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Kentucky's Voice for Accessible, Quality Addiction Care | |
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DON'T FORGET TO RENEW YOUR ASAM/KYSAM MEMBERSHIP.
Many of you have already received this newsletter. However, I wanted to resend it since many members were likely on vacation during the holidays The upcoming KYSAM semi-annal meeting on Jan. 28, 2023, is getting closer. CME and HB1 credit pending. Free to members. See below for further information.
Note changes in article on Voices of Hope. Several errors in the previous article were corrected.
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KYSAM Semi-Annual Meeting | |
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The KYSAM semi-annual meeting will take place on Saturday, Jan. 28, 2023, at the Griffin Gate Marriott in Lexington, Ky. The key- note speaker will be Corey Waller, MD, MS, FACEP, DFASAM. Dr. Waller is the Chief Medical Officer of Brightview Addiction Treatment. He is board certified in emergency medicine and addiction medicine. He is a nationally recognized expert on the treatment of substance use disorder, and he works with ASAM and related organizations to advance the evidence- based treatment of addiction. He is the editor of The ASAM Criteria. Other speakers include Kelly Ruff of UK PATHways speaking on caring for pregnant and parenting women with SUD, Laura Fanucchi, MD with an update on the Healing Communities Study, Katrina Nickels, MD, on pain management, Marvin Bishop, MD, on comparison addiction withdrawal, and Allison Koetter, MD (Medical Director Southern Indiana Comprehensive Treatment Centers and volunteer faculty UK College of Public Health) speaking on macro and micro induction. We are working to make CME and HB1 credit available. All of these speakers are recognized in their respective fields. Further details will be provided in emails from our Administrative Coordinator, Miranda Sloan. The conference is free for members. A continental breakfast and box lunch will be provided. You are encouraged to attend the meeting, get CME’s and network with colleagues.
To register go to admin@kysam.org.
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KYSAM Bi-Annual Conference
Saturday, January 28th, 2023
Lexington Griffin Gate Marriott Golf Resort & Spa
Tentative Schedule
8:00am – 9:00am Registration & Breakfast
9:00am – 10:00am Corey Waller, MD, MS
10:00am – 10:15am Break
10:15am – 11:15am Kelly Ruff, LPCC, UK PATHways
Caring for Pregnant and Parenting Women
Laura Fanucchi, MD
Healing Communities Study
11:15am – 12:15pm Katrina Nickels, MD
Pain Management
12:15pm – 1:00pm Lunch
1:00pm – 2:00pm Marvin Bishop, MD
Comparison Addiction Withdrawal
2:00pm – 3:00pm Alison Koetter, MD
Micro & Macro Induction
3:00pm – 3:15pm Closing Comments
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MEET Stacy Frederick, APRN | |
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Though the pathway to medicine is not straightforward for everyone, Stacy Frederick knew exactly what she wanted, and she pursued it with a passion. She was focused on the healthcare field as a teenager. She became a nurse’s aide at the age of 15. She joined the Navy as a hospital corpsman out of high school. After her military experience, she began nursing school at Good Samaritan Hospital in Cincinnati, Ohio. She started working in an inpatient hospice program after graduation. She pursued her Bachelor’s degree and then went to grad school at Indiana Wesleyan. She currently works three days per week in chronic pain management in Lexington and two days in outpatient addiction with Beall Recovery Centers. At the Recovery Center, she prescribes suboxone, sublocade, and vivitrol. She also does some counseling. Her background is family medicine.
In the pain clinic, Stacy primarily focuses on treatment planning and education. Stacy is the go-to person for difficult patient discussions in the pain clinic. Since she doesn’t do procedures which the other NP’s do, she has the “privilege” of dealing with difficult patients. She notes that she has unofficially assumed the role of counselor. She isn’t sure how she got this designation, but she has developed some expertise at explaining to patients why they can’t just get more pain medication. I have asked her to share her tips with us in a future newsletter.
Stacy’s interest in addiction care is an outgrowth of her experience in hospice, palliative, and pain management. She spent time reflecting on how the opioid epidemic happened and how she could be involved in the solution. She, like many others, advocated for better pain management. However, she began to see the downside of that as opioid overdoses increased. She wanted her practice to reflect evidence- based criteria. She met our current KYSAM Secretary, Katrina Nickels, when they worked together at Bluegrass Care Navigators. Katrina encouraged Stacy to become involved with KYSAM.
Stacy loves the medical/behavioral field so much that her leisure time is spent reading material related to the field. She listens to lectures and watches videos by Dr. Jordan B. Peterson who published the book, Maps of Meaning: The Architecture of Belief, which combines psychology, mythology, religion, literature, philosophy and neuroscience to analyze systems of belief and meaning. She also enjoys Michael Schermer, publisher of Skeptic, a magazine that investigates pseudoscientific claims and advocates scientific skepticism and Gad Saad, author of the book The Parasitic Mind: How Infectious Ideas are Killing Common Sense.
Stacy grew up in Louisana. She lived in Ohio at one point and then moved to Lexington. Her parents followed her and now live with her. She has two labrador retrievers, a 17 year old son and a 23 year old daughter.
She feels that KYSAM’s primary mission should be providing support for clinicians on the front lines treating SUD. She would like to see KYSAM guide clinicians to available resources and provide some opinions on common questions that many providers have.
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An Update on OTC Naloxone | |
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Martika Martin, PharmD, MBA, BCGP is the Director of Clinical Outreach for the Kentucky Pharmacy Education and Research Foundation. Her role on the Overdose Data to Action Grant, through the CDC and the Kentucky Injury Prevention and Research Center is to be an academic detailer, providing education and resources to clinicians in the state of Kentucky on opioids, opioid use disorder, and harm reduction.
Her input is appreciated, and hopefully future articles will be forthcoming.
In 2015, Narcan®, became the first commercially available form of naloxone for opioid overdose that was easy to administer by non-healthcare professionals. Before that, the only form of naloxone was an injectable, stored in a glass vial or ampule that would have to be drawn in a syringe for administration or using an off-label atomizer to convert it into a nasal spray. Generic Narcan nasal spray was approved by the FDA in 2019. In 2021, the FDA approved an 8mg naloxone nasal spray, Kloxxado™, which is twice the dose of Narcan®. In 2021, the FDA also approved a 5mg dose of injectable naloxone, Zimhi™, supplied in a pre-filled syringe.
Since the introduction of these “community use” naloxone products, estimated sales and dispensed prescriptions for naloxone use has increased across all healthcare settings from 2017 to 2021. In 2021, an estimated 1.5 million prescriptions for naloxone were dispensed from pharmacies, 95% of those for the nasal spray. These estimates did not include donations from manufacturers or direct sales to community-based distribution programs. While sales and prescriptions of naloxone have increased, overdose deaths have risen in the past few years, reflecting a possible need for increased access and availability of naloxone in non-healthcare settings.
On November 16, 2022, the FDA released a federal notice stating that it was their opinion that naloxone nasal spray up to 4mg and naloxone autoinjector for intramuscular or subcutaneous injection up to 2 mg have the potential to be safe and effective for use as directed in nonprescription drug labeling without the supervision of a healthcare provider. In other words, they are voicing their interest in having manufacturers apply for over-the-counter status, either through an application for a non-prescription naloxone or a supplemental application to switch an FDA-approved naloxone product from prescription to nonprescription status. The public comment period for this notice is open until January 17, 2023.
In the Federal Notice, the FDA cited evidence for the positive benefits of increasing naloxone access, including evidence supporting community-based overdose education and naloxone distribution programs leading to positive patient outcomes such as high rates of opioid overdose reversal attempts, The FDA estimates that nearly 20,000 deaths were averted because of layperson naloxone administration from 1999 to 2020. While the major adverse effect of naloxone is precipitated withdrawal in individuals physically dependent on opioids, which may cause other serious adverse events such as pulmonary edema, cardiac arrhythmias, and agitation, the benefit of reversing potentially fatal overdose is significant and likely outweighs these risks.
The FDA stated that even if naloxone products were available over-the-counter, there is still the need for public health programs to educate on the importance of prompt activation of emergency medical services, recognizing an opioid overdose, alternate causes of unresponsiveness, respiratory support prior to naloxone administration, naloxone administration, and appropriate interventions in addition to naloxone administration.
The FDA stated that they believe that the prescription requirements for certain naloxone products may not be necessary to protect public health. The FDA recognized the efforts of community-based naloxone distribution programs and state naloxone access laws that illustrate that naloxone can be used safely and effectively without patient-specific prescriptions. To ease the process of bringing over-the-counter naloxone to market, the FDA has developed a model naloxone Drugs Facts Labeling (a requirement for over-counter-drugs) and assessed it’s understandability by consumers, a major and time-consuming process for manufacturers wishing to bring an over-the-counter product to market.
While the impact of naloxone products going over-the-counter is not fully known, especially for community-based naloxone distribution programs, the thought is that over-the-counter status will continue to reduce barriers to access that persist despite these community-based programs and naloxone access laws.
On December 6, 2022 Emergent BioSolutions announced that the FDA has accepted for priority review its supplemental New Drug Application for Narcan® Nasal Spray as an over-the-counter emergency treatment for known or suspected opioid overdose, with a Prescription Drug User Fee Act goal date of March 29, 2023 (the date by which the FDA must respond to the application).
The November 16 federal notice can be accessed here.
The Press Release from Emergent BioSolutions can be accessed here.
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Special Focus on Advocacy in Kentucky | |
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A lot is happening here in Kentucky on the advocacy front. There are many advocacy groups working to improve access to treatment, implement evidence -based treatments, and support those in recovery. However, sometimes as clinicians it is difficult to know how to utilize them for ourselves and our patients. Here is information about some national and state -wide groups that have various functions in the addiction world.
Voices of Hope: I had the privilege of touring this facility located at 644 North Broadway, Lexington, and meeting Amanda Fallin-Bennett, PhD, who works with Voices of Hope through University of Kentucky (and is a co-founder of the organization) and David Brumett, program manager. The facility is easily accessible and very bright and welcoming. Voices of Hope provides no-cost recovery support services for persons who use drugs. They provide services free with no strings attached. They promote diversity and inclusion. Their services include recovery groups, telephone recovery support, and recovery coaching. In some cases, they can provide housing vouchers. Harm reduction materials, such as safer smoking and safer using kits and sanitary products, were readily available in restrooms and at the front desk so that there is a low barrier to take the items for use off-site. Drugs and alcohol are not permissible on VOH property. One of the main attractions is their laundry facilities. The only requirement for using the laundry facilities is acceptance of a brief coaching session. Their philosophy is that people are in recovery when they say they are in recovery. VOH believes that everyone’s journey to recovery is different and personal. They also work to develop leadership from within the recovery community. They utilize these leaders as volunteers and possibly eventually board members.
Voices of Hope is was founded in 2015 and is funded by many grants including the Healing Communities grant as well as other advocacy groups. It is a standalone nonprofit. They are now present in several counties including Boyd, Boyle, Fayette, Franklin and Kenton though their available services may differ from county to county depending on funding. They recently received support from JCOIN (see below) to provide peer Recovery Coaches to several prisons to help connect people with services when they are released. They also support research and community education about addiction.
Shelley Elswick, President, CEO, and Co-founder contributed information for this article.
Go to their website for more information: voicesofhopelex.org.
The Justice Community Opioid Innovation Network: This program, JCOIN, is designed to advance scientific knowledge on effective policies, practices, and interventions to improve care for individuals that are justice-involved with opioid use disorder. JCOIN is led by NIDA (National Institute on Drug Abuse) and funded through NIH HEAL (Helping to End Addiction Long-term) initiative. JCOIN provides free online courses and resources to support health and justice professionals and the general public learn about the science of addiction and evidence-informed practices to improve care and delivery services. They provide free training and technical assistance to help community-based organizations develop strategies to improve substance use disorder treatment delivery. They facilitate practitioner and researcher partnerships to elevate research and evaluation in a variety of justice and health settings. They have several prepared webinars and courses for state and local leaders and for county executives on understanding substance use disorder and MAT from an evidence based perspective with the goal of eliminating stigma. For more information go to their website:https://www.heal.nih.gov/research/research-to-practice/jcoin.
Addiction Policy Forum: This is a national organization. It appears to be geared mainly towards patients and families. It has access to training and education about addiction, resources for families, a helpline, and a link to download a smart phone app that allows patients to track recovery progress, connect with trained counsellors through messaging, journal, and access helpful videos. The app is free. They are active in advocacy on the national level. There are videos for patients, families and clinicans on various aspects of addiction treatment. This could be especially helpful to families who are trying to understand addiction and navigate getting treatment for their loved one. Some of their work is funded by the JCOIN and NIDA. Check out their website here.
People Advocating Recovery and Addiction Policy Advocacy Council: This is a state organization. People Advocating Recovery (PAR) is made up of grass roots organizers whose goal is to create a state free of stigma and of barriers to treatment. The Addiction Policy Advocacy Council (APAC) is the legislative arm of PAR. PAR was founded in 2002. PAR’s legislative advocacy priorities include restoring voting rights for ex-felons, increasing representative of recovering persons on state advisory boards, increasing funding for indigent care, and working to promote pre-trial diversion programs. For more information go to https://peopleadvocatingrecovery.org.
Shatterproof: Founded by Gary Mendell after his son, Brian, died of an overdose in October, 2011. Gary felt that the stigma of addiction, the lack of dissemination and utilization of available research, and the lack of intervention early in teenage years contributed to Brian’s lack of treatment. Shatterproff focuses on key priorities that make a measurable difference in saving lives. Their emphasis is on changing healthcare systems so that everyone has access to evidence-based treatment, ending the stigma of addiction through education and empowering communities to support those who are touched by addiction. The organization is very involved in advocacy on Capitol Hill.
To find out more, go to shatterproof.org.
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A New Problem: Pharmacy Access
There has been a great deal of focus on access to evidence-based treatment for patients with SUD. However, even when patients access good treatment, there may still be barriers to getting the prescribed medication. A recent survey done by the ASAM Practice Management and Regulatory Affairs Committee from Feb. 2020 until Sept. 2022 included 191 respondents who were prescribers from 32 states. Most of the responses came in 2022. The most common pharmacy obstacles reported indicated that the pharmacy or pharmacist declined to fill the prescription for buprenorphine (45%) while 41% indicated that the pharmacy was unable to fill the prescription due to inadequate stock. According to the prescribers, the most common reason that pharmacies declined to fill the prescription was corporate policy limiting or prohibiting dispensing of the medication (25%), concern that the prescription was clinically inappropriate (16%), or believing that the DEA has a cap on the quantity of buprenorphine that can be dispensed (14%). In cases where the pharmacy was unable to fill the prescription due to stock issues, 41% of respondents indicated that there was a supplier shortage and 25% indicated that the pharmacy’s wholesale supplier had limited the amount of the medication that the pharmacy could order or stock. The respondents indicated that patients had to get scripts filled at a different pharmacy or had to wait up to 48 hours or more to get the script filled. Almost half of the responses came from Indiana, Florida, Texas, Tennessee, and Illinois. Also, 96% of the reports involved large, national retail chain pharmacies.
A recent open access paper from Addiction Science & Clinical Practice described a “secret shopper” survey of 1374 outpatient pharmacies and 48 inpatient pharmacies in Florida. They accrued 200 successful calls to outpatient pharmacies and 25 successful calls to inpatient pharmacies. Of the 200 outpatient pharmacies, 38% had any buprenorphine available. Miami-Dade County had the least available and Palm Beach had the most available. Of the pharmacies that did have buprenorphine available, 82% had enough in stock for a 2 week supply of 16 mg daily. Only 55% of the outpatient pharmacies that did not have buprenorphine available were willing to order it with a median wait time of 2 days. Of the inpatient pharmacies, 88% had buprenorphine on the inpatient formulary.
I have encountered this issue here in Kentucky, and I suspect that many of you have as well. Furthermore, the “lock-in” continues. I have many patients who still find themselves locked into a particular pharmacy because they went to a different pharmacy to get their scripts filled for appropriate reasons. They are accused of doctor shopping. Then if their pharmacy doesn’t have the medication, the pharmacy has to get an override for them to go to another pharmacy, which is another delay. Then, of course there is the issue of rude pharmacists and technicians who perpetuate the stigma of addiction by their attitude toward patients filling legitimate prescriptions. We have much work to do in this state and nationally on these issues.
Syros A, Rodriguez M, Rennick A, et. al. Availability of medications for opioid use disorder in outpatient and inpatient pharmacies in South Florida: a secret shopper survey. Addiction Science and Clinical Practice. https://doi.org/10.1186/s13722-022-00346-x.
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New Research in the Addiction Field | |
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Serkland, Trond Trœtteberg MD; Dale, Gro Helen MD, PhD; Kaldestad, Ingeborg Caroline MD; Berg, Jon Andsnes MD; Methlie, Camilla Borthen MD. Oxazepam Detected in Urine 79 Days After Withdrawal of Diazepam: A Case Report. Journal of Addiction Medicine: 7/8 2022 - Volume 16 - Issue 4 - p e274-e277
doi: 10.1097/ADM.0000000000000944
The authors describe the case of a 30-year-old woman who had detectable metabolites of oxazepam 79 days after withdrawal from diazepam. They point out that there are not many studies of detection time of metabolites of various substances in the urine. It is possible that clinicians may need to consider interindividual variability when interpreting the results of a urine drug test. A high body mass index and genetic polymorphism may play a role in the prolonged detection of metabolites.
Wanar, Amita BA; Isley, Breanna Cassidy BA; Saia, Kelley MD; Field, Thomas A. PhD. False-positive Fentanyl Urine Detection after Initiation of Labetalol Treatment for Hypertension in Pregnancy: A Case Report. Journal of Addiction Medicine: 11/12 2022 - Volume 16 - Issue 6 - p e417-e419
doi: 10.1097/ADM.0000000000001010
The authors point out that labetalol hydrocholoride, used for hypertensive disease in pregnancy, may interfere with urine drug testing. They describe 3 cases of pregnant or post pregnant women who were treated with labetalol for hypertension and had presumptive positive urine results for fentanyl. The subsequent GC/MS was negative.
From ASAM Weekly Dec. 20:
Recreational 2-Methyl-2-Butanol Use: An Emerging Wave of Misuse of an Ethanol Substitute on the Horizon? 🔓
The Primary Care Companion For CNS Disorders
This case report describes an ER presentation of a 25-year-old male with presentation suggestive of ethanol intoxication, undetectable blood ethanol and history of use of 2-methyl-2-butanol. Internet sites promote it as a more potent intoxicant than ethanol and it is available from mainstream internet retailers. It is an inhibitor of the GABA-A receptor with a duration of action of 12-24 hours. Intoxication resolved over 3 days in the reported case. It is not metabolized to aldehydes by alcohol dehydrogenase and is not associated with hangover. It is not detected on routine toxicology and appeals to those wishing to evade routine screening. It produces an elevated anion gap causing concern in this case for ingestion of methanol, ethylene glycol, or isopropanol. Use is increasing in Eastern Europe and may rise in the US.
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On December 8, with other organizations, ASAM signed onto two letters to Congressional leadership in support of the inclusion of Title IV – Public Health Response to Infants Affected by Substance Use Disorder of S. 1927, the Child Abuse Prevention and Treatment (CAPTA) Reauthorization Act of 2021, (“the Act”) in an end-of-the-year legislative package. Describing S. 1927 as “must-pass legislation this Congress,” the letter praises the Act’s creation of this new title under CAPTA, which substantially updates and improves current statute to encourage a family-centered treatment approach for infants affected by parental substance use disorder (SUD) and their parents. Importantly, Title IV takes steps to ensure that the use of medications to treat SUD in pregnancy does not trigger the intervention of the child welfare system without separate evidence of child abuse or neglect.
The American Society of Addiction Medicine (ASAM) applauded Congress for the advancement of bipartisan legislation that would facilitate access to cannabis for research purposes. If signed into law by President Biden, H.R.8454 -The Medical Marijuana and Cannabidiol Research Expansion Act would make it easier for researchers to study cannabis, which would potentially open the door to additional cannabis-derived medicines and therapies.
Specifically, the legislation is intended to streamline the approval process for cannabis research, remove certain barriers to acquiring cannabis for research purposes, and encourage the federal government to facilitate more medical research on cannabis. Importantly, the Medical Marijuana and Cannabidiol Research Expansion Act would also clarify that it is not against federal law for physicians to discuss the risks and benefits of cannabis with patients in their care.
Legislative champions for the passage of this bipartisan legislation include Reps. Earl Blumenauer (OR) and Andy Harris (MD) in the House and Sens. Dianne Feinstein (CA), Brian Schatz (HI), and Chuck Grassley (IA) in the Senate.
On November 17th, ASAM joined a letter, spearheaded by the Campaign for Tobacco Free Kids (CTFK) and addressed to the Chairs and Ranking Members of the Labor, Health and Human Services, Education, and Related Agencies Subcommittees of the U.S. Senate and House Committees on Appropriations, urging the committees to fund the Centers for Disease Control and Prevention’s (CDC) Office of Smoking and Health (OSH) at $261.5 million, as was delineated in the U.S. Senate Appropriations Committees’ Chairman’s mark from July 2022. Over 31 million people in the U.S. continue to smoke cigarettes, and OSH plays a vital role in the reduction of tobacco use. Additional resources will allow OSH to address rising rates of youth e-cigarette use.
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Kentucky Legislative News | |
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On November 15th, 2022, Governor Andy Beshear signed an executive order allowing persons with certain medical conditions to possess and use medical cannabis in Kentucky if purchased outside of the state. Persons using medical cannabis will be required to have a written certification of condition approved for medical cannabis use by a physician licensed to practice in the Commonwealth of Kentucky and documentation of provider-patient relationship with the individual. Some qualifying conditions included were: severe and chronic pain, PTSD, Hepatitis C, Fibromyalgia, severe arthritis, and epilepsy. Persons using the medical cannabis will not be allowed to possess more than 8 ounces. Beshear created the Team Kentucky Medical Cannabis Advisory Committee in another executive order in June 2022 to conduct public meetings and gather feedback regarding attitudes toward medical cannabis. The effective date of this executive order is Jan. 1, 2023. Several bills have been introduced in the past to advance legalization of medical marijuana including HB 136 which did not pass in the Senate. It is expected that the legislative efforts will continue in 2023 with the goal of creating a medicinal cannabis program in the state.
See the Executive Order 2022-798 here: https://governor.ky.gov/attachmensts/20221115_Executive-Order_2022-798_Medical-Cannabis.pdf.
The second annual ASAM State Advocacy Summit took place on October 20th, 2022. Beth Conolly from the Office of National Drug Control Policy discussed the Biden administrations areas of focus. Focus will continue on expansion of naloxone access. Access to naloxone has been highly variable among the states. The Biden administration supported 1.5 billion in funding for SOR (State Opioid Response)grants to continue to expand availability for FDA approved medications for OUD in 2022. Other areas of focus include changes to 'Take-home' doses of methadone during the pandemic and state level regulation of SUD treatment for pregnant and parenting women.
KMA Physicians Day at the Capitol will take place on February 22, 2023. This event presents an opportunity for physicians to meet with key policy makers. Please contact Miranda Sloan if you would like to be involved.
Danielle Anderson, MD
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Save these dates!
Semi-Annual Meeting Jan. 28, 2023, Griffin Gate Mariott, 1800 Newtown Pike, Lexington, Ky. 40511. Watch for email link from our Administrative Coordinator, Miranda Sloan, for registration information.
KYSAM Annual Meeting, August 26, 2023, in conjunction with KMA meeting. Details to be announced.
We are looking for members who are interested in being on a committee. Two of the committees now forming are Advocacy and Education. The Advocacy Committee, chaired by Danielle Anderson, will follow legislative news, work with the Board on KYSAM's response to proposed legislation and on legislative initiatives KYSAM should undertake. The Education committee, chaired by Cheryl McClain, will work on making education about addiction more available to Kentucky medical professionals, the public, and other interested parties. The members will also plan the CME presentations for our annual meetings. The social media and communication committee needs more members. This committee focuses on updating the website, possibly implementing a new website, publishing the newsletter, publicizing KYSAM activities, and facilitating communication among members. It works in conjunction with our Administrative Coordinator. If you like to write, have a message to share and value communication, and especially if you have any website design skills, please consider helping. If you are interested in being on one of these committees, please email our Administrative Coordinator, Miranda Sloan, at admin@kysam.org.
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ASAM 54th Annual Meeting, April 13-16, 2023. National Harbor, Washington, DC. Super early bird registration deadline is Dec. 31. After Dec. 31, registration fee increases from $695 to $795 for members.Go to ASAM.org.
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ASAM’s NEW Diversity Travel Scholarship provides funding to individuals identified as a member of an underrepresented group in the medical field to attend ASAM’s 2023 Annual Conference, April 13-16, in Washington DC. Deadline to apply: December 31, 2022. Applicants will be notified by February 1, 2023.
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