The Breadth of Addiction Medicine

The DEI Shift's mission is to create a podcast series on diversity, equity, and inclusion (D.E.I.) in medicine that sparks discussion and provides practice-changing data and stories for a physician, student, allied health professional, and health care leader audience. Listeners will be able to gain useful information to improve their practices and environments, to gain empathy, cultural competency, and humility, and to learn more about emerging D.E.I. concepts. The DEI Shift will discuss issues related to gender, race, sexuality, religion, ability, socioeconomics, and so much more.

Co-Hosts: Dr. Marianne Parshley, Dr. Brittäne Parker

The DEI Shift Guest: Dr. Chwen-Yuen Angie Chen

Editor/Assistant Producer: Joanna Jain

Production Assistants: Alexandra Babakanian, Ann Truong, Likitha Aradhyula

Learning objectives:

1. Define the terms dependence, substance use disorder, and addiction.

2. Summarize 3 practice settings where addiction treatment occurs.

3. List 4 of the key components of the American Society of Addiction Medicine’s multidimensional patient assessment for developing an addiction treatment plan.

4. Review some of the challenges with addiction in the setting of the COVID-19 pandemic.

[0:00] Intro

Introduction of our co-hosts, guest, and the episode topic

[01:07] Defining terms

• Physical dependence: dependence on substance, which does not necessarily indicate any disorder or addiction; may simply reflect a pharmacological effect
• Substance Use Disorder: unhealthy use, including hazardous or at risk use of any substance, such as but not limited to alcohol and opiates
• Addiction: treatable, chronic medical disease involving complex interactions of brain circuits, genetics, environment, and the individual's experiences

[02:47] Introducing our Guest, Dr. Chwen-Yuen Angie Chen

• Attended University of California, Davis School of Medicine and finished her Internal Medicine training at Santa Clara Valley Medicine in San Jose
• Board Certified in Internal Medicine and Addiction Medicine
• Clinical Associate Professor at Stanford University School of Medicine in the Division of Primary Care and Population Health

[04:08] “A Step in Your Shoes” Segment

[05:54] Outline of topics

[06:24-9:29] The Continuum of Care in Addiction Medicine

• Addiction is defined further by Dr. Chen
  • Addiction is a chronic relapsing and remitting disorder.
  • While there is a disease model, it is important to recognize the behavioral component of addiction that requires a different set of tools to address.
• Discussion of Addiction Medicine practice settings
  • Treatment of addiction spans a variety of practice settings from the emergency room, ICU, or medical ward to a residential facility with full time nursing staff. Outpatient settings include partial hospitalizations, intensive outpatient treatment programs, primary care offices, and specific opioid treatment facilities such as methadone clinics.
• Management of substance use disorders should be thought of as a chronic process
  • Expectations that recovery occurs after one admission to a rehabilitation facility sets patients up for disappointment and frustration.
  • Analogy of addiction to diabetes which is a chronic process that physicians follow throughout a patient’s life.
• American Society of Addiction Medicine criteria for appropriate placement of patients in inpatient versus outpatient settings

[09:30] Dr. Chen talks about her advocacy work in Addiction Medicine

• Spoke with the local legislator and proposed resolutions to aid patients dealing with addiction.
• Partnered with consortiums of treatment centers, society medicine, such as California Society of Addiction Medicine, and the American College of Physicians.

[13:00] Cultural competency and destigmatization

• Cultural competency is usually framed as cultural identity, however, does not solve barriers to treatment.
• Ethical and political bureaucracies perpetuate biases and disparities that are unspoken and yet adversely impact the treatments patients receive.
• Resources are truly limited for those who are dealing with addiction as they face great structural violence against them.

[15:28] Screening for substance use disorder in primary care and inpatient settings

• Medical trainees and the limited curriculum real estate
  • Make addiction medicine part of each curriculum
• Addressing substance use disorder in many practice settings
  • Need to be aware of our own assumptions and screen everyone, especially those with medical conditions often associated with substance & alcohol use disorders.
  • Need to ask better questions such as “How much alcohol do you have weekly? Monthly”, instead of asking “Do you use alcohol?”
  • Important to include questions about cannabinoids and vaping

[20:48] COVID-19 pandemic and new challenges with substance use disorder in the US

• A study reported a 54% increase in national sales of alcohol for the week ending March 21, 2020 compared with 1 year before and online sales increased 262% from 2019 to 2020.
• In June 2020, 13.3% of nearly 5,500 surveyed U.S. adults reported that they had started or increased substance use in the last 30 days to cope with pandemic-related stress or emotions, according to study results published in August 2020 by MMWR and 12/2020 CDC Health Advisory.
• The American Psychological Association conducted a survey of US adults in late February 2021 by the The Harris Poll which showed that nearly 1 in 4 adults (23%) reported drinking more alcohol to cope with their stress during the coronavirus pandemic. This was amplified in parents, essential workers, and people of color.

[25:15] Overdose prevention education and naloxone use

• The number of overdose deaths  increased 18.2% from the 12-months ending in June 2019 to the 12-months ending in May 2020 per the CDC’s emergency health alert in December 2020, with the largest increase between March 2020 and May 2020.
• A 2020 article in the Journal of Addiction Medicine by Dr. Linda Wang reported that a majority of residents felt confident in assessing a patient's risk for opioid overdose, however only 45% felt confident in providing overdose prevention education and prescribing naloxone.
• The hidden epidemic (benzodiazepines): In conjunction with opiates, benzodiazepines is where you can find the highest risk of overdose

[29:43] Outro

Twitter and Instagram @TheDEIshift, email at thedeishift@gmail.com, and our website www.thedeishift.com

Additional Reading/Resources:

Saitz R, Miller SC, Fiellin DA, Rosenthal RN. Recommended Use of Terminology in Addiction Medicine. J Addict Med. 2021 Jan-Feb 01;15(1):3-7. doi: 10.1097/ADM.0000000000000673. PMID: 32482955.

American Society of Addiction Medicine Criteria: https://www.asam.org/asam-criteria/about

Ryan Crowley, Neil Kirschner, Andrew S. Dunn, et al. Health and Public Policy to Facilitate Effective Prevention and Treatment of Substance Use Disorders Involving Illicit and Prescription Drugs: An American College of Physicians Position Paper. Ann Intern Med.2017;166:733-736. [Epub ahead of print 28 March 2017]. doi:10.7326/M16-2953

Ayu A.P. Et al. Effectiveness and Organization of Addiction Medicine Training Across the Globe Eur Addict Res 2015;21:223-239. https://doi.org/10.1159/000381671

American Psychological Association. (2021, March 11). One year later, a new wave of pandemic health concerns. http://www.apa.org/news/press/releases/stress/2021/one-year-pandemic-stress

The Nielsen Company. Rebalancing the ‘COVID-19 Effect’ on alcohol sales. Published May 7, 2020. Accessed August 27, 2020. https://www.nielsen.com/us/en/insights/article/2020/rebalancing-the-covid-19-effect-onalcohol-sales/

Czeisler MÉ , Lane RI, Petrosky E, et al. Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1049–1057. DOI: http://dx.doi.org/10.15585/mmwr.mm6932a1

Rubin R. Alcohol-Related Diseases Increased as Some People Drank More During the COVID-19 Pandemic. JAMA. 2021;326(3):209–211. doi:10.1001/jama.2021.10626

Rutledge, S.M., Schiano, T.D., Florman, S. and Im, G.Y. (2021), COVID-19 Aftershocks on Alcohol-Associated Liver Disease: An Early Cross-Sectional Report From the U.S. Epicenter. Hepatol Commun, 5: 1151-1155. https://doi.org/10.1002/hep4.1706

Wang, Linda MD; Cunningham, Chinazo O. MD, MS; Browder, Casey MHA; Iyer, Shwetha MD Internal Medicine Residents’ Feelings of Responsibility, Confidence, and Clinical Practice in Opioid Overdose Prevention and Naloxone Prescribing, Journal of Addiction Medicine: September/October 2020 - Volume 14 - Issue 5 - p e147-e152 https://journals.lww.com/journaladdictionmedicine/Abstract/2020/10000/Internal_Medicine_Residents__Feelings_of.16.aspx

Increase in Fatal Drug Overdoses Across the United States Driven by Synthetic Opioids Before and During the COVID-19 Pandemic; Distributed via the CDC Health Alert Network; December 17, 2020, 8:00 AM ET; CDCHAN-00438 HAN Archive - 00438 | Health Alert Network (HAN)

Liu S, O’Donnell J, Gladden RM, McGlone L, Chowdhury F. Trends in Nonfatal and Fatal Overdoses Involving Benzodiazepines — 38 States and the District of Columbia, 2019–2020. MMWR Morb Mortal Wkly Rep 2021;70:1136–1141. DOI: http://dx.doi.org/10.15585/mmwr.mm7034a2

Resources for physicians:

American Society of Addiction Medicine COVID-19 Task Force recommendations

Caring for patients during the covid-19 pandemic: Supporting Access to Alcohol Use Disorder and Alcohol Withdrawal Treatment During the COVID-19 Pandemic

https://www.asam.org/docs/default-source/covid-19/7-tf_-supporting-access-to-alcohol-use-disorder-and-alcohol-withdrawal-treatment_updated-11132020.pdf

Health and Public Policy to Facilitate Effective Prevention and Treatment of Substance Use Disorders Involving Illicit and Prescription Drugs: An American College of Physicians Position Paper; Ryan Crowley, BSJ; Neil Kirschner, PhD; Andrew S. Dunn, MD; and Sue S. Bornstein, MD; for the Health and Public Policy Committee of the American College of Physicians*; Ann Intern Med. 2017;166:733-736. doi:10.7326/M16-2953

https://www.acpjournals.org/doi/pdf/10.7326/M16-2953

(SBIRT) Screening, Brief Intervention, Referral to Treatment

AUDIT/AUDIT-C (Alcohol Use Disorders Identification Test)

https://pubs.niaaa.nih.gov/publications/Audit.pdf

https://www.hepatitis.va.gov/alcohol/treatment/audit-c.asp

DAST (Drug Abuse Screening Test)

http://www.sbirtoregon.org/wp-content/uploads/DAST-English-pdf.pd

https://www.sbirt.care/tools.aspx

CAGE and CAGE-AID and UNCOPE: ETOH (+/- other drug use)

https://www.hopkinsmedicine.org/johns_hopkins_healthcare/downloads/all_plans/CAGE%20Substance%20Screening%20Tool.pdf

https://ncsacw.samhsa.gov/files/TrainingPackage/MOD2/ExampleScreenQuestionsUNCOPE.pdf

http://www.evinceassessment.com/PDF/UNCOPE_Plus.pdf

https://www.hopkinsmedicine.org/johns_hopkins_healthcare/downloads/all_plans/CAGE%20Substance%20Screening%20Tool.pdf

SAFERR: Screening and Assessment for Family Engagement, Retention and Recovery

https://ncsacw.samhsa.gov/files/SAFERR.pdf

https://ncsacw.samhsa.gov/files/SAFERR_AppendixD.pdf  (Screening tools)

Resources on advocacy

Earnest, Mark A. MD, PhD; Wong, Shale L. MD, MSPH; Federico, Steven G. MD Perspective: Physician Advocacy: What Is It and How Do We Do It?, Academic Medicine: January 2010 - Volume 85 - Issue 1 - p 63-67 doi: 10.1097/ACM.0b013e3181c40d40

 

Resources for patients:

www.checkupandchoices.com

https://www.samhsa.gov/find-help/national-helpline

https://www.getnaloxonenow.org/#home

 

Credits:

Guest: Dr. Chwen-Yuen Angie Chen

Co-hosts/Producers: Dr. Brittäne Parker, Dr. Marianne Parshley

Executive Producer: Dr. Tammy Lin 

Co-Executive Producers: Dr. Pooja Jaeel, Dr. Tiffany Leung

Senior Producers: Dr. Maggie Kozman, Dr. DJ Gaines

Editor/Assistant Producer: Joanna Jain

Production Assistants: Alexandra Babakanian, Ann Truong, Likitha Aradhyula

Website/Art Design: Ann Truong

Music: Chris Dingman

Disclaimer: The DEI Shift podcast and its guests provide general information and entertainment, but not medical advice. Before making any changes to your medical treatment or execution of your treatment plan, please consult with your doctor or personal medical team. Reference to any specific product or entity does not constitute an endorsement or recommendation by The DEI Shift. The views expressed by guests are their own, and their appearance on the podcast does not imply an endorsement of them or any entity they represent. Views and opinions expressed by The DEI Shift team are those of each individual, and do not necessarily reflect the views or opinions of The DEI Shift team and its guests, employers, sponsors, or organizations we are affiliated with.

Season 3 of The DEI Shift podcast is proudly sponsored by the American College of Physicians Southern California Region III Chapter. 

The DEI Shift theme music is by Chris Dingman. Learn more at www.chrisdingman.com.

Contact us: thedeishift@gmail.com, @thedeishift, thedeishift.com

Contributors

Marianne Parshley, MD, FACP – co-host

Brittane Parker, MD, FACP – co-host

Chwen-Yuen Angie Chen, MD, FACP – guest

Joanna Jain – editor/assistant producer

Alexandra Babakanian – production assistant

Ann Truong – production assistant

Likitha Aradhyula – production assistant

Maggie Kozman, MD, ACP Member – staff

Dirk Gaines, MD, ACP Member - staff

Pooja Jaeel, MD, ACP Member - staff

Tammy Lin, MD, MPH, FACP - staff

Stock: Abbott Laboratories, AbbVie, Inc., Gilead Sciences, Inc., Sanofi US Services, Inc.

Reviewers

Tiffany Leung, MD, MPH, FACP

Independent Contractor: PlushCare, Inc.

Sarah Takimoto, MD, ACP Member

Relevant financial relationships appear in italics below each individual’s name. All financial relationships have been mitigated. All others have nothing to disclose or no relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Release Date: November 12, 2021

Expiration Date: November 12, 2024

CME Credit

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the American College of Physicians and the DEI Shift.  The American College of Physicians is accredited by the ACCME to provide continuing medical education for physicians.

The American College of Physicians designates each enduring material (podcast) for 0.5 AMA PRA Category 1 Credit™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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