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January 2016

Big drug problems; tips on tobacco; don’t tell me what to do; Stump the Shrink


There has been a lot of attention, rightly so, about the epidemic of opioid overdose deaths. The Centers for Disease Control and Prevention (CDC) reported in December 2015, that drug overdoses in the U.S. rose again in 2014, driven by surges in deaths from heroin and painkillers.

  • More than 47,000 Americans died of a drug overdose in 2014, an increase of 7 percent from the previous year
  • The increase was driven largely by deaths from heroin and prescription opioids.
  • Almost 19,000 deaths were due to opioid painkillers, an increase of 16 percent from 2013.
  • Deaths from heroin overdoses increased 28 percent, to about 10,500. The rise in opioid-related deaths is due partly to synthetic opioids such as fentanyl and tramadol, according to a U.S. Department of Health and Human Services news release. Heroin is often cut with fentanyl to increase its effect.


Don’t forget an even larger drug problem than opioids – alcohol. 

With all the attention to opioid painkillers and heroin, it is easy to lose sight of an even greater drug problem with a legal drug we take for granted. That drug is alcohol. Each year, alcohol causes nearly double the deaths of opioid drug overdoses. 

Fact about alcohol use and health

  • Excessive alcohol use led to approximately 88,000 deaths and 2.5 million years of potential life lost (YPLL) each year in the United States from 2006 – 2010, shortening the lives of those who died by an average of 30 years.
  • Excessive drinking was responsible for 1 in 10 deaths among working-age adults aged 20-64 years. The economic costs of excessive alcohol consumption in 2010 were estimated at $249 billion, or $2.05 a drink.

Young people are targeted to use alcohol

  • A study of 2,800 US 12th graders conducted by Texas A&M and the University of Florida revealed that alcohol is a gateway drug, finding “the vast majority of respondents reported using alcohol prior to either tobacco or marijuana initiation.”

(Barry AE, King J, Sears C, Harville C, Bondoc I, Joseph K (2016): “Prioritizing Alcohol Prevention: Establishing Alcohol as the Gateway Drug and Linking Age of First Drink With Illicit Drug Use”Journal of School Health. 2016 Jan;86(1):31-8. )

  • 55 percent of young people, 15- to 20-year-olds have been exposed to online alcohol marketing and advertising on the Internet.

 (Auden C. McClure, Susanne E. Tanski, Zhigang Li, Kristina Jackson, Matthis Morgenstern, Zhongze Li, James D. Sargent February 2016: “Internet Alcohol Marketing and Underage Alcohol Use” Pediatrics.) 

TIP 2 Remember that smoking and tobacco use are still the biggest drug problem.

Even more than opioid drugs and alcohol, smoking and tobacco are more deadly and devastating to health. 

Smoking and Tobacco Use – Health Consequences

  • Smoking leads to disease and disability and harms nearly every organ of the body.
  • More than 16 million Americans are living with a disease caused by smoking.
  • For every person who dies because of smoking, at least 30 people live with a serious smoking-related illness.
  • Smoking is the leading cause of preventable death.
  • Worldwide, tobacco use causes nearly 6 million deaths per year, and current trends show that tobacco use will cause more than 8 million deaths annually by 2030.
  • Cigarette smoking is responsible for more than 480,000 deaths per year in the United States, including nearly 42,000 deaths resulting from secondhand smoke exposure.
  • This is about one in five deaths annually, or 1,300 deaths every day.
  • On average, smokers die 10 years earlier than nonsmokers.
  • If smoking continues at the current rate among U.S. youth, 5.6 million of today’s Americans younger than 18 years of age are expected to die prematurely from a smoking-related illness. This represents about one in every 13 Americans aged 17 years or younger who are alive today.

Secondhand smoke exposure and children

  • A study conducted by CDC researchers found that “nearly half of nonsmoking kids in middle school and high school encountered secondhand tobacco smoke in 2013, and rates were even higher among smokers.”
  • Lead author Israel Agaku, a researcher at the Centers for Disease Control and Prevention, said “These findings are concerning because the U.S. Surgeon General has concluded that there is no safe level of secondhand smoke exposure.”

 (Israel T. Agaku, Tushar Singh, Italia Rolle, Ayo-Yusuf Olalekan, Brian A. King (February 2016):”Prevalence and Determinants of Secondhand Smoke Exposure Among Middle and High School Students” Pediatrics.) For all who believe the solution to our drug problems is to legalize and tax drugs, note that our most deadly drugs are legal and taxed – alcohol and nicotine.

For all who believe the solution to our drug problems is to legalize and tax drugs, note that our most deadly drugs are legal and taxed – alcohol and nicotine.


Medications in addiction treatment are both clinical and cost-effective interventions. While the effectiveness of addiction medications has been researched and documented, their utilization is low and coverage varies widely. Less than 30% of treatment programs offer medications and less than half of eligible patients in those programs receive medications. 


You can get ASAM’s National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use for free.

The American Society of Addiction Medicine (ASAM) released its National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use (Practice Guideline) in June 2015. The Practice Guideline assists clinicians in understanding prescribing pharmacotherapies to patients with addiction related to opioid use.

  • It addresses knowledge gaps about the benefits of treatment medications and their role in recovery, while guiding evidence-based coverage standards by payers.
  • ASAM worked with Treatment Research Institute (TRI) to develop the Practice Guideline using the RAND/UCLA Appropriateness Method (RAM), a consensus process that combines scientific evidence with clinical knowledge.

See more at:


Skills from the co-author of the Tobacco Use Disorder chapter in The ASAM Criteria (2013). 

For decades, tobacco use has ranked amongst the top preventable causes of morbidity and mortality. Healthcare intervention for tobacco use disorder has historically been ignored and not reimbursed. 

Drs. Susan Blank and Lori Karan are the co-authors of the Tobacco Use Disorder section of Chapter 9 “Emerging Understandings of Addiction” in The ASAM Criteria (2013). Susan Blank, MD is President of the Georgia Society of Addiction Medicine (GSAM) and Co-Founder and Chief Medical Officer of the Atlanta Healing Center in Norcross, Georgia. 

Lori Karan D., MD, FACP, FASAM is Medical Director of the Department of Public Safety, and is Professor of Psychiatry, John A Burns School of Medicine, Honolulu, Hawaii. She is also an Associate Clinical Professor of Medicine, University of California, San Francisco. 

Here is a brief excerpt from their chapter:

“While we recognize that nicotine is one of the most difficult types of addiction to overcome, addiction treatment professionals have not assumed a leadership role in the treatment of tobacco addiction. Most addiction treatment programs do not even list nicotine addiction on the problem list or treatment plan, even though many, if not most, of their patients are actively consuming tobacco products.” (The ASAM Criteria,2013, page 368). 

Here are Dr. Karan’s tips on “The Right Treatment at the Right Time” for nicotine addiction:

  1. A nicotine or tobacco user’s stage of change needs to be assessed. Interventions geared towards a patient in Precontemplation stage of change (not interested in quitting) are different from those geared towards someone who is in the Action phase and ready to quit.
  2. It may be more helpful to distinguish between “current use,” “past use,” and “no history of use” instead of, or in addition to, the “light” and “heavy” smoker categories.
  3. All forms of nicotine and tobacco use (present and future) should be included. E-cigarettes exploit the current loophole of not containing tobacco. Hookah and other forms of nicotine and tobacco use also exist.
  4. Assessments need to include important medical, psychiatric, and addiction co-morbidities and socioeconomic factors.   
    * Personalized reasons to quit (whether the patient has asthma, congestive heart failure, bladder cancer, chronic pain, healing wounds, and/or is pregnant, etc.) are helpful motivators.
  5.  Nicotine and other addictive drugs are mood-altering and share some of the same brain pathways.
    * Alcohol and illicit drugs are often used with tobacco use. Do we address nicotine and tobacco and ignore the alcohol when a patient only smokes when they get high?
  6. Treatment planning should take into account the multidimensional assessments and be holistic. We need to get away from care silos.
  7. The intervention and intensity of treatment should be tailored and not “cookie cutter.”
    * A patient with depression may need concomitant treatment of that diagnosis in order for an intervention about nicotine/tobacco use to be successful.
    * As people with tobacco use disorders of less severity quit, co-morbid assessment and treatment are becoming increasingly important.


It’s always interesting how we so easily take things for granted; and the shiniest, loudest, most sensational person, policy or public problem receives all the attention. This is what I am talking about in this Tips & Topics edition, where our biggest, deadliest drug problems are good ole legal alcohol and tobacco – not heroin, other opioids or methamphetamine. However they get all the current attention. 

It’s the same with the debate over gun control – the current loud and contentious public policy debate getting so much attention. “No one is going to take my guns away. No one can tell me when and where I will wear my gun. The government can’t tell me what to do.” 

OK, I hear the anger, frustration and concern. But we take for granted that:

  • The government tells you how fast you can drive your car on which road, in which city, in which neighborhood.
  • You can’t drive your car without paying money to the government to license it; and then they keep making you pay every year whether you want to or not.
  • You are required to wear a seat belt or get fined – even though you are likely to be the only one to die if you don’t wear your seat belt. What’s that about? I’ll decide if I want to die or be maimed in a car accident, thank-you!
  • You can’t build a house anywhere, any way, any time without the government telling you where to build it and how big it can be – even though you are the one paying for it and it’s your house, not the government’s.
  • On top of that, some communities even tell you what color it has to be and whether you can even build something else in your backyard…YOUR backyard.
  • Governments, unions and employers make you pay money to them for taxes, dues or health co-pays whether you agree with what they are doing or not. 

The list could go on, but you get the point.

So it is all a matter of degree. It’s all on a continuum of personal freedom and choice and what’s best for the community and public good. Monday, February 1, 2016 marks the official beginning of the debate over this continuum this election year in the USA as the presidential race starts in earnest.

Nobody’s going to tell me what to do!!! Oh really?

stump the shrink

Engaging a new client in treatment is always important, but not always easy. Here is a question from Jacquelyn Summerlin from Detroit, Michigan: 

I am having difficulty with a new 56 year female client who presents with severe depression over the unwanted divorce from her husband of 33 years. The divorce happened a little over a year ago. When attempting to develop goals and outcomes for treatment, she consistently states, “I want my husband back”.

The husband got involved in a workplace relationship and divorced the client to be with the younger woman. They have since married and have a child on the way. The client has a job, an agreeable property/financial settlement from the divorce, good health, supportive friends and two young adult children who live in other parts of the country and busy with their own lives. Her depression over the divorce is not disrupting any of this but she is very sad, feels like life is not worth living and there are occasional thoughts of suicide. All she wants to talk about is how she can go about getting her husband back.

I know I have to start with where the client is, but how do I help her identify treatment goals that can help her with this unwelcome change and define a new life without him? Thank you for your attention to this matter.” 

– Jacquelyn Summerlin  

My Response

Hi Jacquelyn:

I can understand your dilemma, but it isn’t really too complicated if you start, as you said, with what the client wants. So in this case, she wants her husband back. You can start there. The first treatment plan is going to be finding out if getting her husband back is even possible. That could take one phone call with the husband , with your client present, to get a definitive answer. It might be clear in one minute that he has moved on and is not coming back. 

You could actually try saying that to her – even before the call:

He has probably moved on and I don’t think I can help you get you husband back if it is an impossible goal.” Your client might come round and say:

Yes, you are right. He has moved on and he told me that already.”  Then your next goal can be:

Do you want to work on getting over the loss, since your original goal is not possible?”  If she says yes, then work on that. 

However…What if your client is not yet convinced her ex-husband has moved on and that she still thinks it is possible to get him back?  You then make a call to the ex-husband, with your client present, so both you and she can hear the answer from the horse’s mouth, so to speak. He likely will say that getting back together is out of the question.  At that point you are back to re-contracting with your client to help her get over the marriage loss; or whatever she wants to work on.  That could be, for example:  How do I find someone else? or What do I do with loneliness and my depression? 

What if…At the first visit your client expresses something she wants that is unethical (e.g. Help me get revenge at my ex-husband by trying to sabotage his marriage). Your response will be: That is not a goal I am willing to work on with you. Is there something else you want that I can help you with? In general, there might be times when a client wants something you know is not possible. For example: client requests you to “help me get my child back.” You already know that Child Protective Services has made a final decision to pursue adoption and the case for reunification is closed. What do you say then? You tell her you cannot work on an impossible goal, however you can work with her on getting over the loss of the child. 

I hope this helps. – David 

Jacquelyn’s follow-up response:

Thank you so much for your advice. It helps a lot because I have been at a loss with this very depressed client. She’s frozen in time and as the clinician, I have become frozen along side her! I often ask grieving and depressed clients, “What do you want to be doing a year from now?” Most can imagine being in a very different place in their lives and can begin taking tiny steps to get to where they want to be. But not this lady. She said she wants to be reunited with her husband a year from now.   I feel I can be of help to her now as a result of your guidance.”

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