Recovery Month is a national observance held every September to educate Americans that substance use treatment and mental health services can enable those with mental and substance use disorders to live healthy and rewarding lives. Now in its 30th year, Recovery Month celebrates the gains made by those in recovery.

Click here for SAMHSA’s Recovery Month webinar series  https://recoverymonth.gov/events/webinar-series-2019

This is an official
CDC HEALTH ADVISORY

Distributed via the CDC Health Alert Network
August 30, 2019, 9:35 AM ET
CDCHAN-00421

Severe Pulmonary Disease Associated with Using E-Cigarette Products

Summary
The Centers for Disease Control and Prevention (CDC) is providing: 1) background information on the forms of e-cigarette products, 2) information on the multistate outbreak of severe pulmonary disease associated with using e-cigarette products (devices, liquids, refill pods, and cartridges), and 3) clinical features of patients with severe pulmonary disease. This health advisory also provides recommendations for clinicians, public health officials, and the public based on currently available information.

General Background
E-cigarettes typically contain nicotine, most also contain flavorings and other chemicals, and some may contain marijuana or other substances. They are known by many different names and come in many shapes, sizes and device types. Devices may be referred to as “e-cigs,” “vapes,” “e-hookahs,” “vape pens,” “mods,” tanks, or electronic nicotine delivery systems (ENDS). Some e-cigarette devices resemble other tobacco products such as cigarettes; some resemble ordinary household items such as USB flash drives, pens, and flashlights; and others have unique shapes. Use of e-cigarettes is sometimes referred to as “vaping” or “juuling.” E-cigarettes used for dabbing are sometimes called “dab” pens.

E-cigarettes can contain harmful or potentially harmful substances, including nicotine, heavy metals (e.g., lead), volatile organic compounds, and cancer-causing chemicals. Additionally, some e-cigarette products are used to deliver illicit substances; may be acquired from unknown or unauthorized (i.e., “street”) sources; and may be modified for uses that could increase their potential for harm to the user. For example, some e-cigarette pods or cartridges marketed for single use can be refilled with illicit or unknown substances. In addition, some e-cigarette products are used for “dripping” or “dabbing.” Dripping involves dropping e-cigarette liquid directly onto the hot coils of an e-cigarette which can result in high concentrations of compounds (e.g., tetrahydrocannabinol [THC] and cannabinoid compounds). Dabbing involves superheating substances such as “budder”, butane hash oil (BHO), and “710” that contain high concentrations of THC and other plant compounds (e.g., cannabidiol [CBD]).

Youth, young adults, pregnant women, as well as adults who do not currently use tobacco products should not use e-cigarettes. E-cigarettes containing nicotine have the potential to help some individual adult smokers reduce their use of and transition away from cigarettes. However, e-cigarettes are not currently approved by the Food and Drug Administration (FDA) as a quit smoking aid, and the available science is inconclusive on whether e-cigarettes are effective for quitting smoking.

Outbreak Background
As of August 27, 2019, 215 possible cases have been reported from 25 states and additional reports of pulmonary illness are under investigation. One patient (in Illinois) with a history of recent e-cigarette use was hospitalized on July 29, 2019 with severe pulmonary disease and died on August 20, 2019. Although the etiology of e-cigarette-associated pulmonary disease is undetermined, epidemiologic investigations in affected states are ongoing to better characterize the exposures, demographic, clinical, and laboratory features and behaviors of patients. All patients have reported using e-cigarette products. The exact...... Read More

In a video presentation released with the NSDUH report, Elinore F. McCance-Katz, MD, PhD, Assistant Secretary for Mental Health and Substance Use, highlighted the State Targeted Response Technical Assistance grant. Dr. McCance-Katz says the Opioid Response Network "puts teams in every state to address the needs of that state as it relates to opioid issues." She underscored that the "program has had over 1,000 requests already and those requests have all been met to meet the needs of Americans living with opioid issues." 

Highlights include:

• 19.3 million Americans report a substance use disorder. Among those with substance use disorders, 7.4 million struggle with illicit drugs.  
• Positive findings when looking specifically at opioids. In 2018 there were 10.3 million opioid misusers. This is down from 11.4 million in 2017. Declines reported for both prescription pain reliever misuse and heroin use.
• Where misuse of prescription opioid subtypes is concerned, buprenorphine and methadone see the highest rate of misuse. Dr. McCance-Katz says this "speaks to the need to continue to educate on safe and effective use of these medications." 

The NSDUH report helps to guide policy directions and decision-making about what types of resources are needed and where resources should be directed. For example, NSDUH's 2016-17 report found that SAMHSA efforts only provided technical assistance to grantees, and the number of grantees was low compared to the number of practitioners, community members and others who need access to information. So, SAMHSA expanded training and technical assistance nationally.

How is SAMHSA responding to the 2018 report? Dr. McCance-Katz says SAMHSA will continue to support states' prevention, treatment and recovery efforts through STR grants, SOR grants, TOR grants and others.

Read other news in the ORN Bulletin.

Recharge and reconnect with thousands of your fellow physicians and medical students at the largest gathering of DOs in the world, Oct. 25-28 in Baltimore.

AOAAM's 2019 program consists of 29 hours of CME including collaborative sessions with American College of Osteopathic Family Physicians (ACOFP), the American College of Osteopathic Pediatricians (ACOP) the American College of Osteopathic Neurologists and Psychiatrists (ACONP), American Academy of Osteopathy (AAO), the Association of Military Osteopathic Physicians & Surgeons (AMOPS) and the American Osteopathic Association Division of Public Health & the Bureau of Scientific Affairs. This year we will offer the Essentials of Addiction Medicine Course and Advanced Studies of Addiction Medicine Course. Our Distinguished Speaker is Albert Wu, MD, Executive Vice President, American Board of Addiction Medicine. Click here to view our complete agenda.

Reserve Your Spot

Community Group Finds Common Ground with Nation's First 24/7 Opioid Treatment on Demand Clinic In response to a request for technical assistance, the Arizona Opioid Response Network team helped the nation’s first 24/7 Opioid Treatment Program in Phoenix, Arizona form a collaborative working relationship with a local community task force to have the program located in their community. Read more.

Update: ORN Partners with CA to Address Post Incarceration Drug Overdose Deaths Previously we announced that ORN is working with California Correctional Health Care Services on developing a road map to increase access to evidence-based treatment for its 35 correctional settings and an estimated 100,000 inmates with substance use disorders. Through July and August, a series of Motivational Interviewing training's have been scheduled. We are happy to report that, to date, the training's have 682 registrants. Stay tuned for updates. See April's story.

Read more news.

AOAAM is pleased to announce that on Saturday, July 27, 2019, the AOA House of Delegates passed House Resolution 232. This resolution allows osteopathic physicians who completed an AOA approved fellowship in addiction medicine to take a primary certifying exam in addiction medicine, and also creates a practice pathway for qualified DOs to take a primary certifying exam in addiction medicine. It is the intent of the AOA that any DO with an active primary AOA board certification in any specialty will be able to seek certification through this pathway.

Thanks to our AOAAM Delegate Margi Kotz, DO, alternate Delegate Steve Wyatt, DO, past presidents, and Executive Director Nina Vidmer, who have been working tirelessly for years on getting the CAQ reinstated.

Julie Kmiec, DO
AOAAM President

By Michael Nedelman and Arman Azad, CNN Updated 12:35 PM ET, Wed July 24, 2019
Study: E-cigarette maker Juul triggers nicotine 'arms race'

(CNN)Tobacco opponents and Juul executives are testifying on Capitol Hill this week during a two-day hearing on the company's role in "the youth nicotine epidemic," according to the House Oversight Subcommittee on Economic and Consumer Policy.

The hearing will scrutinize the leading vape company's marketing, health claims and relationship with Big Tobacco -- namely, tobacco giant Altria, which invested nearly $13 billion in Juul Labs late last year.

The list of attendees sets the stage for a heated clash over whether e-cigarettes should be subject to stronger regulation, weighing their potential benefit to adults who want to quit smoking against the risk that a generation of young people will become addicted to nicotine.

Democratic Rep. Raja Krishnamoorthi of Illinois, the chairman of the subcommittee, announced last month that his panel was investigating Juul, and asked the company to "provide memoranda and communicationsregarding its social media practices, advertising, and the product's long-term impact on consumer health."

"The safety and well-being of America's youth is not for sale," Krishnamoorthi said in a letter to Juul CEO Kevin Burns dated June 7. "I am extremely concerned about reports that JUUL's high nicotine content is fueling addiction and that frequent JUUL use is sending kids across the country into rehab, some as young as 15."

Social media about Juul continues to soar, new study says

During the first day of the hearing, on Wednesday, committee members will hear from representatives of groups such as the American Academy of Pediatrics and Parents Against Vaping E-cigarettes. Other witnesses include experts such as Dr. Robert Jackler, founder of Stanford Research Into the Impact of Tobacco Advertising.

In research shared exclusively with CNN and now posted online, Jackler's team found that the amount of Juul-related content posted by Instagram users has exploded in the months since the company shut down its own social media accounts in November.

In the eight months since Juul phased out its social media, more than half a million Instagram posts have featured hashtags related to Juul, the paper says. That's double the number that had been posted in the three and a half years before Juul discontinued its accounts.

"Among #juul posts, 15.4% showed JUUL products, 28.1% JUUL competitors, and 3.7% products from both JUUL and its competitors," says the paper, which has not yet undergone peer review. "Reflecting the popularity of #juul as a gathering place for its largely youthful audience, non-vaping related posts made up the remaining 52.8%." 

Read more....

This study was designed to evaluate synthetic cannabinoid (SC)-induced psychotic disorders in terms of their structure and clinical characteristics among hospitalized patients in Russia. It was a longitudinal, observational cohort study which included a total of 46 male patients who underwent the inpatient treatment in the intensive care unit or emergency department due to the SC-induced psychoses. Data on sociodemographic and disease-related characteristics, psychometric assessment scales obtained in face-to-face interviews, were recorded in all patients. The duration of catamnestic follow-up period was 2 years, with the major focus on manifestation of the schizophrenic process. Mean (SD) age of the patients with psychotic disorders induced by the SC use was 23.2 (3.5) years. Among 46 patients, 29 (63%) were SC-dependent and 17 (37%) were diagnosed with SC abuse. Average age at onset was 16.4 for psychoactive substances and 19.7 years for SC use. Marijuana was the most common first used substance. Based on our observations, we identified four clinical variants of the SC-induced psychoses. Our findings revealed that psychotic disorders are typical for the SC intoxication and most commonly influence young adults. Based on our observations, we identified four clinical variants of the SC-induced psychoses and revealed the signs which may indicate them. This study emphasizes the role of appropriate psychiatric management of SC-induced psychoses, since often only catamnestic long-term follow-up enables clinicians to determine the correct diagnosis and reveal the manifestation of the schizophrenic process.

Read more online.

V. Yu. Skryabin MD & M. A. Vinnikova PhD, MD
Journal of Addictive Diseases
Published on 7/4/2019

Senators Markey and Murkowski Introduce Legislation to Support Access to Opioid Use Disorder Treatment in Correctional Facilities

Providing MAT in correctional facilities can help reduce opioid overdose deaths upon re-entry by 60 percent

Data indicates recently released individuals are 129 times more likely to die from opioid overdose in first two weeks of release

Washington (June 28, 2019) – Senators Edward J. Markey (D-Mass.) and Lisa Murkowski (R-Alaska) today introduced the Community Re-Entry through Addiction Treatment to Enhance (CREATE) Opportunities Act, legislation to help expand access to medication-assisted treatment (MAT) like Suboxone for justice-involved individuals. This legislation would create a new grant program within the Department of Justice for state and local governments to provide MAT in their correctional facilities. The program would require grantees to provide more than one MAT option and to develop a plan for connecting individuals to continued treatment upon release into the community. Data indicates recently released individuals are 129 times more likely to die from opioid overdose in first two weeks of release.

Companion legislation has been reintroduced in the House of Representatives by Rep. Ann McLane Kuster (NH-2).

“Our local jails are on the front lines of the response to the nation’s opioid overdose crisis,” said Senator Markey. “Too often, our local jails witness some of the most devastating impacts of the opioid crisis, but don’t have the resources to mount a robust and appropriate response. My bill would help change that. We know we cannot incarcerate our way out of this crisis. Instead, we must rehabilitate in order to reduce recidivism and save lives. Providing reliable access to evidence-based treatment within correctional facilities will help counties and states respond to this crisis like the public health issue that it is. I thank Senator Murkowski and Representative Kuster for their partnership in this endeavor.”

“Opioid use has skyrocketed in Alaska. And for those struggling with opioid abuse or a mental health disorder who are in the criminal justice system, the transition from incarceration into their community can be incredibly difficult.  To truly break the vicious cycle of substance abuse, we must ensure those incarcerated have a path to treatment,” said Senator Murkowski. “By combining access to approved medications in combination with behavioral health therapy, we’re not just decreasing the rate of relapses, re-incarcerations, and overdoses, we’re giving those in the criminal justice system hope for a future that isn’t dictated by substance abuse.”

“Too many incarcerated individuals in our jails suffer from untreated mental health and substance use disorder, and most lack access to the treatment they need,” said Rep. Kuster. “Medication assisted treatment (MAT) has an important role to play in helping incarcerated individuals suffering from substance use disorder recover and reclaim their lives to become productive, contributing members of our society. Reducing recidivism is a win for our communities: it’s good for public safety, public health, and budgets. The CREATE Opportunities Act is commonsense legislation to provide a commonsense solution to put an end to the cycle between addiction and the criminal justice system.”

A copy of the CREATE Opportunities Act can be found HERE.

“Drugs do not know age, race, gender, religion or economic status and the cost of addiction is astronomical – it tears families apart, ransacks communities and undermines public safety,” said Major County Sheriffs of America (MCSA) President Sheriff Grady Judd. “On behalf of the largest Sheriff’s Offices in the U.S. we endorse Senator Markey’s effort to address the lack of access to medication-assisted treatment (MAT) in local correctional facilities. Through the creation of a new grant program within the Department of Justice, Sheriffs will have access to funds that provide a much-needed tool for corrections and can help reduce the likelihood of overdose deaths after release. We look forward to working with Senator Markey’s office to move this bill across the finish line.”

“People exiting the criminal justice system are at high risk of overdose deaths,” said Michael Collins, Director of the Office of National Affairs at Drug Policy Alliance. “Rhode Island’s jail system has shown that offering all three MATs is a successful way of reducing fatalities. We applaud Senators Markey and Murkowski for their work on this important bill.”

“In jails across America, sheriffs see first-hand the devastating impacts that the mental health crisis and the opioid epidemic have on their communities,” said NSA’s Executive Director, Jonathan Thompson. “This common-sense legislation introduced by Senator Markey provides a solution to inmates lack of mental health care/medically assisted treatment, when they need it most. We commend Senator Markey’s efforts to create a grant program that can be widely accessed by both urban and rural sheriffs.”

“Counties experience the human toll of addiction every day in our communities. We are the nation’s first responders and deliver services to residents in our emergency rooms, public health departments and justice systems. As we pursue proven solutions in our fight against addiction, greater access to medication-assisted treatment is important,” said National Association of Counties Executive Director Matthew Chase.“NACo applauds Senators Markey and Murkowski’s efforts to strengthen resources available to local officials, and we look forward to working with our congressional partners to reduce overdoses and addiction-related fatalities.”

“Today ASAM commends Senators Markey and Murkowski for their efforts to provide evidence-based addiction treatment to people with opioid use disorder who have been incarcerated,” said Paul H. Earley, MD, DFASAM, president of the American Society of Addiction Medicine (ASAM). “The CREATE Opportunities Act would establish a much-needed federal grant program that can provide addiction treatment access during incarceration and warm handoffs to community-based care upon release that will significantly reduce the risk of opioid-related overdose.  In short, this legislation will save lives.”

“Harm Reduction Coalition welcomes the bipartisan CREATE Act that recognizes that the provision of evidence-based medication treatment is critical to preventing painful withdrawal symptoms, relapse, overdose and increased risk of death that occurs with incarcerating people with opioid use disorder,” said Kimberly Sue, MD, PhD, Medical Director, Harm Reduction Coalition. “Provision of medication for opioid use disorder is both compassionate and the community standard of care; not providing medication such as buprenorphine or methadone therapy has been found by several judges across multiple states to be a violation of the Americans with Disabilities Act (ADA) as well as a violation of the Eighth Amendment of the Constitution prohibiting cruel and unusual punishment. This legislation is an important first step in addressing structural harms contributing to the American opioid overdose crisis.”

“Research has shown that psychosocial interventions in combination with medications provide the greatest chance for success in treating substance use disorders,” CEO, Dr. Arthur C. Evans, American Psychological Association. “The American Psychological Association applauds this legislation, which will help inmates increase access to this effective form of treatment so that they can initiate and maintain recovery, increasing their chance of successful and safe reentry to their communities.”

“Sheriffs across the country are on the front lines of the opioid epidemic.  Substance use is a major driver of crime and individuals leaving prison in Massachusetts are 120 times more likely to die of a fatal overdose compared to others suffering from substance use disorders,” said Middlesex Sheriff Peter J. Koutoujian.“It is critically important sheriffs have the resources necessary to support initiatives like our Medication Assisted Treatment And Directed Opioid Recovery (MATADOR) program, which has shown proven results in increasing public safety, reducing recidivism and improving health outcomes since its launch nearly four years ago.  I want to thank Senator Markey for recognizing the urgent need to provide direct federal resources to address this public health and public safety crisis.”

Organizations endorsing the legislation include: American Society of Addiction Medicine, National Sheriffs’ Association, Major County Sheriffs of America, Drug Policy Alliance, Harm Reduction Coalition, AIDS United, National Association for Behavioral Healthcare, National Council for Behavioral Health, SMART Recovery, Center on Addiction + Partnership for Drug-Free Kids, Young People in Recovery, National Alliance for Medication Assisted Recovery, American Psychological Association, CADA of Northwest Louisiana, Connecticut Certification Board

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Twelve States Pass “Right to Know” Laws

Utah and Washington are the latest states to pass a Patient Notification Law. The laws require all practitioners to have a conversation with their patients on the addictive nature of opioids before they are prescribed and discuss possible non-opioid alternatives that are available.

According to the advocacy campaign Prevent Opioid Abuse , versions of the legislation have passed in California, Connecticut, Maryland, Michigan, New Jersey, Nevada, Oklahoma, Ohio and Rhode Island and West Virginia. Efforts to adopt it are currently underway in six other states and Puerto Rico. In New Jersey the law takes it a step further and requires physicians, physician assistants, dentists and optometrists to complete one Continuing Medical Education credit on topics that include responsible prescribing practices, as well as risks and signs of opioid abuse, addiction and diversion.

Read more.