FSAM NEWS

Mental Health Parity

2008-04-08T22:13:00.000-07:00

Dear Friends and Colleagues:
Representative Ed Homan (R-Tampa) has been tirelessly working on a Mental Health Parity Bill.
Today, it passed with 18-Yeas and )-Nays the Healthcare Council.
House Bill 19 amends s. 627.6688, F.S., to add substance-related disorders to the mandated offering required
by that section. The bill repeals s. 627.669, F.S., which imposes a mandated offering for substance abuse
services. The bill further amends s. 627.6688, F.S., to specifically define those mental health conditions that
must be covered within the mandated offering, generally including all diagnostic categories of mental health
conditions listed in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders and as
listed in the mental and behavioral disorders section of the current International Classification of Diseases.
The bill deletes current law limiting mental health benefits by specific service areas, such as inpatient benefits,
and inserts a general statement that the mental health benefits may not be more restrictive than the treatment
limitations and cost-sharing requirements that are applicable to other diseases, illnesses, and medical
conditions.
The bill mandates that the parity requirements be separately applied to each benefit package offered by an
employer.
The bill would have an indeterminate negative fiscal impact on the State Employees’ Group Health Self-
Insurance Trust Fund.
The effective date of the bill is January 1, 2009.
For more detailed information please visit http://edhoman.com/public/parity.html

Bill Number: 0019
Bill Name: HB 19
Action: Favorable With Council Substitute
Committee: Healthcare Council
Location: Morris Hall (17 HOB)
Duration: 3.50
Date: 4/8/2008 8:30:00 AM
Sponsor: Homan (CO-SPONSORS) Anderson; Brandenburg; Brisé; ...
Subject: Coverage for Mental, Nervous, and Substance-relate...

Y Anderson Y Galvano Y Harrell Y Patronis Y Schwartz
Y Ausley Y Garcia, R. Y Hays Y Porth Y Skidmore
Y Bean Y Gibson, H. Y Hooper Y Roberson Y Zapata
Y Cusack Y Grimsley Y Hudson

Total Yeas: 18 Total Nays: 0 Total Missed: 0 Total Votes: 18

Please contact your legislator to thank them for their support and encourage them to move this bill forward for final passage.
Also contact Rep. Ed Homan to express your support for his efforts and contribute to his campaign.
Yours
Bernd

AMA NEWS Article

2008-03-24T18:58:00.000-07:00

"Because so many patient problems have fallen at the feet of primary care, we need to look at ways primary care can be part of the solution and not part of the problem," said Michael M. Miller, MD, president of the American Society of Addiction Medicine.

Dear Friends and Colleagues:
Attached a very informative article from a recent AMA NEWS edition.
Some great quotes including Mark Gold and Michael Miller,MDs.
Bernd

AMA NEWS 03/17/08

HEALTH & SCIENCE

Dangerous diversions: Specter of prescription drug abuse creates tough balancing act for doctors

Questioning patients about past addictive disorders can alert physicians to the need for care when prescribing medication with the potential for misuse.

By Susan J. Landers, AMNews staff. March 17, 2008.

Walking the line between appropriately prescribing controlled substances and unwittingly contributing to the increase in prescription drug abuse becomes less precarious when certain precautions are taken, say those familiar with the balancing act.

Prescription drug abuse is widespread and on the rise. Nearly 7 million Americans abused prescription drugs in 2005, compared with 3.8 million in 2000 -- an 80% jump, says the Justice Dept.

While research has shown that most medications are prescribed responsibly and that the Internet and street sales feed the illegal drug trade, physicians could play a larger role in fighting this problem, several experts said.

Prescribing of controlled substances has increased dramatically, said Robert DuPont, MD, president of the Institute for Behavior and Health, a nonprofit drug abuse policy organization in Rockville, Md., a block from the National Institute on Drug Abuse, where he served as the first director.

"Before the last decade, doctors were very reluctant to prescribe these medications to outpatients. But because of concern about the undertreatment of pain, their prescription has become ubiquitous," Dr. DuPont said.

If physicians think their practices are immune from prescription abuse, they should think again, said Mark Gold, MD, distinguished professor and chief of addiction medicine at the University of Florida's McKnight Brain Institute in Gainesville.

10% of adults will have some kind of addictive disorder in their lifetimes.
Properly prescribed medications can be diverted by teens pilfering drugs from their parents' medicine cabinet before heading out to a party. Or patients may sell their medications to supplement their incomes. And then there are the "doctor shoppers" who hit a different physician's office every day, seeking controlled substances.

Regardless of how it happens, the outcome of this abuse can be deadly. Actor Heath Ledger, who died Jan. 22 after taking a variety of prescribed medications, can be counted among its victims, as can musicians Elvis Presley, Judy Garland, Dinah Washington and Jimi Hendrix.

For as long as there have been medicines, the danger of overuse, experimentation and abuse has existed. The rise of patent medicines -- based largely on morphine and cocaine -- in the middle and late 1800s resulted in one in 200 Americans becoming addicted. These widely used substances were embraced by doctors and patients alike before harm was detected and the first drug control laws were passed.

That was then. The drugs of choice now, according to the National Institute on Drug Abuse, are opioids commonly prescribed to treat pain; central nervous system depressants used to treat anxiety and sleep disorders; and stimulants used to treat narcolepsy and attention-deficit hyperactivity disorder.

Pain reliever or drug of abuse?

But there is a flip side. The same medications subject to abuse provide much-needed relief to patients. A larger problem comes when pain is not treated adequately or when patients are afraid to ask for pain relief because they fear they might become addicted, said A. Thomas McLellan, PhD, CEO and founder of the Treatment Research Institute, a nonprofit group in Philadelphia that studies addiction.

American Medical Association policy also cautions that undertreating pain is a concern that must be balanced against the risk of abuse.

70 million Americans experience pain every day.
Undertreatment of chronic pain is an important public health concern, said B. Todd Sitzman, MD, MPH, president of the American Academy of Pain Medicine. An aging population means that arthritis, cancer, degenerative disc disease and other disorders will become more common, leading to an increase rather than a decrease in pain scripts, he said.

The need for both pain treatment and addiction treatment is clear. "We know there are 70 million Americans who experience pain every day. Along with that, we know 10% of the adult population will have some kind of addictive disorder in their lifetime, although most will be addicted to some legal substance, like alcohol."

Primary care physicians can address these problems before even picking up a pen and prescription pad, several physicians said. "Because so many patient problems have fallen at the feet of primary care, we need to look at ways primary care can be part of the solution and not part of the problem," said Michael M. Miller, MD, president of the American Society of Addiction Medicine.

A report about prescription drug abuse will be presented at the AMA Annual Meeting in June. Current AMA policy supports physician education, research activities and the development of state-based programs.

As a first step, physicians need to ask questions about a patient's history of addiction or previous difficulties in controlling their prescription drug use, Dr. Miller said. While addiction to opioids and psychostimulants is relatively rare when the medications are properly prescribed, these screening questions can alert physicians to the need to exercise particular caution, he said.

Doctors can incorporate such queries into a busy practice, Dr. Gold said. Questions about tobacco use, once a rarity, are commonplace today.

Doctors may think that national statistics don't apply to their practices, he said, but that's not the case. "Tobacco, alcohol and drug problems are so important in our society and health system, it is imperative for physicians to acquire the skill to ask and intervene."

Physicians also should consider what might happen to the medication that isn't used right away, said Kyle Kampman, MD, medical director of the Charles O'Brien Center for Addiction Treatment at the University of Pennsylvania. Physicians often provide too many pills, he said. "We hate to see somebody in pain run out of medicine, so sometimes we may be a little too generous."

Pharmaceutical leftovers are kept in case patients need them again. And where are they stored? In medicine cabinets and kitchens, where they can be found by children and others, Dr. Kampman said.

Physicians need to warn patients to lock up unused medications, he added. "Patients tell me they worked as a maid at the height of their addiction and they would go through people's medicine cabinets. I had a patient who was a roofer tell me, 'If you ever let a roofer in your house and in the bathroom, chances are they are looking through your medicine cabinet.' "

Physicians also need to look for signs of abuse, such as patients who return early for a refill. "It's a joke among addiction providers that sinks and toilets seem to be magnets for people's medications. That's an excuse you often hear: 'I dumped my medicine down the sink or down the toilet.' So that should ring alarm bells," Dr. Kampman said.

If this occurs, it's best to confront a patient directly, he said. Sometimes patients will acknowledge a problem, and the physician needs to stop prescribing and insist the patient be evaluated for substance abuse, Dr. Kampman said.

Other times, patients' pain is undertreated, leading them to take increasing amounts of a medicine. In these cases, referral to a pain specialist is necessary, he added.

Every physician prescribing controlled substances has clear responsibilities set forth by the Federation of State Medical Boards, Dr. Sitzman said. These duties -- which include obtaining a physical exam before prescribing, having a written treatment plan and stressing the responsibilities of both patient and physician -- aren't always followed closely, he said.

Physicians should tell patients that it is illegal to share medications with other people, and that unused or expired drugs should be destroyed, Dr. DuPont said. Destroying them means rendering them unusable by mixing them with cat litter or coffee grounds. Flushing them down the toilet is permissible only if the label says so, according to the Office of National Drug Control Policy.

Detecting doctor shoppers

Turning to a prescription drug monitoring program, a searchable database for tracking users of controlled substances, is another option for physicians on the trail of doctor shoppers. For instance, the Indiana Scheduled Prescription Electronic Collection & Tracking program is gaining popularity in that state.

"It takes about 30 seconds to check to see if patients are filling other prescriptions," said family physician Terry Haffner, MD, of Kokomo. Previously available only to law enforcement agencies, the INSPECT program opened to doctors last July.

Congress enacted the National All Schedules Prescription Electronic Reporting Act in 2005 with strong doctor support. But the law, which authorizes a system of federally supported, state-based drug monitoring programs, has yet to be funded.

NASPER investment is critical, said Andrea Trescot, MD, president of the American Society of Interventional Pain Physicians. If it were funded, the law would provide an important preventive tool, she said.

Talk-show host Rush Limbaugh might not have gotten into trouble with prescription abuse if NASPER had been operational, she noted. He was charged in 2006 with doctor shopping to get extra pain killers. "When he saw a second doctor, [that] doctor would have said, wait a second, maybe there is a problem here. Let's see if we can intervene before you crash, burn and die."

Discuss on SermoBack to top.

ADDITIONAL INFORMATION:

Getting pain pills

Friends and relatives were the primary source of prescription pain relievers abused by those 12 and older, a new survey finds. But physicians were also sources.

56% of respondents said they had received pain relievers free from a friend or relative.

19% received them from a doctor.

9% bought them from a friend or relative.

7% identified another source.

5% took them from a friend or relative.

4% bought them from a drug dealer.

Source: "2006 National Survey on Drug Use and Health: national findings," Substance Abuse and Mental Health Services Administration, September 2007

Back to top.

Controlling controlled substances

Specialists in pain medicine and addiction medicine suggest ways to prevent drug diversion:

Ask patients about a history of addiction or any previous difficulties in controlling prescription drug use.
Don't prescribe too many pills. Those that aren't used are often kept where they can be found by teens and visitors.
Warn patients to lock up their medications.
Encourage patients to dispose of unused medicine by mixing it with coffee grounds or cat litter, wrapping it in a plastic bag, and then a paper bag, before throwing it in the trash.
Be aware of signs of misuse or of inadequate pain relief, such as "losing" prescriptions and medications or running out early.
Back to top.

Abusing Rx drugs, and more

More than 2.1 million teens reported abusing prescribed substances in 2006, according to a national survey on drug use and health released last September. People 12 and older who reported using an illicit drug for the first time in the past year (numbers are in thousands):

2,150,000 used pain relievers

2,063,000 used marijuana

1,112,000 used tranquilizers

997,000 used cocaine

860,000 used ecstasy

783,000 used inhalants

267,000 used sedatives

264,000 used LSD

258,000 used meth

91,000 used heroin

69,000 used PCP

Source: "2006 National Survey on Drug Use and Health: National Findings," Substance Abuse and Mental Health Services Administration, September 2007

Back to top.

Weblink

American Society of Addiction Medicine (www.asam.org)

American Academy of Pain Medicine (www.painmed.org)

American Society of Interventional Pain Physicians (www.asipp.org)

Impaired Healthcare Professionals in the news

2008-03-17T20:39:00.000-07:00

Dear Friends and Colleagues:

Attached you find an article from the Sunday edition of the Miami Herald regarding the issue of impaired healthcare professionals.
Despite the apparent criticism of an opaque system that appears (for the public at least) to protect impaired practitioners Dr.Pomm points out the obvious success rate of the monitoring system.
I think that we need to proactively monitor our own profession and report those who truly need assistance and support.
We should not leave it up to the public or the lawyers to judge us but be proactive in the pursuit of protecting our patients and our profession.
I am looking forward to your comments.
Yours
Bernd

==============================================================================
Posted on Sun, Mar. 16, 2008
Healthcare practitioners with drug problems hidden by the system

BY JOHN DORSCHNER AND PATRICK DANNER
In August 2006, the former wife of a Broward psychologist sent a letter to state authorities saying she had visited his home 'and saw cocaine paraphernalia, an empty bottle of Oxycontin and a small Ziploc bag . . . with `whitish-beigy' colored small rocks,'' according to a court document.

That event started an investigation and later a lawsuit against ''John Doe, Ph.D.'' The psychologist's name has not been revealed. The Department of Health won't say if he's still practicing. ''Everything about this case is confidential,'' says spokeswoman Eulinda Jackson.

The case is another example of how far state regulators will go to protect healthcare professionals.

''Doctors like to protect other doctors,'' says Sidney M. Wolfe, a physician with the Washington-based Public Citizen consumer group which has published a series of studies on how lax regulatory groups are in disciplining healthcare professionals.

In the case of the unknown psychologist confidentiality is key in order to get professionals to seek help, says Raymond Pomm, head of the group that handles the impaired physicians' program. ``If we don't protect them, they won't come knocking on the door.''

But court records reveal John Doe, Ph.D. refused to participate. Pomm's program, Professional Resource Network, asked him to respond to his ex-wife's allegations. He didn't. In October 2006, PRN sent him a certified letter. He didn't respond. Over the next year, PRN kept repeating the request.

Finally, in November, the Department of Health sued ''John Doe Ph.D'' in Broward Circuit Court to compel him to submit to a mental and physical test. Wherever his real name appeared in court documents, it was blacked out. The psychologist has yet to respond.

''It's always been troubling to me that the profession protects itself to the detriment of the public,'' says Ervin Gonzalez, a Coral Gables lawyer who has represented patients in malpractice lawsuits. ``The profession closes in and has star chamber-type proceedings that no one knows about or hears about. I think it should be in the sunshine. I think it should be transparent.''

Gonzalez says doctors generally are allowed to continue to practice while the Department of Health brings such actions. That due process is a fundamental right, but ''after there is a probable cause finding and evidence of a legitimate risk to the public, then I think the public should know,'' he says.

That means making the physician's name public at that point so patients can decide for themselves. ''It's a matter of great public importance, I believe,'' Gonzalez says.

According to the state's Medical Quality Assurance Division, 127 complaints were received in fiscal 2007 concerning Florida's 3,571 licensed psychologists. In 12 cases, investigators found there was probable cause that state rules had been violated. Final outcome: No licenses revoked, one suspended and 11 psychologists were fined.

State officials have asked that the John Doe Ph.D. file be sealed completely, but the judge has yet to make a decision and a hearing last month was postponed. The state statute governing such cases requires that the psychologist's name be kept confidential in court documents and proceedings be closed to the public. But nothing in the statute says that the entire file must be sealed.

The attorney for the Health Department in the case, Cynthia L. Jakeman, did not respond to a request for comment.

Pomm says PRN has a ''very strict'' program of testing and compliance, and the doctors are highly motivated because they don't want to lose their licenses. He says 87.2 percent of medical doctors and osteopathic physicians successfully complete the program and never relapse -- a far better success rate than most rehab programs.

''We see 9.3 percent relapse one time, 1.7 percent relapse two times only and 1.8 percent three times or more. These are very good rates,'' says Pomm.

However, ''before July 1, 2005, there was a loophole,'' in which practitioners who had successfully completed the program and were thought to have relapsed could not be forced to take a urine test. ''We fixed that with legislation,'' says Pomm. Under the present PRN program, if a practitioner misses a urine test or a group counseling session, ``we basically pull them out of practice.''

In the case of John Doe Ph.D., court filings hint at multiple problems. One document indicates he successfully completed a PRN program in January 2006. In a filing in a custody battle for his children, he said he had been ''clean'' of ''hard-core'' drugs from August 2000 to April 2006, ``when he began taking a prescription of oxycodone for chronic neck, back and right knee pain.''

On Aug. 5, 2006, he said he was in an opiate detox program. Less than three weeks later, his ex-wife notified PRN of seeing drug paraphernalia in his home.

When the Health Department sued John Doe Ph.D., it stated ''probable cause existed to believe that respondent was unable to practice psychology with reasonable skill and safety,'' which appears to indicate that the department was asking the psychology board to suspend his license. However, in the minutes of that board's regular meetings, available on the Internet, there is no indication of any Broward psychologist being suspended for drug allegations.

Arthur Levin of the Center for Medical Consumers in New York says ''it's just crazy'' for regulators to protect the identity of a healthcare practitioner who refuses to cooperate. Levin appreciates the need for confidentiality. ``I live with somebody who is in recovery. But it's a little different in the case of a professional.''

Some believe impairment problems are not as critical with a psychologist as they would be with, say, a heart surgeon, but Michael Herkov, a clinical psychologist and a professor at the University of North Florida, says psychology also involves life-and-death decisions.

''Psychologists don't just listen,'' says Herkov. ``Bartenders listen. Psychologists are involved in the diagnosis and treatment of mental disorders. . . . More people die each year from suicide than do from homicide. Decisions have to be made. Do you have to be hospitalized immediately? . . . These are situations with serious consequences.''

Court records show it's unusual for the Department of Health to sue a John Doe to demand the taking of mental and physical exams. There are only four such cases in Miami-Dade and Broward counties over the past five years. The other two cases in Broward involve John Doe, MD and Jane Doe, LPN (licensed practical nurse).

In Miami-Dade, the lone such case involves a Jane Doe, RN (registered nurse). There is no indication of what the case was about or how it was resolved.

When a consumer hears rumors about a practitioner and drug use, such allegations are virtually impossible to check out.

Some months ago, a person called a Miami Herald reporter and named a Miami-Dade cosmetic surgeon who continued to practice while having drug problems. The caller gave detailed information, such as saying the surgeon relapsed six times in rehab programs.

On the Department of Health website, the surgeon is indicated as having a ''clear/active license.'' No disciplinary actions are listed.

When a reporter asked Pomm about the surgeon, he said he couldn't say anything about specific doctors.

JOURNAL CLUB: Cocaine Abuse - A Case report

2008-02-23T14:34:00.000-08:00

Attached a case report published in the current edition of CONSULTANT http://www.consultantlive.com/print.jhtml;jsessionid=ZCJKOW4131PZGQSNDLPSKHSCJUNN2JVN?articleID=206503919&url_prefix=
Looking forward to your comments.
Yours
Bernd

Renal Infarction: An Unusual Complication of Cocaine Abuse
By ASIM ABBASI, MD, ANDY ARWARI, MD, ALI ALIZADEHSOVARI, MD, and SAMER NUHAILY, MD,
February 01, 2008 URL: http://www.consultantlive.com/showArticle.jhtml?articleId=206503919
A 63-year-old African American man presented with severe epigastric pain of 1 day's duration. The pain was sharp and continuous and radiated toward the left flank. There were no aggravating or relieving factors or previous similar episodes. The patient denied fever, chills, urgency, frequent or painful urination, and gross hematuria. Earlier that day, he had taken an antacid for presumed gastritis and had a bout of emesis. The patient had a history of cocaine abuse and admitted that he had smoked one fourth of a bag of cocaine the day before presentation.

Blood pressure was 159/93 mm Hg; heart rate, 73 beats per minute; temperature, 36.9°C (98.4°F); respiration rate, 18 breaths per minute; and oxygen saturation, 98% on room air. The chest was clear. Cardiac findings were within normal limits. The abdomen was scaphoid, without scars, rashes, or lesions. There was severe epigastric tenderness and tenderness to percussion of left costovertebral angle, without guarding, spasm, or rebound; no masses or abnormal pulsations were noted. Genitourinary and rectal findings were normal; stool was guaiac-negative. Other physical findings were noncontributory.

The differential diagnosis included renal colic, pyelonephritis, acute gastritis, mesenteric ischemia, and renal infarction. Intravenous hydration with normal saline was started, pending the results of further investigations.

The white blood cell count was 17,300/µL, with 77.2% neutrophils; the hemoglobin level was 13.6 g/dL. Hematocrit was 40.2%; platelet count, 266,000/µL; blood urea nitrogen, 7 mg/dL; serum creatinine, 1.0 mg/dL; total protein, 6.1 g/dL; and serum albumin, 3.0 g/dL. Total bilirubin was 1.1 mg/dL; aspartate aminotransferase, 63 U/L; alanine aminotransferase, 41 U/L; alkaline phosphatase, 51 U/L; serum sodium, 135 mEq/L; potassium, 3.5 mEq/L; chloride, 104 mEq/L; carbon dioxide, 36.2 mEq/L; and lactate dehydrogenase, 341 U/L. A urinalysis showed trace proteinuria, 1 to 3 red blood cells per high-power field, and no white blood cells or casts. Urine toxicology confirmed the presence of cocaine.

CT scans of the abdomen showed acute infarcts in the medial upper pole and lateral lower pole of the left kidney (Figure). There was no vascular disease in the abdominal aorta, celiac artery, or superior mesenteric arteries. No definite plaque lesions were seen in the right or left renal arteries.

Duplex ultrasonography showed normal blood flow in both renal arteries. Blood and urine cultures were negative. Screening for hypercoagulability (factor V Leiden, prothrombin gene, protein C, protein S, antithrombin III, antiphospholipid antibody, and homocysteine); collagen disease (rheumatoid factor and antinuclear antibody); and lipid disorders was negative for thromboembolic phenomena. A transesophageal echocardiogram showed no evidence of an intracardiac thrombus or valvular vegetations.

Cocaine-induced renal infarction was diagnosed by exclusion. The patient was given supportive therapy for 3 days and was discharged. His renal function was observed during the hospitalization, and renal failure did not occur. His serum creatinine level at the time of discharge was 1.1 mg/dL.

RENAL COMPLICATIONS OF COCAINE ABUSE
Cocaine abuse has reached epidemic proportions in United States.1 Cocaine use has deleterious effects on multiple organ systems. Common toxic effects on the vascular system include myocardial ischemia, mesenteric ischemia, and cerebrovascular accidents. Myocardial ischemia and cerebrovascular accidents are the most common causes of hospitalizations related to cocaine abuse. The annual cost of cocaine-related hospitalizations has exceeded $80 million.2

Renal injury. Renal complications of cocaine abuse are relatively rare. The pathophysiology of renal injury involves changes in renal hemodynamics, glomerular matrix synthesis, degradation, oxidative stress, and induction of renal atherogenesis. These changes may lead to both acute and chronic renal injury. There are several case reports of acute tubular necrosis caused by rhabdomyolysis after cocaine abuse.3 Acute renal failure with accelerated hypertension or malignant hypertension can be precipitated by cocaine use.4

Other renal complications include acid-base and electrolyte imbalance (with both acidemia and alkalemia), increased incidence of urinary tract infection in cocaine-exposed infants, and increased risk of chronic renal failure in patients with hypertension—especially in African Americans.

Renal infarction. Spontaneous renal infarction secondary to cocaine abuse is rare. Patients usually pre- sent with persistent flank or abdominal pain with or without fever, nausea, and vomiting. Of the reported cases of cocaine-induced renal infarction, most involved the right kidney. The predilection for the right kidney may be related to increased resis- tance to blood flow in the right renal artery, compared with the left renal artery, because of its longer course.5

Pathophysiology. The precise mechanism of cocaine-induced renal infarction is unclear. Platelet aggregation and endothelial and vasospastic injury secondary to thromboxane synthesis are possible causes.6 Renal biopsy findings may include arterial and venous thrombosis as well as obliterative arteriopathy. However, our observation in this case and a review of the literature suggest that renal infarction can occur without thrombosis in patients with a history of cocaine abuse.

Laboratory studies. Leukocytosis, hematuria, and elevated levels of lactate dehydrogenase are common but nonspecific findings in patients with renal infarction. These findings can also be seen in patients who have renal venous thrombosis, papillary necrosis, and nephrolithiasis.

Diagnosis. A CT scan of the abdomen is both sensitive and specific for the diagnosis of renal infarction. With the use of intravenous contrast, renal arteries can also be evaluated for plaques or clots. Sagittal reconstruction through the abdominal aorta can adequately demonstrate findings in the aorta, celiac trunk, and superior mesenteric arteries. Coronal reconstruction of the renal arteries is usually best.

The possibility of infarction secondary to an embolic phenomenon should be ruled out with hypercoagulability studies and transesophageal echocardiography.

Treatment and outcome. There is no consensus on the treatment of renal infarction. For this patient, supportive therapy was started early on admission. Because his renal function did not decline, no further treatment was warranted. He was referred to social services for treatment of cocaine abuse but was lost to follow-up.

KEY POINTS FOR YOUR PRACTICE
Consider renal infarction in a patient with a history of cocaine abuse who presents with acute abdominal or flank pain.
A CT scan of the abdomen is both sensitive and specific for the diagnosis of renal infarction.
Further evaluation with transesophageal echocardiography and laboratory studies for thromboembolic phenomena is indicated to rule out embolic infarction.

Journal Club

2008-02-10T19:54:00.000-08:00

Dear Friends and Colleagues;
Attached a series of articles published in Family Medicine Journals and Magazines regarding substance Abuse and Dependence:
1) Baclofen Cuts Alcohol Use in Cirrhosis Patients
2) Warning Reissued for Fentanyl Deaths, Side Effects
3) FDA Warns About Methadone-Related Deaths, Serious Events
4) Research Sought on Physicians' Addiction Recovery

I look forward to your comments.

Bernd

====================================================================================
Family Practice News
Volume 38, Issue 2, Page 23 (15 January 2008)

Baclofen Cuts Alcohol Use in Cirrhosis Patients

JOHN R. BELL (Associate Editor)
Alcohol-dependent persons with cirrhosis of the liver who were treated with baclofen, a ?-aminobutyric acid-B receptor agonist, were more than six times as likely to cease their alcohol use as were patients who took a placebo, according to a study.

The trial is the first “in which effectiveness and safety of an anticraving drug has been investigated in individuals with advanced liver disease,” wrote Dr. Giovanni Addolorato of the Catholic University of Rome, and colleagues. They reported results for 84 alcohol-dependent patients with a diagnosis of cirrhosis who were randomly assigned in equal number to a 12-week regimen of either baclofen or placebo.

The baclofen dosage was 5 mg three times daily for the first 3 days and 10 mg three times daily thereafter. Mean patient age was 49 years in both groups. Patients were seen weekly for the first month, then every 2 weeks until the end of the study (Lancet 2007;370:1915-22).

At 12 weeks, 30 (71%) of the 42 patients in the baclofen group were abstinent from alcohol, compared with 12 (29%) of the 42 patients in the placebo group (odds ratio 6.3).

In addition, those given baclofen showed improvements in measures of liver function, including ALT, bilirubin, international normalized ratio, ?-glutamyltransferase, and albumin. The drug was also associated with a greater number of nondrinking days than was placebo (63 days vs. 31 days), as well as a lower rate of relapse to heavy drinking at 60 days (19% vs. 45%).

Treatment with baclofen also reduced alcohol cravings, as measured with the obsessive-compulsive drinking scale.

Baclofen was not associated with any hepatotoxicity. There were no incidents of encephalopathy or hyperammonemia and no serious events leading to discontinuation of the drug. Tolerability was reported as fair, with headache, tiredness, vertigo, and sleepiness reported in small numbers of patients in both groups.

These results “suggest that baclofen, because of its anticraving action and safety, could have an important role for treatment of alcohol-dependent patients with advanced liver disease,” the researchers wrote. They cautioned that further studies are needed to establish optimal treatment duration and longer-term tolerance.

In a commentary accompanying the report, Dr. James C. Garbutt of the University of North Carolina at Chapel Hill, and Barbara Flannery, Ph.D., of RTI International, Baltimore, called the findings “surprisingly robust” and of potentially great clinical importance, given the routine exclusion of alcoholic patients with cirrhosis from trials of anticraving drugs because of the concern about hepatotoxicity (Lancet 2007;370:1884-5).

They also noted that the higher dropout rate in the placebo group (31%) versus the baclofen group (14%) is of interest, because it may have skewed the results in favor of baclofen, given that these were assumed to be because of relapse, and thus affected the primary end point.

The study authors declared no financial conflict of interest. The study was supported by the Italian Ministry for University, Scientific, and Technological Research, and by the European Research Advisory Board.
====================================================================================
Family Practice News
Volume 38, Issue 2, Page 23 (15 January 2008)

Warning Reissued for Fentanyl Deaths, Side Effects

Recent reports of death and life-threatening side effects associated with the fentanyl patch prompted the Food and Drug Administration to once again issue a warning about improper prescribing and use of the transdermal administration.

The last warning came in 2005 after similar reports.

The warning applies to the name brand Duragesic patch (manufactured by Johnson & Johnson) as well as other, generic versions of the patch, and to all dosages, Dr. Robert Rappaport said during a teleconference with reporters.

This particular warning does not, however, apply to other fentanyl formulations.

A warning about the buccal formulation of fentanyl was issued in September 2007. Fentanyl was approved in 1990 for opioid-tolerant patients who had chronic, moderate to severe pain.

The patch is given most commonly to patients who have cancer.

“The fentanyl patches are to be prescribed only for patients who are already tolerant of opioid drug products,” according to Dr. Rappaport.

“Unfortunately, what we are still seeing is that, in some cases, prescribers are giving these patches to patients who are not opioid tolerant, [either] for treatment post surgery, for mild pain, even for a headache. And in those patients this can cause serious and life-threatening respiratory depression.”

Signs of fentanyl overdose include trouble breathing or slow or shallow breathing, slow heartbeat, severe sleepiness, cold or clammy skin, trouble walking or talking, or feeling faint, dizzy, or confused, according to the agency.

Dr. Rappaport, who is the FDA's director of the division of anesthesia, analgesia, and rheumatology products, also emphasized the importance of patient education.

“The prescribers must inform and educate their patients about how to use these products and the dangers of using them in certain ways.

“For instance, [the patches] cannot be used in a setting where they would be exposed to heat, such as in a hot tub, [with] a heating pad, or a heated water bed,” he emphsized, because the high temperatures may increase the amount of fentanyl that reaches the blood stream.

For a full guide to the proper handling, disposal, and replacement of the patches, see www.fda.gov/cder/drug/infopage/fentanyl/fentanyl_apply.pdf.

“We are working with the … manufacturers to continue to add more warnings and cautions on the label and more instructions on the proper use of these products. And we're adding a medication guide that patients will receive with their product at the pharmacy as well,” said Dr. Rappaport.

Although the Food and Drug Administration has said that it did not have available the exact numbers of serious adverse events that have been reported since the last warning, Dr. Rappaport confirmed that at least one event had occurred when a physician prescribed the patch for headache relief, “and it's likely to be a considerably higher number than that.”

In July 2005, the agency issued a similar warning that the patch should be used only in strict accordance with the directions on the product label and in the package insert.

Dr. Rappaport defended the usefulness of the patch in opioid-resistant patients who suffer from chronic pain. However, although these products “fill an important need, improper use and misuse can be life-threatening,” he added.

Health care professionals who encounter any adverse or serious events associated with fentanyl are urged to contact the MedWatch program atwww.fda.gov/medwatch/report/hcp.htmor by telephone at 800-FDA-1088.

=====================================================================================
Family Practice News
Volume 36, Issue 24, Page 5 (15 December 2006)

FDA Warns About Methadone-Related Deaths, Serious Events

Reports of deaths, cardiac arrhythmias, respiratory depression, and other serious adverse events in people treated with methadone for pain prompted the Food and Drug Administration to issue a public health advisory and revise its prescribing information for methadone hydrochloride.

The advisory, which appeared Nov. 27 on the FDA's Web site, states that deaths and life-threatening side effects have been reported in patients just starting treatment with methadone and in those who have switched from other narcotic analgesics to methadone.

“These adverse events are the possible result of unintentional methadone overdoses, drug interactions, and methadone's cardiac toxicities (QT prolongation and Torsades de Pointes),” according to the information for health care professionals also posted on the site. The FDA emphasizes that physicians who prescribe methadone should be familiar with the drug's toxicities and distinctive pharmacologic properties, and that patients on methadone should be closely monitored, particularly when treatment is started and when the dose is adjusted.

The FDA has not changed any requirements governing methadone administration or dosage, according to officials who participated in a teleconference about the advisory. The new label represents the first revision in decades, however, and contains detailed prescribing information not previously available. For example, an expanded section on drug-drug interactions includes drugs that did not exist when physicians started prescribing methadone for pain control in the 1940s. The revision also contains a new table on converting oral morphine to oral methadone for chronic administration.

Conversion tables for other opioids and time frames for methadone rotation are not provided—primarily because these are difficult issues. “Where we did not see consensus in the literature we remained silent,” said Dr. Celia Jaffe Winchell, a team leader for addiction-treatment drugs in the FDA's Center for Drug Evaluation and Research.

Although methadone-related deaths have been on the rise for some years, Dr. Winchell said the FDA decided to act now because recent reports of adverse events and deaths “suggest a lack of information about methadone on the part of prescribers and patients may have played a role.”

These recent reports followed growing use of methadone for chronic pain, according to Dr. Winchell. Starting in the 1970s, methadone prescribing had been largely confined to tightly regulated addiction treatment programs. Over the last decade, calls for better treatment of chronic pain led to resurgence of analgesic use with a wide spectrum of practitioners, not just pain and addiction specialists, starting to prescribe methadone.

“One of the things we are trying to achieve with this series of patient and physician alerts is to educate people about just how complicated the use of methadone can be,” said Dr. Robert Rappaport, director of the FDA's Division of Anesthesia, Analgesia, and Rheumatology Products.

The FDA cannot stop methadone prescribing by physicians who are not pain specialists, Dr. Rappaport said. And even if it could, there are not enough pain specialists to meet the need. Therefore, the agency is seeking to increase knowledge about special properties of methadone that can put patients at risk.

“What we are trying to do is to get the word out to everybody,” Dr. Rappaport said.

Methadone's analgesic effects last for 4–8 hours, but its elimination half-life is 8–59 hours. Because of that, methadone's peak respiratory depressant effects “typically occur later and persist longer than its peak analgesic effects,” according to the FDA.

The agency recommends that physicians evaluate drugs that will be administered with methadone for potential interactions, that the risks of methadone should be carefully weighed against its potential benefits—and that the 40-mg dispersible methadone tablets should not be prescribed for pain, since this formulation is approved only for detoxification and maintenance treatment of narcotic addiction.

Because cross-tolerance between methadone and other opioids is incomplete, switching patients from other opioids to methadone is complex, so patients with a tolerance for other opioids can experience a methadone overdose.

The FDA also recommends that health care professionals who prescribe methadone carefully read and follow the prescribing information for Dolophine, the marketed methadone product, which was revised and approved on Nov. 17. Methadone is approved for moderate to severe pain that is not responsive to nonnarcotic analgesics, as well as for detoxification and maintenance treatment of opioid addiction.

The public health advisory on methadone, new prescribing information, and information for patients and physicians can be found atwww.fda.gov/cder/drug/infopage/methadone/default.htm. Serious adverse events associated with methadone can be reported to the FDA's MedWatch program atwww.fda.gov/medwatch/report.htm, by fax at 800-FDA-0178, or by calling 800-FDA-1088.

Senior Writer Elizabeth Mechcatie contributed to this report.
=====================================================================================
Family Practice News
Volume 38, Issue 1, Page 47 (1 January 2008)

Research Sought on Physicians' Addiction Recovery

CORONADO, CALIF. — Of 104 physicians in New York state who were admitted to substance abuse treatment programs between 2003 and 2004 and were monitored for a mean of 41 months by the state's Committee for Physicians' Health, only 9 (9%) were discharged because of noncompliance with program expectations.

That might spell success at first glance, but at the annual meeting of the American Academy of Addiction Psychiatry, Dr. Marc Galanter emphasized the need for more research to optimize treatment outcomes for physicians in recovery.

“There are still a number of issues to be considered,” said Dr. Galanter, professor of psychiatry and director of the division of alcoholism and drug abuse in the department of psychiatry at New York University, New York. “One is the need for prospective study—following the treatment contemporaneously—which we have yet to see,” he said. “Another is to better understand the role of medication.

Buprenorphine inevitably will be used more widely; however, the question of whether physicians should be allowed to practice while taking opioid maintenance therapy is likely to become a political issue at the state level. Dr. Galanter advised that a more active role for cognitive-behavioral therapy “be studied because this is a modality that is currently regarded as essential to effective treatment.”

Dr. Galanter based his remarks on results from a study he led that sought to provide an independent evaluation of the oversight and rehabilitation of 104 substance-abusing physicians who had completed their monitoring period by the New York State Committee for Physicians' Health (CPH). About 30% of physicians who enroll in the CPH program receive at least 28 days of inpatient treatment. Components of ambulatory management include workplace monitoring, 12-step program attendance, and random urine toxicologies.

The researchers, who were not affiliated with CPH, selected the 104 records at random (Am. J. Addict. 2007;16:117–23). The mean age of the study participants was 42 years, most (96) were male, about half (51) were married, and 66 were employed as physicians at the time of admission.

More than half (59) had a history of substance abuse treatment, and 38 had attended 12-step meetings before program admission. In addition, 33 were in psychotherapy of some sort prior to admission, and 27 were taking psychiatric medications, primarily antidepressants.

“This underlines the importance of psychiatric input and oversight in these programs,” said Dr. Galanter, who is also the editor of the journal Substance Abuse.

The most common primary substance of abuse was alcohol (38), followed by prescription opiates (35). The top five medical specialties represented were anesthesia (22 physicians), internal medicine (11), family medicine (10), obstetrics and gynecology (9), and pediatrics (8).

On average, the overall period of treatment and monitoring was 41 months, and 30 participants required inpatient hospitalization at study entry.

Fifteen physicians did not want to attend 12-step meetings but were pressed by counselors to do so. Of those, nine later went. “The outcome of those pressed to go was not significantly different from that of the other patients,” he said. “So apparently the coercive nature of the treatment in that regard was not compromising to the outcome.”

Of the 104 patients, 38 relapsed as confirmed by urine toxicology or by confirmation from an informed source. Even under good circumstances, some relapse is inevitable before the patient is stabilized, Dr. Galanter said.

“The pressure of the needs of public health that they experience puts them in a difficult position,” Dr. Galanter said. “My impression is that it's remarkable how effective they are in balancing the physician needs against the demands of the general public.”

Predictors of relapse included past use of cocaine, unemployment at the time of program admission, a greater mean number of urines tested, and a longer length of program involvement.

Nine patients were discharged for noncompliance with program expectations. “They essentially lost the option of practicing medicine,” he said. “Relatively speaking, this gives you an idea of a very good outcome, considering that full compliance is essential to success in this program.”

Letter To The Editor

2007-12-27T08:37:00.001-08:00

Attached a letter to the editor sent to the Miami Herald, Sun Sentinel and SunPost in response to their articles about prescription drug abuse.

LETTER

Prescription opioid use and dependence reached a record high threatening the public health of our society.
North America, with 4 percent of the world population consumes more than 50 percent of the world's supply of morphine and narcotic prescription drugs! It is unlikely that Americans suffer from an opioid deficiency syndrome but are using them for any aches or pains for which those drugs are not intended for.
The prescription of those drugs are strictly regulated by the Drug Enforcement Administration (DEA) but they can be easily obtained from unscrupulous black marketeer selling those drugs via the Internet, drug dealers and also from self-declared pain specialists, better described as " drug dealers in white coats", who advertise their services on backpages of local newspapers.
Many doctors who appropriately prescribe pain medications are caught between the regulatory scrutiny of law enforcement agencies, and the demands of their patients for immediate pain relief. Most of us rely on the information supplied by the patient and cannot verify the accuracy of the information. Those doctors are then blamed for an overdose death and as a result are increasingly reluctant to issue pain medications.
Therefore, we need to built in safe guards to protect physicians and patients by creating a state-wide prescription drug database to identify and to curb narcotic prescription drug abuse. Such legislation would save countless lives and protect physicians and patients who legitimately require appropriate pain management modalities. The legislation should also include the narcotic pain medications dispensed in doctors offices. Otherwise, doctor shoppers will use those pill mills in medical practices to feed their addiction.

Bernd Wollschlaeger,MD
President of the Florida Society of Addiction Medicine
16899 NE 15th Avenue
North Miami Beach,L 33162
Phone: 305-940-8717

Prescription Drug Abuse in the News

2007-12-27T08:35:00.000-08:00

Attached another article from a local newspaper regarding the prescription drug abuse.
According to the Florida Department of Law Enforcement I2007 Interim Report Prescription drugs (76%) are found to dominate at lethal levels when compared to illicit drugs (24%). Prescription drugs are also found to be the majority of non-lethal occurrences at 64% in contrast to illicit drugs at 36%. The prescription drugs tracked in this report are: all Benzodiazepines, Carisoprodol/Meprobamate, and all Opioids except Heroin.
As an organization we need to speak up and especially point the finger on those "drug dealers in white coat" aka our fellow colleagues, who run lucrative pill mills that readily supply drugs to anyone who is willing to pay.As long as we hesitate calling them what they are, drug dealers, we will NOT address the problem.
The silence of the medical profession will encourage those " doctors" to continue their business.
Now its time to speak up!
Yours
Bernd

SUNPOST 12/20/07

Prescription for Death

Prescription drugs claim more lives than cocaine and heroin combined

By Angie Hargot

Photo illustration by James Wilkins

Florida corpses are telling a disturbing tale — and they’re using terms like blow, smack or meth less often than harder-to-pronounce, and more deadly, prescription drugs.

Prescription drug use isn’t just increasing in Florida — it’s killing nearly three times more people than cocaine, heroin and methamphetamines combined, in part because of a growing supply of street pharmaceuticals.

In the first six months of this year, cocaine, heroin and methylated amphetamines caused the deaths of 470 people statewide, while the five most commonly prescribed painkillers and tranquilizers caused 1,324 deaths, according to a Florida Department of Law Enforcement report detailing drug use identified by state medical examiners during autopsies.

Cocaine, the state’s deadliest substance, killed 398 people statewide, while heroin killed 38 and methylated amphetamines killed 34, according to the report.

However, during the same time period, methadone, a drug often prescribed to heroin addicts, killed 392 people; benzodiazepines, which include widely prescribed tranquilizers such as Valium and Xanax, 353; oxycodone, commonly sold as OxyContin, 323; hydrocodone, a painkiller often prescribed as Vicodin and Lortab, 134; and morphine, 122.

“We’ve become a medicated society,” said Howard Lerner, clinical director of South Miami Hospital’s substance abuse treatment program. “Ten years ago, we never saw drugs marketed on TV. Now they’re selling them like McDonald’s hamburgers. The availability is a progression of the numbers. Many more people are attracted to it.”

‘Lethal Levels’

Of the 87,500 people who died in Florida between January and June, medical examiners detected drugs in the systems of 3,980 corpses at the time of autopsy — nearly 5 percent more than in the second half of 2006, according to the Dec. 4 report.

Yet prescription drugs, which “dominate at lethal levels when compared to illicit drugs,” accounted for 69 percent of all the drugs found at autopsy — 2 percent more than in the previous six-month period, according to the report.

“In general, there is certainly an increase across the board” in prescription drug use and abuse, Lerner said. “Because of an increase in marketing, there’s a lot more usage. “Younger people are selling them on the streets.”

That doesn’t mean illicit street drugs more commonly associated with overdoses aren’t still killing plenty of Floridians, either directly or indirectly.

Take cocaine, for example. Medical examiners detected various amounts of cocaine in 1,008 corpses statewide, of which it killed 398. Yet, 13 percent of the 610 who died with nonlethal levels of cocaine in their systems were homicide victims.

In Miami-Dade County, the narcotic was found during 84 autopsies and caused 16 deaths.

“The leading causes of death in this country are all drug-related — alcohol, murder …,” said Jay M. Holder, a board-certified addictionologist who runs the Exodus Treatment Center in Miami.

In fact, 57 percent of the 59,000 people arrested by the Miami-Dade County Narcotics Bureau in the last year had records of violent crimes and robberies. Even more had theft and burglary records, said Major Charles Nanney, whose bureau polices everything from marijuana grow houses to a burgeoning MySpace market for MDMA, more commonly known as ecstasy.

“There is a crime-drug nexus,” Nanney said. “The main use is still cocaine and heroin. Twenty-five years ago a kilo of coke was $50,000. Now the price is lower.”

Rx Factor

Still, the growing number of prescription-related deaths has garnered much concern among government and law enforcement officials, as well as substance abuse counselors. The problem, according to Nanney, “comes down to availability.”

There’s no doubt the findings are troubling.

“We have seen an increase in prescription drug deaths in recent years,” FDLE spokesperson Kristin Perelluha said.

Although heroin, which killed 84 percent of the 45 people with the drug in their systems, topped the list of the state’s most lethal drugs — those that caused death in more than 50 percent of people in which it was found — methadone, oxycodone and fentanyl followed closely behind.

Methadone, which is often prescribed to treat the pain associated with heroin withdrawal, caused the deaths of 354 more people than heroin statewide. It killed 392 — nearly 74 percent — of the 533 people in whom the substance was found. Methadone was found in eight Miami-Dade decedents, of which it killed three.

The report also noted a 5 percent increase in the use of benzodiazepines, the most widely prescribed and detected prescription drug. Benzodiazepines killed 353 — 30 percent — of the 1,167 people in whom it was found, including 260 from alprazolam alone, which is often sold under the trade names Xanax and Niravam.

“What we’re seeing is the same individuals with cocaine and heroin addiction, now also with a whole litany of prescription drugs,” Holder said, adding that time-released medications are particularly dangerous when mixed with alcohol. “OxyContin is very powerful. An addict will chew that, and it’s 100 percent absorbed immediately, bypassing the time-release.”

Use of oxycodone, the painkiller often marketed under the brand name OxyContin, increased 9 percent from last year, killing 323 — about 57 percent — of the 568 people in whom the substance was found, including six of nine in Miami-Dade. The pills sell for $20 to $30 each on the street, said Nanney, who, in his 20 years of service, has arrested several doctors for selling OxyContin prescriptions.

“There has been a crackdown on oxycodone and OxyContin,” Lerner said, adding that prescriptions often fall into the hands of some abusers who go “doctor shopping,” frequenting different doctors and getting prescriptions for pain medications from each of them. That tactic can also lead to overdoses even for those prescribed the medication for genuine ailments. Taking them with alcohol can cause respiratory failure, for example.

The street pharmaceutical market also carries a unique problem: dosing. “It’s not logical,” Nanney said. “Someone might know ‘I can take this much cocaine,’ for example, but the same size pill could be 20 mg or 40 mg. It’s easy to overdose.”

Hydrocodone, a painkiller prescribed under the brand names Vicodin and Lortab, caused the deaths of 134 users statewide, though it was found in 380 bodies. It killed one of two deceased Miami-Dade users.

Morphine, another painkiller, killed 122, or nearly half of the 280 deceased users statewide, and half of the 10 users in Miami-Dade.

Fentanyl, a pain reliever sold under the name Actiq, which is 80 times more potent than morphine and often administered via a mouth swab or lollipop to facilitate speed of absorption, killed more than half of the 103 people who had it in their systems.

Many hospitals have recently pushed to better control the prescription of opiates, Lerner said, the use of which continues to increase. Medical examiners detected a 27 percent increase in one opiate-based painkiller, hydromorphone, which is two to eight times stronger than morphine and marketed under the trade name Dilaudid.

Some of these drugs, Lerner said, are sold by unethical doctors who “open clinics to distribute meds to anyone who has the money to pay for them.”

Both Holder and Lerner, who mostly counsel patients for cocaine and alcohol problems, said that they also see patients with addictions who are taking prescription drugs according to their doctor’s instructions, who prescribed them without asking enough questions about the indicators of a possible addiction.

Behind the Eight Ball

Still, Florida is one of few states that does not track prescriptions. So far, 35 states have passed legislation to create prescription monitoring systems, with at least 24 of them already in use. The Florida Legislature has routinely rejected similar efforts for the last six years, citing privacy issues.

However, some state lawmakers now want to implement a pilot program that would create a $1.6 million computerized monitoring system to track painkiller prescriptions in Broward County. The proposed system, which would be funded with private money and federal grants, would keep patient medication records that could be accessed by doctors, pharmacists, patients, law-enforcement agencies and the Agency for Health Care Administration.

“If you open the New Times and look at the local ads, a significant percentage are pain management clinics that even specifically say ‘OxyContin’ in their ads,” Holder said. “Basically they are saying, ‘Come get your prescription.’ What’s killing people may not be the drugs, but the doctors that give patients the drugs.”

Comments? E-mail angie@miamisunpost.com.

Pain and Addiction in the news

2007-11-04T16:55:00.000-08:00

Dear Friends and Colleagues:
Attached you find an e-mail from Dr. Andrea Trescot and a link to a congressional hearing "NASPER: Why Has the National All Schedules Prescription Electronic Reporting Act Not Been Implemented?"
I am very proud of Dr. Trescots accomplishments and was honored working with her on the FMA Pain Journal http://www.fmaonline.org/education/PainJournal2006.pdf project which was forwarded to the committee members.
We all need to work together to stop the epidemic of pain medication abuse. Why do US citizens who comprise 4% of the world population consume >90% of the worlds Hydrocodone supply!!!!!
Now is time to act to take measures to stop the rampant abuse of pain medications without jeopardizing the access to medications of those in need.
FSAM will participate in an outreach program to educate physicians from other specialty societies about this issue.
We need to work together and make change happen.
Yours
Bernd

===========================================================================
> My testimony before the House Committee on Energy and Commerce can be found at http://energycommerce.house.gov/cmte_mtgs/110-oi-hrg.102407.NASPER.shtml.
> The full download is about an hour and a half; my testimony starts about 1:20. After my 5 minute statement, you will hear the questions by Rep Whitfield, who holds the journal up for the cameras. A copy of the journal may be going to the White House.

FSAM: Where Are We Today?

2007-10-29T19:48:00.000-07:00

Dear Friends and Colleagues:
I just returned from an ASAM Chapter Council meeting (10/27-10/28/07) in Washington and want to share some of my observations and thoughts with you.
Almost thirty representatives from eleven state, two regional chapters and one international chapter were present for the two-day meeting.
With 136 chapter members Florida has met its 2007 recruitment goal - more can be achieved - and now ranks No.3 after California and New York.
Among others we discussed:
1) MAKING OF OUR MEDICAL SPECIALTY: hopefully, most of you know that ASAM has founded the American Board of Addiction Medicine (ABAM) and has created the 14-member Medical Specialty Action Group, yours truly included, to select specialty directors to serve on the new board. This is a tedious and long process but we anticipate that within 3-15(?) years we will have established the specialty of addiction medicine. We heard a detailed report by Kevin Kunz regarding the progress made and please contact me for further details.
2) PARITY ISSUES: Ken Roy provided us with a superb overview of the status of two bills in the House (HR 1424) and Senate (S 558) and he outlined the pros and cons of both versions. At this point in time ASAM is pleased that both chambers of congress deal with the issues of Mental Health and Addiction Treatment parity. ASAM prefers and supports the House version and is concerned about the many flaws contained in the Senate version. If those bills pass both chambers of congress they will be discussed in the conference committee to find a compromise version. We will keep you posted about the progress made.
3) ADOPT A RESIDENCY: Norm Wetterau presented a program that intends to improve the education in primary care regarding addiction medicine related issues by adopting a residency program to precept student, train faculty and to help make changes in the residency that would improve treatment of addictive diseases. Some of you may already pursue similar activities and I suggest that we all pool our experience and resources to improve the outcome of our efforts.
4) CAPITOL CAMPAIGN: develop a program that will raise funds to support ABAM, Parity efforts, he work of the chapters council and other projects. We also heard a presentation from a consultant group in Washington how to obtain federal funds to finance and support projects on state and national level. I will forward more detailed information and a project proposal, which we should submit for funding through federal earmarks. Project examples could include substance abuse counseling at schools, specific substance abuse counseling and treatment programs etc.

I also want to remind you that I persistently pursue the realization of the following goals set by my person at the beginning of my presidency:

1.Reorganize FSAM as a full-service membership organization promoting the interest of healthcare professionals involved in addiction care, research and treatment.
STATUS: Formation of a membership committee (pending) and development of a recruitment and retention program. VOLUNTEERS WANTED!!

2.Promote excellence of care in addiction medicine through education and training of physicians and other allied healthcare professionals.
STATUS: We develop and prepare an enhanced and improved annual meeting.

3.Achieve cooperative relationships with other medical specialties to foster the integration of screening and intervention modalities in patient care.
STATUS: All THREE FSAM resolution submitted at the FMA Annual meeting (Parity included) passed including SBI efforts to be supported by the FMA.

4.Create a FSAM Political Action Committee (PAC), educate political decision makers about the importance of sustainable funding mechanism for community based addiction treatment modalities and advocate for the promotion of addiction care and research in primary care.
STATUS: PENDING. VOLUNTEERS NEEDED. We have developed a close working relationship with a legislator (Florida House Representative Ed Homan) who has introduced a Metal Health Parity bill in the House. We not only need to support him verbally but also FINANCIALLY!!!

5.Establish a planning committee to design a strategic plan outlining the vision of our organization for a statewide drug control and treatment program.
STATUS; PENDING. IDEAS? VOLUNTEERS?

PLEASE CONTACT ME VIA E-MAIL info@miamihealth.com or PHONE (305)940-8717 FOR MORE INFORMATION, YOUR QUESTIONS OR SUGGESTIONS.
YOURS
Bernd

JOURNAL CLUB

2007-10-10T22:14:00.000-07:00

Dear Friends and Colleagues:
Attached a very interesting article regarding the promising results of a study using Topiramate for the treatment of alcohol dependence. For more information see http://jama.ama-assn.org/cgi/content/full/298/14/1641.
The authors conclude that:
"Our finding in this study that topiramate is a safe and consistently efficacious medication for treating alcohol dependence is scientifically and clinically important. Alcoholism ranks third and fifth on the US and global burdens of disease, respectively. Discovering pharmacological agents such as topiramate that improve drinking outcomes can make a major contribution to global health. Because topiramate pharmacotherapy can be paired with a brief intervention deliverable by nonspecialist health practitioners, a next step would be to examine its efficacy in community practice settings."

Looking forward to your comments.
Yours
Bernd

============================================================================

Topiramate for Treating Alcohol Dependence
A Randomized Controlled Trial

Bankole A. Johnson, DSc, MD, PhD; Norman Rosenthal, MD; Julie A. Capece, BA; Frank Wiegand, MD; Lian Mao, PhD; Karen Beyers, MS; Amy McKay, PharmD; Nassima Ait-Daoud, MD; Raymond F. Anton, MD; Domenic A. Ciraulo, MD; Henry R. Kranzler, MD; Karl Mann, MD; Stephanie S. O’Malley, PhD; Robert M. Swift, MD, PhD; for the Topiramate for Alcoholism Advisory Board and the Topiramate for Alcoholism Study Group

JAMA. 2007;298:1641-1651.

ABSTRACT

Context Hypothetically, topiramate can improve drinking outcomes among alcohol-dependent individuals by reducing alcohol's reinforcing effects through facilitation of -aminobutyric acid function and inhibition of glutaminergic pathways in the corticomesolimbic system.

Objective To determine if topiramate is a safe and efficacious treatment for alcohol dependence.

Design, Setting, and Participants Double-blind, randomized, placebo-controlled, 14-week trial of 371 men and women aged 18 to 65 years diagnosed with alcohol dependence, conducted between January 27, 2004, and August 4, 2006, at 17 US sites.

Interventions Up to 300 mg/d of topiramate (n = 183) or placebo (n = 188), along with a weekly compliance enhancement intervention.

Main Outcome Measures Primary efficacy variable was self-reported percentage of heavy drinking days. Secondary outcomes included other self-reported drinking measures (percentage of days abstinent and drinks per drinking day) along with the laboratory measure of alcohol consumption (plasma -glutamyltransferase).

Results Treating all dropouts as relapse to baseline, topiramate was more efficacious than placebo at reducing the percentage of heavy drinking days from baseline to week 14 (mean difference, 8.44%; 95% confidence interval, 3.07%-13.80%; P = .002). Prespecified mixed-model analysis also showed that topiramate compared with placebo decreased the percentage of heavy drinking days (mean difference, 16.19%; 95% confidence interval, 10.79%-21.60%; P < .001) and all other drinking outcomes (P < .001 for all comparisons). Adverse events that were more common with topiramate vs placebo, respectively, included paresthesia (50.8% vs 10.6%), taste perversion (23.0% vs 4.8%), anorexia (19.7% vs 6.9%), and difficulty with concentration (14.8% vs 3.2%).

Conclusion Topiramate is a promising treatment for alcohol dependence.

Membership Issues

2007-09-26T19:45:00.001-07:00

Dear Friends and Colleagues:
I have participated in todays ASAM Membership Committee conference call.
Membership recruitment and retention is essential for the viability of our organization and we need to extend every effort to speak to those doctors who have yet to renew their dues.
I will therefore assist John to identify those members to be called ASAP to renew their membership.
I also consider it as a priority to form a membership committee to develop a membership recruitment and retention plan.
It is of interest to note that residents (physicians in postgraduate training programs) only comprise 5% of the total ASAM membership.
We need to attract those physicians early in their career and convey to them the message that addiction medicine may be a career choice in the future.
With the formation of ABAM (American Board of Addiction Medicine) and the subsequent creation of addiction medicine fellowships I see a unique opportunity to attract those physicians towards our profession.
All of these issues should be dealt with by an active and strong membership committee co-chaired by the Chapter President.
What are your thoughts regarding this issue?
Yours
Bernd

Science Of Addiction: A JAMA Book Review

2007-08-14T14:16:00.000-07:00

The Science of Addiction: From Neurobiology to Treatment

By Carlton K. Erickson, 288 pp, $32.
New York, NY, WW Norton Professional Books, 2007.
ISBN-13 978-0-3937-0463-1.

JAMA. 2007;298:809-810.

The term "addiction" commonly triggers stereotypic misperceptions about the compulsive, out-of-control use of illicit drugs resulting from a perceived amendable behavioral flaw. In 1988, the United States Supreme Court in a disputed decision declared alcoholism to be "willful misconduct." However, several decades of comprehensive genetic and neurobiological research have provided indisputable evidence that addiction is brain disease resulting from mesolimbic brain dysregulation that, if diagnosed in a timely fashion, can be properly treated. Addiction meets all characteristics of the disease concept, ie, (1) a clear biological basis; (2) unique, identifiable signs and symptoms; (3) a predictable course and outcome; and (4) the inability to control the cause of the disease.

In this context, Erickson's book provides a compelling overview of the "science of addiction" and superbly summarizes the state of the art of addiction medicine. In 10 easy-to-read chapters, the author guides the reader through basic neuroanatomy, neurobiology, and neurochemistry; the pharmacology of different drugs of abuse, including alcohol, depressants, and stimulants; current treatment algorithms; the strategies of addiction research; and the future outlook of the evidence-based research principles.

The text begins with a challenge of the terminology and characterization of "addiction," calling it unscientific, broad, too vague, and stigmatized. According to the author, the term provokes "pejorative misperceptions," and he uses the term "chemical dependence" instead to properly identify the impaired control over the drug use, the defining hallmark of this brain disease. He also suggests separating the colloquial term "addiction" from the scientific terminology of "chemical dependence," thereby not precluding its use but understanding its limitation. Erickson emphasizes that "the reluctance to define addiction as a disease stems partly from a desire to hold drug users accountable for their actions," and that "any approach that tries to understand addiction from a purist or unitary view misses other key components." Chemical dependence is a "compulsive, pathological, impaired control over drug use, leading to an inability to stop using drugs in spite of adverse consequences."

Drugs with a dependence liability not only produce a positive mood but trigger the mesolimbic dopamine system, resulting in an activation of the so-called "reward pathway." Neuroscientists believe that in some individuals the function of these neurotransmitter systems is disrupted due to genetic "miswiring," long-term exposure to a drug, or—more likely—a combination of genetic heritability, drug exposure, and environmental influences. This may explain why any drugs of abuse can induce dependence in susceptible individuals but not for every person who may use them occasionally or who has abused them during their lifetime.

The detailed review of the basic science of chemical dependence provides ample evidence that the dysregulation in the mesolimbic dopamine system constitutes the disease, just as poor dopamine function in the basal ganglia is the etiologic cause of Parkinson disease. Therefore, drug-seeking and drug-taking are only the symptoms of the disease, just as muscle rigidity and tremors are only the symptoms of Parkinson disease.

The author also provides a brief but comprehensive overview of the genetics of chemical dependence. Family, twin, and adoption studies demonstrate that genetic factors contribute to the risk of alcoholism. Scientists have identified some possible causative genes and certain risk genes which, in susceptible individuals exposed to drugs of abuse, may activate a cascade of neurochemical events leading to chemical dependence. The argument that chemical dependence is a brain disease, comparable to other brain diseases, begs the question about similar treatment approaches.

Erickson correctly emphasizes that any treatment approach cannot rely on pharmacological solutions alone. The treatment must be individualized and should take so-called harm reduction strategies, also known as harm minimization, into consideration. Such an approach includes methadone maintenance and needle-exchange programs that often ruffle the feathers of the proponents of abstinence-based programs.

In the last few years, new pharmacological treatments have broadened the opportunities for the outpatient management of patients with chemical dependencies. For example, anticraving, antirelapse, and abstinence-enhancing medications are now part of the treatment armamentarium for alcohol dependence and include naltrexone, acamprosate, and topiramate. The US Food and Drug Administration approval of buprenorphine for the treatment of opioid dependence extends the treatment outreach from federally approved methadone clinics to almost all physicians who have completed an 8-hour certification course.

In the remainder of the book, Erickson reviews the scientific methodology of addiction research and the exciting results of brain imaging studies in chemical dependence. These include positron emission tomography, functional magnetic resonance imaging, and single-photon emission computerized tomography. The imaging modalities illustrate that drug treatment as well as the anticipation of the active drug itself can trigger neurochemical changes and are valuable tools for studying the effectiveness and compatibility of interactional behavioral interventions and pharmacotherapy.

Unfortunately, the author has missed the opportunity to discuss the screening and brief intervention methods that can be incorporated into the clinical practice identifying patients at risk for chemical dependence. For example, the National Institute on Alcohol Abuse and Alcoholism has published valuable screening and brief intervention tools on its Web site1 that can assist health care professionals in risk stratification strategies for patients with chemical dependence. However, the book provides the knowledge that chemical dependence is a brain disease, and an understanding of this disease concept of addiction ensures that millions of individuals with chemical dependence can now receive appropriate and suitable treatments.

In summary, I recommend this excellent book as a "must-read" for any medical student, physician, or other allied health professional dedicated to the care of their patients with the treatable disease of addiction.

Financial Disclosures: None reported.

Bernd Wollschlaeger, MD, Reviewer
University of Miami
Miami, Florida
info@miamihealth.com

REFERENCES

1. National Institute on Alcohol Abuse and Alcoholism. A Pocket Guide for Alcohol Screening and Brief Intervention. http://pubs.niaaa.nih.gov/publications/Practitioner/PocketGuide/pocket_guide.htm. Accessibility verified July 18, 2007.

Book and Media Reviews Section Editor: John L. Zeller, MD, PhD, Contributing Editor.

Upcoming Events

2007-08-09T08:34:00.000-07:00

Dear Friends and Colleagues;
I want to inform you about two upcoming events:

1. August 22-24th, 2007, Florida Alcohol And Drug Abuse Association, Orlando Florida

* Stacy Seikel, August 22nd,6:30PM - 10:00 PM Presentation about
"Prometa, A Treatment Program for Methamphetamine,Cocaine and Alcohol
Addiction"

1. August 24th-27th, 2007, FMA Annual Meeting, Hollywood, Florida

* Reference Committees will discuss three FSAM resolutions

Please call me for any questions or further information.
Yours

Bernd

California To end Physicians Monitoring Program

2007-08-07T18:30:00.000-07:00

Dear Friends and Colleagues:
Attached some info regarding a very troublesome development in California.
Yours truly,
Bernd
============================================================================
Calif. To End Program for Addicted Doctors
August 7, 2007
News Summary

The Medical Board of California has decided to end its diversion program for doctors who are grappling with addiction problems, the San Diego Union-Tribune reported Aug. 5.

The decision came in the wake of a report that concluded that the 27-year-old diversion program didn't do enough for addicted doctors and failed to protect patients. The program is scheduled to end next June unless the board decides to somehow overhaul it.

If the program ends, California would be the only state in the U.S. without a diversion mechanism for addicted doctors.

Under the program rules, doctors who confidentially sought help with addiction problems could keep their licenses if they attended treatment and self-help groups, and submitted urine tests. The Medical Board appoints a monitor to keep track of their progress, but the report said oversight was lacking.

Research showed that about 18 percent of doctors who entered the program completed treatment, far short of the 90 percent completion rate in North Carolina, for example.

Jeoffry Gordon, a past president of the Medical Board, said the state should offer some type of treatment to doctors. Others suggested that physicians be barred from practicing for six months while they get treatment.
============================================================================

Chantix For The Treatment Of Alcohol Addiction?

2007-07-10T22:03:00.000-07:00

Anti-smoking drug Chantix works for alcohol too
Medical Studies/Trials
Published: Tuesday, 10-Jul-2007

According to researchers a popular anti-smoking pill may also curb the urge to drink alcohol.

The drug varenicline is already on the market under the brand name Chantix to help smokers kick the habit but new preliminary research now suggests it could also be useful in helping heavy drinkers quit.

The research which was carried out on rats provided the rodents with intermittent access to 40 proof alcohol for four months and by varying the access to the liquor supply the rats were made to crave it.

The researchers say every time the rodents had access to booze, they upped their intake and drank all day and withdrawing the alcohol made them want to drink even more.

After months of this behaviour and a total of 37 binge-drinking sessions, all the rats cut their drinking in half when given varenicline.

When taken off the drug, the rats did not immediately imbibe more, a rebound effect that has affected other treatments.

Varenicline has been available as a smoking cessation aid for nearly a year in the U.S. and the European Union, and as well as being safe it does not suppress the appetite and is not metabolized in the liver.

Bartlett says this is a major plus because long term drinkers often have liver damage.

According to the researchers the drug targets a pleasure center in the brain and has the potential to be considered as a treatment for addictions such as gambling and painkillers.

Varenicline works by latching onto the same receptors in the brain that nicotine binds to when inhaled in cigarette smoke, an action that leads to the release of dopamine in the brain's pleasure centers; the drug blocks any inhaled nicotine from reinforcing that effect.

The new study suggests alcohol also acts on the same locations in the brain and varenicline, might be equally as effective for curbing drinking.

Selena Bartlett, a University of California neuroscientist who led the study says the drug has already proven itself safe for people trying to stop smoking and is now a potential drug to fight alcohol dependence.

Experts say smoking and drinking often go together and a single drug able to tackle both addictions is not surprising.

The researchers at the University of California along with the National Institute on Alcohol Abuse and Alcoholism, plan to conduct clinical trials in humans of the drug's effectiveness in curbing alcohol cravings and dependence.

The drug is already approved by Food and Drug Administration and this should speed the process up.

But skeptics warn that varenicline does not work for all smokers and it's highly unlikely it will work for all drinkers and some experts insist there is a common biological basis for addictions to both alcohol and tobacco.

Although drug company Pfizer provided the drug for the study it was not involved in the research and is apparently undecided whether to seek broader FDA approval for the drug.

The study is published in the journal Proceedings of the National Academy of Sciences.

Addiction Research In The News

2007-07-10T21:56:00.000-07:00

I hope you didn't miss todays (07/10/07) great interview with Dr. Volkow on NPR (Fresh Air) entitled "No,really, this is your brain on drugs."
Nora Volkow, director of the National Institute on Drug Abuse, ranks as one of the U.S.'s leading addiction researchers. She's helped demonstrate that addiction is in fact a disease — a disease of the brain — and that all addictions, whether it's to drugs, alcohol, tobacco, sex, gambling or even food, are more alike than was previously thought.Volkow, who's the great-granddaughter of Russian revolutionary Leon Trotsky, grew up in Mexico City — in the house where her famous ancestor was assassinated.
Very informative and fascinating.
A MUST for anybody who is interested in addiction and want to draw others towards other profession.

LINK: http://www.npr.org/templates/story/story.php?storyId=11847222

Yours

Bernd

Buprenorphine Use In the US

2007-06-25T12:55:00.000-07:00

The First Three Years of Buprenorphine in the United States: Experience to Date and Future Directions.

Review Article, Journal of Addiction Medicine. 1(2):62-67, June 2007. Fiellin, David A. MD

Abstract: Buprenorphine, primarily as the buprenorphine/naloxone combination, has been available in the United States for office and specialty treatment program-based care since 2003. The existing evidence, collected primarily from federal sources, indicates that access to this type of treatment has expanded, that more than 50% of the 12,000 physicians able to provide this care are not addiction specialists, that buprenorphine diversion is low, that physician scrutiny by federal agents is infrequent, and among those receiving treatment patient acceptance is high. Implementation has been slowed because of physician training and support needs, reimbursement, and limits on the number of patients each physician can treat. As a result there are geographic variations in access and unmet treatment needs. The United States Congress has moved twice to loosen numerical limitations, now allowing each physician to treat up to 100 patients. Future research and evaluation are needed to ensure that opioid-dependent patients receive optimal care with buprenorphine.

(C) 2007 American Society of Addiction Medicine

Buprenorphine: The Basic Pharmacology Revisited.

Invited Review
Journal of Addiction Medicine. 1(2):68-72, June 2007.
Cowan, Alan PhD

Abstract:
The historical background leading to the current use of buprenorphine as an analgesic and its role in the management of opioid dependence is summarized. The popular description of buprenorphine as a "partial agonist" is discussed in relation to efficacy in animal models of antinociception and clinical analgesia. The latest information on the respiratory depressant effects of buprenorphine and its N-dealkylated metabolite (norbuprenorphine) is presented. New data on the buprenorphine withdrawal syndrome in rats are described.

(C) 2007 American Society of Addiction Medicine

Is Compulsive Gambling an Addiction?

2007-06-25T12:54:00.001-07:00

AMA Won't Call Compulsive Gaming 'Addictive'
June 25, 2007

There's not enough evidence to suggest that compulsive video-game playing rises to the level of addiction as with alcohol or other drugs, according to the American Medical Association (AMA).

Reuters reported June 24 that an AMA panel dropped a proposal to include video game addiction in the American Diagnostic and Statistical Manual of Mental Disorders (DSM).

"There is nothing here to suggest that this is a complex physiological disease state akin to alcoholism or other substance abuse disorders, and it doesn't get to have the word addiction attached to it," said Stuart Gitlow of the American Society of Addiction Medicine and Mt. Sinai School of Medicine in New York.

The proposal was debated at the recent AMA annual meeting in Chicago. The study panel recommended that the issue of video-game addiction be revisited when the next revision of the DSM is due, in five years.

Some doctors argued strongly for inclusion of video-game addiction. "Working with this problem is no different than working with alcoholic patients. The same denial, the same rationalization, the same inability to give it up," said Thomas Allen of the Osler Medical Center in Towson, Md.

FSAM Resolutions Gain Support

2007-06-19T21:59:00.001-07:00

Dear Friends and Colleagues:
GOOD NEWS!!!!!
I presented the FSAM to the South Florida Caucus, representing an influential and sizeable voting block of ~50 delegates .
All resolution were adopted and will be supported by the three largest county medical societies in Florida (Dade, Broward, Palm Beach).
Now we have to continue the political battle at the state medical society meeting in Miami in August.
I will attend the AMA Annual meeting in Chicago this weekend and (among many other issues) will lobby support for the ABAM (American Board of Addiction Medicine) .
As of tomorrow our resolutions will be part of the FMA Delegates handbook and listed as sponsored by FSAM, Dade, Broward and Palm Beach Medical Societies. Stacy is trying to gain the support of the Orange County Medical Society.

Yours
Bernd

PS: Attached you find some more information about my book, which was featured today on the frontpage of the Miami Herald http://www.miamiherald.com/460/story/144059.html .

Web Site: www.agermanlife.com

UDDL Repeal In Florida

2007-06-18T21:51:00.000-07:00

Dear Friends and Colleagues;
Attached some background info regarding the UDDL status in Florida:
======================================================================================
Section 627.629,Florida Statutes (2000), permits an insurance company to include the following exclusion in a health insurance contract "Intoxicants and Narcotics: The insurer will not be liable for any loss resulting from the insured being drunk or under the influence of any narcotic unless taken on the advice of a physician."A person is "drunk" when operating a motor vehicle if he or she has a blood alcohol level of .08 gram per alcohol per 100 milliliters of blood. See § 316.193, Fla. Stat. (2000). Even though driving under the influence is a crime in Florida, there currently is no statutory authorization for an alcohol exclusion in a Florida No-fault Automobile Insurance PIP policy. See § 627.736(2), Fla. Stat. (2000). When the no-fault laws were first enacted, the legislature did permit an alcohol exclusion in a PIP policy if the circumstances involved a conviction for DUI. See ch. 71-252, § 7, Laws of Fla. See also Travelers Indem. Co. of Am. v. McInroy, 342 So. 2d 842 (Fla. 1st DCA 1977). Experience with that exclusion caused the legislature to withdraw its authorization in 1982. See ch. 82-243, § 554, Laws of Fla. Unfortunately, a Florida Supreme Court decision from 2001 is blocking the UDDL repeal:
"CONCLUSION: Ms. Steck had a blood alcohol level more than three times the legal limit for driving while intoxicated when she walked into Dale Mabry Highway, a major Tampa thoroughfare, and was struck by a car. Any reasonable, disinterested third party would agree that her injuries suffered in the accident resulted from her drunkenness.
The polestar for interpreting statutes is legislative intent. Statev. Webb,398 So.2d 820, 824 (Fla. 1981). The Legislature permits health insurers to exclude losses,which result from the commission of felonies or engaging in an illegal occupation. Can anyone reasonably believe that when Section 627.629 was enacted to permit exclusions“for any loss resulting from the insured being drunk,” the Legislature intended for this
exclusion to be limited only to biological effects upon the body from the use of intoxicants?
This Court should follow Harris, should specifically reverse Mason II, and should hold that the drunkenness exclusion authorized by Section 627.629, Florida Statutes and included in Ms. Steck’s policy excludes coverage for all expenses caused, either directly or indirectly, by her walking into the path of oncoming traffic while drunk. The summary judgment on liability in favor of Ms. Steck should be reversed, and this case should be remanded with directions that summary judgment be entered in favor of BCBSF in regard to all expenses incurred to treat injuries sustained
in the June 29, 1997 accident.
=====================================================================================

Looking forward to your comments.
Bernd

Is Alcohol Cardioprotective?

2007-06-18T20:56:00.000-07:00

Drink to your health - is alcohol really cardioprotective?

In the April 2007 edition of the New Zealand Family Physician is a clinical review Drink to your health is alcohol really cardioprotective? by Graham Gulbransen and Ross McCormick which begins: A convenient and widely held belief is that a few drinks are good for the heart. This view is based largely on epidemiological studies similar to those that mistakenly showed that menopausal hormone replacement therapy (HRT) was cardioprotective. Because of confounding and misclassification, non-randomised uncontrolled studies can never confirm such beliefs. This article reviews the medical literature on alcohol and coronary heart disease (CHD), looking at evidence for and against cardioprotection.

The review starts with an introduction:
"In 1926 Raymond Pearl first described the J-shaped alcohol-mortality curve: moderately alcoholised fowls had the lowest mortality, followed by those not exposed, with heavily alcoholised fowls having the highest mortality!

"In the past 30 years more than 100 epidemiological studies have suggested that moderate alcohol consumption (in humans!) is cardioprotective. In New Zealand we follow the Alcohol Advisory Council of New Zealand guidelines that define safer or moderate drinking as up to 20 grams of alcohol daily for women and 30 grams for men. However, a 1987 Lancet editorial, Dying for a Drink urged caution, The higher mortality among abstainers has not been fully explained but may well be a spurious finding in a group of men who may be at higher risk for other reasons The U [J] shaped curve has been interpreted uncritically The message we should be delivering unequivocally is that alcohol is bad for health."

NZFP Volume 34 Number 2, April 2007 122-126. 2007 The Royal New Zealand College of General Practitioners
Drink to your health is alcohol really cardioprotective? Graham Gulbransen and Ross McCormick. Correspondence to Graham Gulbransen gg@woosh.co.nz