established. ABAM has created guidelines and standards for the development of addiction medicine fellowship programs to enable US and international institutions to develop addiction medicine training programs that are eligible for accreditation by the ABAM Foundation. To date, 19 programs at academic centers in North America have been accredited by ABAM. The goal is for ABAM-accredited programs to grow in number and quality and, in time, this discipline will gain recognition from the American Board of Medical Specialties. The process will enable physicians completing their specialty training in a spectrum of disciplines (eg, internal medicine, family medicine, pediatrics) to pursue further standardized training to gain expertise to treat and prevent the spectrum of medical problems associated with substance use disorders. The development of a new medical specialty is not without challenges and potential consequences. Because most patients with addiction will continue to receive care from primary care physicians, efforts must be made to avoid a degree of subspecialization that makes the use of existing and new addiction treatments less accessible to individuals working in primary care. Since they likely will provide care in primary care settings, newly trained addiction medicine specialists are perfectly positioned to join together with addiction psychiatrists to press for important curricular space for addiction medicine training in medical schools and residency training, and to create continuing medical education opportunities for generalist physicians. Ultimately, through the greater in corporation of addiction medicine into the spectrum of medical training, patients will be better served by narrowing the health care quality chasm in addressing substance use disorders. The development of addiction medicine as a formal medical subspecialty also has the potential to begin the slow process of public education required to treat those who are alcohol- or drug-addicted with compassion and care, and to move away from over reliance on punitive approaches that have not served the interests of patients, public health, or taxpayers.7

Addiction: Current Criticism of the Brain Disease Paradigm

Abstract: To deepen understanding of efforts to consider addiction a “brain disease,” we review critical appraisals of the disease model in conjunction with responses from in-depth semistructured stakeholder interviews with (1) patients in treatment for addiction and (2) addiction scientists. Sixty-three patients (from five alcohol and/or nicotine treatment centers in the Midwest) and 20 addiction scientists (representing genetic, molecular, behavioral, and epidemiologic research) were asked to describe their understanding of addiction, including whether they considered addiction to be a disease. To examine the NIDA brain disease paradigm, our approach includes a review of current criticism from the literature, enhanced by the voices of key stakeholders. Many argue that framing addiction as a disease will enhance therapeutic outcomes and allay moral stigma. We conclude that it is not necessary, and may be harmful, to frame addiction as a disease.

Producing the “Problem” of Addiction in Drug Treatment

Abstract: In this article, we argue that the “problem” of addiction emerges as an effect of treatment policy and practice as well as a precursor to it. We draw on the work of Marrati to analyze interviews with policy makers and practitioners in Australia. The interviews suggest that the episode-of-care system governing service activity, outcomes, and funding relies on certain notions of addiction and treatment that compel service providers to designate service users as addicts to receive funding. This has a range of effects, not least that in acquiring the label of “addict,” service users enter into bureaucratic and epidemiological systems aimed at quantifying addiction. Rather than treating pre-existing addicts, the system produces “addicts” as an effect of policy imperatives. Because addiction comes to be produced by the very system designed to treat it, the scale of the problem appears to be growing rather than shrinking.

Safe methadone induction and stabilization: report of an expert panel.

Abstract: Objectives Methadone is a well-studied, safe, and effective medication when dispensed and consumed properly. However, a number of studies have identified elevated rates of overdose and death in patients being treated with methadone for either addiction or chronic pain. Among patients being treated with methadone in federally certified opioid treatment programs, deaths most often occur during the induction and stabilization phases of treatment. To address this issue, the federal Substance Abuse and Mental Health Services Administration invited the American Society of Addiction Medicine to convene an expert panel to develop a consensus statement on methadone induction and stabilization, with recommendations to reduce the risk of patient overdose or death related to methadone maintenance treatment of addiction. Methods A comprehensive literature search of English-language publications (1979-2011) was conducted via MEDLINE and EMBASE. Methadone Action Group members evaluated the resulting information and collaborated in formulating the consensus statement presented here, which subsequently was reviewed by more than 100 experts in the field. Results Published data indicate that deaths during methadone induction occur because the initial dose is too high, the dose is increased too rapidly, or the prescribed methadone interacts with another drug. Therefore, the Methadone Action Group has developed recommendations to help methadone providers avoid or minimize these risks. Conclusions Careful management of methadone induction and stabilization, coupled with patient education and increased clinical vigilance, can save lives in this vulnerable patient population.

Neurogenetics and Nutrigenomics of Neuro-Nutrient Therapy for Reward Deficiency Syndrome (RDS): Clinical Ramifications as a Function of Molecular Neurobiological Mechanisms.

Abstract: In accord with the new definition of addiction published by American Society of Addiction Medicine (ASAM) it is well-known that individuals who present to a treatment center involved in chemical dependency or other documented reward dependence behaviors have impaired brain reward circuitry. They have hypodopaminergic function due to genetic and/or environmental negative pressures upon the reward neuro-circuitry. This impairment leads to aberrant craving behavior and other behaviors such as Substance Use Disorder (SUD). Neurogenetic research in both animal and humans revealed that there is a well-defined cascade in the reward site of the brain that leads to normal dopamine release. This cascade has been termed the "Brain Reward Cascade" (BRC). Any impairment due to either genetics or environmental influences on this cascade will result in a reduced amount of dopamine release in the brain reward site. Manipulation of the BRC has been successfully achieved with neuro-nutrient therapy utilizing nutrigenomic principles. After over four decades of development, neuro-nutrient therapy has provided important clinical benefits when appropriately utilized. This is a review, with some illustrative case histories from a number of addiction professionals, of certain molecular neurobiological mechanisms which if ignored may lead to clinical complications.

Stigmatization of Substance Use Disorders Among Internal Medicine Residents

Abstract: Background: Evidence suggests that some physicians harbor negative attitudes towards patients with substance use disorders (SUDs). The study sought to (1) measure internal medicine residents’ attitudes towards patients with SUDs and other conditions; (2) determine whether demographic factors influence regard for patients with SUDs; and (3) assess the efficacy of a 10-hour addiction medicine course for improving attitudes among a subset of residents. Methods: A prospective cohort study of 128 internal medicine residents at an academic medical center in New York City. Scores from the validated Medical Condition Regard Scale (MCRS) were used to assess attitude towards patients with alcoholism, dependence on narcotic pain medication, heartburn, and pneumonia. Demographic variables included gender, postgraduate training year, and prior addiction education. Results: Mean baseline MCRS scores were lower (less regard) for patients with alcoholism (41.4) and dependence on narcotic pain medication (35.3) t...

Preferences Regarding Treatment for Alcohol Problems

Abstract: Aims: The aim of the study was to investigate preferences in the general population regarding type of treatment for alcohol problems and the preferred setting for delivery of treatment and reasons for not seeking treatment for alcohol problems. Method : Data were from a random, cross-sectional, interview survey of 9005 of the Swedish general population. Proportions of respondents preferring a certain treatment and source of treatment, and reasons suggested for why people do not seek treatment, were analysed in relation to number of standard drinks, employment status, education and income. Results: Most frequently endorsed forms of treatment were alcoholics anonymous or similar support groups and psychotherapy. More than 50% preferred psychiatric or addiction specialist treatment. Around 10% preferred primary health care and around 20% the occupational health services. About 5% preferred the social services. Respondents rated ‘feeling ashamed’ as the most important reason why people would not seek help for alcohol problems. Conclusion: Large majorities of the respondents preferred treatment in the health care services and few in the social services. Internet-based treatment and pharmacological treatment attracted few respondents, the majority preferring more traditional forms of treatment. Alcohol treatment remains a stigmatized field, evidenced by shame being the most commonly reported reason for not seeking treatment.

Comorbid internet addiction in male clients of inpatient addiction rehabilitation centers: psychiatric symptoms and mental comorbidity.

Abstract: Addictive Internet use has recently been proposed to be included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Still, little is known about its nosological features, including comorbidity with other mental disorders and disorder-specific psychopathological symptoms. To investigate whether Internet addiction (IA) is an issue in patients in addiction treatment, 1826 clients were surveyed in 15 inpatient rehabilitation centers. Male patients meeting criteria for comorbid IA (n = 71) were compared with a matched control group of male patients treated for alcohol addiction without addictive Internet use (n = 58). The SCL-90-R, the Patient Health Questionnaire, and the seven-item Generalized Anxiety Disorder were used to assess associated psychiatric symptoms and further comorbid disorders. Comorbid IA was associated with higher levels of psychosocial symptoms, especially depression, obsessive-compulsive symptoms, and interpersonal sensitivity. Moreover, the patients with IA more frequently met criteria for additional mental disorders. They display higher rates of psychiatric symptoms, especially depression, and might be in need of additional therapeutic treatment. In rehabilitation centers, a regular screening for IA is recommended to identify patients with this (non-substance-related) addiction and supply them with additional disorder-specific treatment.

"Nonmedical" prescription opioid use in North America: a call for priority action.

Abstract: Nearly four years after the United States Congress heralded a “decade of pain control and research”, chronic pain remains a mounting public health concern worldwide. The escalating prevalence of chronic pain in recent years has been paralleled by a rise in prescription opioid availability, misuse, and associated human and social costs. However, national monitoring surveys in the U.S. and Canada currently fail to differentiate between prescription opioid misuse for the purposes of euphoria versus pain or withdrawal management. Furthermore, there is a lack of evidence-based guidelines for pain management among high-risk individuals, and a glaring lack of education for practitioners in the areas of pain and addiction medicine. Herein we propose multiple avenues for intervention and research in order to mitigate the individual, social and structural problems related to undertreated pain and prescription opioid misuse.

Drug abuse and addiction in medical illness : causes, consequences and treatment

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Opioid Use 12 Months Following Interdisciplinary Pain Rehabilitation with Weaning

Abstract: Objectives To examine the frequency of and factors predicting opioid resumption among patients with chronic non-cancer pain (CNCP) and therapeutic opioid addiction (TOA) treated in an interdisciplinary chronic pain rehabilitation program (CPRP) incorporating opioid weaning. Design Longitudinal retrospective treatment outcome study. Only those with addiction were counseled to avoid opioids for non-acute pain. Setting Large academic medical center. Participants One hundred twenty patients, 32.5% with TOA. Participants were predominately married (77.5%), females (66.7%). Mean age was 49.5 (±13.7). 29.2% had lifetime histories of non-opioid substance use disorders. Methods TOA was diagnosed using consensus definitions developed by American Academy of Pain Medicine, American Pain Society and American Society of Addiction Medicine to supplement Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR) criteria. Non-opioid substance use disorders were diagnosed using DSM-IV-TR. Data, including pain severity, depression and anxiety, were collected at admission, discharge and 12 months. Opioid use during treatment was based on medical records and use at 12 months was based on self-report. Results Only 22.5% reported resuming use at 12 months. Neither patients with TOA nor patients with non-opioid substance use disorders were more likely to resume use than those without substance use disorders. Only posttreatment depression increased the probability of resumption. Conclusions CNCP and co-occurring TOA can be successfully treated within a CPRP. Patients report low rates of resumption regardless of addiction status. This is in marked contrast to reported outcomes of non-medically induced opioid addictions. Prolonged abstinence may depend upon the successful treatment of depression.

Residential placement for veterans with addiction: American Society of Addiction Medicine criteria vs. a veterans homeless program

Abstract: The goal of this study was to compare placements of patients with addiction undertaken by a) a unidimensional, protocol-driven, independent "permanent" housing "wet" program versus b) a multidimensional, patient-individualized, contingency-based housing approach. The sample consisted of eight veterans in a single team's panel admitted to a housing program and eight matched veterans on the verge of homelessness placed by the team according to the American Society of Addiction Medicine (ASAM) criteria. The two groups (matched for sex, race-ethnicity, and age [SD, 5 years]) were similar on demography, substance disorder, and psychiatric comorbidity. Measures consisted of a) description of the placements, b) 12-month postplacement outcomes using a 12-item scale, and c) a Drug Abuse Research Project-based 10-item scale to assess recovery processes at two 6-month preplacement and two 6-month postplacement intervals. The veterans in the housing program escalated drinking and/or drug use; all were readdicted by the end of 12 months after placement. In the ASAM-criteria group, five of the eight patients had brief slips lasting 2 days or less, but none were readdicted at 12 months. The housing program group experienced five nontrivial outcomes: three imprisonments for felonies, one life-threatening medical complication, and one death. In conclusion, the findings support close monitoring and relevant contingencies using the ASAM criteria in the treatment of substance use disorder.

The Addiction Psychiatrist as Dual Diagnosis Physician: A Profession in Great Need and Greatly Needed

Abstract: Addiction is the number one cause of premature illness and death in the U.S., especially among people with mental illness. Yet American medicine lacks sufficient workforce capacity, expertise, training, infrastructure, and research to support treatment for people with co-occurring addictions and mental illness. This essay argues that the addiction psychiatrist is essential in dual diagnosis care.

Knowledge of addiction medicine among internal medicine residents and medical students.

Abstract: Objectives More than 22 million Americans are living with addiction, including nearly seven million who misuse prescription medications. However, most medical schools and residency programs provide little to no education addressing alcohol and drug addiction. Implementation of a new addiction medicine curriculum at a single internal medicine program provided an opportunity for knowledge assessment in a select population of health professionals. We hypothesized that knowledge of addiction medicine would not differ by training level or geographical location of medical school, but that knowledge would improve following a structured curriculum. Methods Study participants included internal medicine and transitional year residents, as well as a group of medical students who were enrolled in a single internal medicine program at the time of the didactic series. A pre-test was administered prior to a four-week structured curriculum. The topics addressed included but were not limited to: 1) an overview of addiction, 2) opioids and chronic pain, 3) benzodiazepines and illicit stimulants, and 4) alcohol. A panel discussion was convened at the end of the fourth session. Following participation in the symposium, participants completed an online post-test. ANOVA was used to compare means. Paired t-tests were used to compare pre-test and post-test scores. Results 36 of 44 eligible medical students and residents completed the pre-test. Mean pre-test percentage scores were 64 percent for fourth year medical students and 62.5 percent for all residents. For residents, U.S. medical school trainees answered 65 percent of the pre-test questions correctly, versus 58.6 percent correct responses among their international medical graduate peers. No inter-group differences were statistically significant. Of the 36 participants, 20 completed both pre-tests and post-tests. The mean post-test score of 68.75 percent was higher than the mean pre-test score of 61.75 percent, p = 0.009. Conclusions Knowledge of addiction medicine can be improved for medical students and residents in an academic medicine department. Significant improvements were observed following completion of eight hours of interactive didactics.

Current Expectations and Existing Deficits among Addiction Specialists

Abstract: Expectations of addiction counselors have changed over the past decade; however, preparation of addiction counselors has not kept pace, creating a deficit between the knowledge and skills required of today's addiction counselors and a workforce possessing such knowledge and skills.

Enhancing screening, brief intervention, and referral to treatment among socioeconomically disadvantaged patients: study protocol for a knowledge exchange intervention involving patients and physicians

Abstract: Background: Screening, Brief Intervention, and Referral for Treatment (SBIRT) is an effective approach for managing alcohol and other drug misuse in primary care; however, uptake into routine care has been limited. Uptake of SBIRT by healthcare providers may be particularly problematic for disadvantaged populations exhibiting alcohol and other drug problems, and requires creative approaches to enhance patient engagement. This knowledge translation project developed and evaluated a group of patient and health care provider resources designed to enhance the capacity of health care providers to use SBIRT and improve patient engagement with health care. Methods/Design: A nonrandomized, two-group, pre-post, quasi-experimental intervention design was used, with baseline, 6-, and 12-month follow-ups. Low income patients using alcohol and other drugs and who sought care in family medicine and emergency medicine settings in Edmonton, Canada, along with physicians providing care in these settings, were recruited. Patients and physicians were allocated to the intervention or control condition by geographic location of care. Intervention patients received a health care navigation booklet developed by inner city community members and also had access to an experienced community member for consultation on health service navigation. Intervention physicians had access to online educational modules, accompanying presentations, point of care resources, addiction medicine champions, and orientations to the inner city. Resource development was informed by a literature review, needs assessment, and iterative consultation with an advisory board and other content experts. Participants completed baseline and follow-up questionnaires (6 months for patients, 6 and 12 months for physicians) and administrative health service data were also retrieved for consenting patients. Control participants were provided access to all resources after follow-up data collection was completed. The primary outcome measure was patient satisfaction with care; secondary outcome measures included alcohol and drug use, health care and addiction treatment use, uptake of SBIRT strategies, and physician attitudes about addiction. Discussion: Effective knowledge translation requires careful consideration of the intended knowledge recipient’s context and needs. Knowledge translation in disadvantaged settings may be optimized by using a communitybased participatory approach to resource development that takes into account relevant patient engagement issues.

Addiction Science: A Rationale and Tools for a Public Health Response to Drug Abuse.

Abstract: New scientific knowledge and effective, evidence-based interventions have provided health leaders and policymakers a remarkable paradigm to guide the development of addiction treatment services around the world. The definition of addiction as a brain disease, validated screening and assessment tools, medication-assisted treatment, and effective behavioral treatments have served as vehicles for both the United States and other countries to guide the transformation of their substance abuse treatment systems. Seeking to expand international research and infrastructure, the National Institute on Drug Abuse (NIDA)'s International Program has engaged international investigators and institutions in addiction research to promote dissemination of addiction science globally. This paper presents three mixed-methods case studies to exemplify the use of advancements in evidence-based practice in addiction treatment as guides and tools for the creation or further development of treatment systems in three countries, Vietnam, Lebanon, and Abu Dhabi. Results indicate that a framework of evidence-based medicine and empirical science creates a necessary platform from which objective conversations about addictions may begin. Other facilitative factors that help create treatment programs internationally include: a receptive and supportive government, support from international donors and technical experts, networking and interest from other international organizations, and often a synergistic and concerted effort by multiple entities and partners. Despite substantial differences in the circumstances that generated these initiatives and the varying scope of the services, common themes across these efforts have been the implementation of science-based approaches to systems transformation and support for a public health approach to addressing drug abuse and addiction.

2013 Update in addiction medicine for the generalist.

Abstract: Increasingly, patients with unhealthy alcohol and other drug use are being seen in primary care and other non-specialty addiction settings. Primary care providers are well positioned to screen, assess, and treat patients with alcohol and other drug use because this use, and substance use disorders, may contribute to a host of medical and mental health harms. We sought to identify and examine important recent advances in addiction medicine in the medical literature that have implications for the care of patients in primary care or other generalist settings. To accomplish this aim, we selected articles in the field of addiction medicine, critically appraised and summarized the manuscripts, and highlighted their implications for generalist practice. During an initial review, we identified articles through an electronic Medline search (limited to human studies and in English) using search terms for alcohol and other drugs of abuse published from January 2010 to January 2012. After this initial review, we searched for other literature in web-based or journal resources for potential articles of interest. From the list of articles identified in these initial reviews, each of the six authors independently selected articles for more intensive review and identified the ones they found to have a potential impact on generalist practice. The identified articles were then ranked by the number of authors who selected each article. Through a consensus process over 4 meetings, the authors reached agreement on the articles with implications for practice for generalist clinicians that warranted inclusion for discussion. The authors then grouped the articles into five categories: 1) screening and brief interventions in outpatient settings, 2) identification and management of substance use among inpatients, 3) medical complications of substance use, 4) use of pharmacotherapy for addiction treatment in primary care and its complications, and 5) integration of addiction treatment and medical care. The authors discuss each selected articles’ merits, limitations, conclusions, and implication to advancing addiction screening, assessment, and treatment of addiction in generalist physician practice environments.

The rise of super (?sub)-specialties courses in psychiatry: Is India ready for it !

Abstract: Byline: N. Manjunatha, Murali. Thyloth, T. Sathyanarayana Rao The field of psychiatry is still growing; [sup][1] however, the phenomenal growth occurred in many areas in the field of Indian psychiatry in last decade. One of them is the increase in postgraduate seats (Diploma in Psychological Medicine (DPM)/Doctor of Medicine (MD)/Diplomate of National Board (DNB) of psychiatry to address the shortage of psychiatrists in our country. In curious latest development two medical institutes in our country started two super-specialties psychiatry courses (after branching out from department of psychiatry) in the academic year of 2011-2012 such as Doctor of Medicine (DM) (Geriatric Mental Health) at 'King George Medical University', Lucknow (http://www.kgmu.org/dept_geriatric.php) and DM (Child and Adolescent Psychiatry) at 'National Institute of Mental Health and Neurosciences' (NIMHANS), Bangalore (http://www.nimhans.kar.nic.in/cap/default.htm) for candidates of MD/DNB psychiatry. Other awaiting super-specialty psychiatry course is DM (Addiction Medicine) at 'National Drug Dependence Treatment Centre' of 'All India Institute of Medical Sciences', New Delhi and 'Centre for Addiction Medicine', NIMHANS, Bangalore. Debate *In an outlook it is a welcome step, however, authors consider this rise of super-specialties in still growing field of Indian psychiatry is a debatable issue. When our country is already facing 77% average national deficit of psychiatrists, [sup][2] will not this step lead further shortage of general psychiatrists in India? India is currently producing 357 MD (Psychiatry) and 129 Diploma in Psychological Medicine (DPM) per year in various medical college/institutes of our country. [sup][3] Along with these reasons and the migration of qualified psychiatrists to developed countries, will this step be a pragmatic one for MD psychiatry candidates to enter DM in these super-specialties? *Then, what is the need of having super-specialty psychiatric courses? Is there a demand for clinical service, if so, having separate clinic/unit in the psychiatry department (one of the requirement of Medical Council of India (MCI) to start MD psychiatry course) shall be sufficient. Is there a demand in research point of view, if so, developing a separate 3 years course is not justified? If the development for teaching purpose due to lack of expertise, having separate clinic/unit within department of psychiatry would suffice. Considering all above points, Indian academic psychiatry is not ready for premature branching out as 3 years DM course. It may be pragmatic to wait till required number of psychiatrists of India is available for clinical service. *Another important aspect of this development is the employability after their training. Authors tend to believe as not so lucrative for these super-specialties as there are already inadequate practicing general psychiatrists and inadequate teaching psychiatric faculties in medical colleges. *In view of public mental health, when India is struggling to provide primary care psychiatry and facing difficulty in the implementation of 'National Mental Health Program', can we afford to have these super-specialties in psychiatry which further reduces the human resources? Progress in Indian Medical Education with Respect to Super-Specialties Authors feel that the developing new courses with new name are becoming fashionable in the field of Indian education. Medical education of our country is not the exception for this and is already developed new courses in last few decades such as DNB, DM, Magister Chirurgiae (MCh), etc., Irony in this development is having same name (i. …

The exclusion of nicotine: closing the gap in addiction policy and practice.

Abstract: Addiction is a complex brain disease with frequently overlapping expressions involving nicotine, alcohol, and other drugs. Yet current health care practices, public policies, and national treatment data too often exclude nicotine or address its use as completely separate from other forms of substance use and addiction, compromising patients’ health and incurring unnecessary health care costs. Effective prevention and treatment requires the inclusion of nicotine in a comprehensive approach addressing all manifestations of addiction within health care policy and practice.

Is your prescribing serving a hidden addiction

Abstract: Addiction to prescription and over-the-counter (OTC) medicines is a hidden, little-researched chronic illness – which could be significantly countered by destigmatisation, ‘up-scheduling’ certain medications, creating a single electronic database across dispensaries and boosting doctor awareness regarding long-term or repeat prescriptions. This is according to Dr Volker Hitzeroth, President of the South African Addiction Medicine Society and convenor of the addictions sub-group of the South African Society of Psychiatrists.

The need for developing preconception counseling in addiction medicine.

Abstract: The current recommendations of the American Society of Addiction Medicine on the management of pregnant women with addictive disorders note the importance of educational aspects even before pregnancy (American Society of Addiction Medicine 2011). Preconception care is a prevention concept, which consists of providing technical and medical knowledge to women of childbearing age who suffer from a specific chronic pathology (de Weerd et al. 2002). Preconception counseling improves health behaviors and is now recommended for pregnant women with diverse chronic pathologies such as diabetes (American Diabetes Association 2004), human immunodeficiency virus (Aaron and Criniti 2007), and epilepsy (Winterbottom et al. 2008). Currently, addiction is also considered to be a chronic disorder (Koob and Volkow 2010). As such, it may deeply interact with some possible concomitant disorders or modifications in health conditions, such as pregnancy (Keegan et al. 2010). Many drug-related addictions and their treatments can have significant effects on the medical outcomes of both the mother and fetus throughout pregnancy. The risks and consequences are specifically associated with the type of addiction. Prenatal tobacco exposure is associated with low birth weight, decreased in utero brain growth, and the risk of sudden infant death syndrome; it has also been shown to affect neurodevelopment and postnatal behavior (Herrmann et al. 2008). Cannabis primarily enhances the risk of adverse birth outcomes (Hayatbakhsh et al. 2012). Alcohol drinking may induce fetal alcohol spectrum disorders or lead to fetal death (Andersen et al. 2012). Heroin misuse and the irrelevant management of maintenance treatments during pregnancy may trigger withdrawal symptoms and increase the risk of prematurity, stillbirth, and neonatal death (Ellwood et al. 1987), and specific supervision of the newborn may be required to detect possible neonatal abstinence syndrome (Jones et al. 2012). Cocaine may be responsible for placentaassociated syndrome, death in utero, and neonatal hypotrophy (Mbah et al. 2012; Ryan et al. 1987), while amphetamine use during pregnancy might have delayed effects on child behavior (Lagasse et al. 2012). For each situation, the main risks are different and do not occur at the same time during pregnancy or post-birth. It therefore appears to be necessary that women who suffer from non-stabilized drug-related addictions and are pregnant be correctly informed of the risks and closely supervised. Thus, it might be particularly relevant for physicians in addiction centers to suggest that any woman of childbearing age be directed, if she plans to have a child, to a specialist with a good knowledge of the specific intricacies between drug abuse and pregnancy. Furthermore, the periconception period is often too late to prevent some teratogenic risks (Anderson et al. 2006), which means that preconception consultation should occur even before pregnancy planning. This is reinforced by reports noting that many women with certain addiction problems become pregnant without having planned the pregnancy (Heil et al. 2011). Consequently, we propose that pregnancy-related education be systematically integrated in the medical care of women of childbearing age who attend addiction medical centers. H. Rose :G. Vaiva Service de Psychiatrie de l’Adulte, CHU Lille, 59037 Lille, France