CSAM Newsletter

By: Chwen-Yuen Angie Chen, MD, FACP, FASAM, Communications Committee Chair

On February 15, 2023 Dr. Caravella McCuistian, PhD presented her findings on the implementation of AB 541 Tobacco Treatment legislation, at the *UCSF Drug Use Research Group meeting (see below for more information on DURG). In attendance were CSAM members Cathy MacDonald, MD (Program Consultant Lifelong Tobacco Treatment Training Program Oakland, CA) and Chwen-Yuen Angie Chen, MD who were instrumental in initiating AB541: https://bit.ly/43cpS0l

Here is a synopsis of Dr. McCuistian‘s presentation:

“California has prioritized smoking cessation among people who use substances through the Tobacco-Free for Recovery Initiative, which includes an intervention aimed at supporting substance use disorder treatment programs in implementing tobacco-free grounds. Dr. McCuistian led an examination of changes in client smoking prevalence, tobacco use behaviors, and receipt of cessation services among the first seven programs participating in the initiative. Program clients completed cross-sectional surveys at the start of the intervention (baseline: n = 249), at an interim timepoint post-baseline (interim: n = 275), and at the end of the intervention 15 months later (post-intervention: n = 219). Over the course of the initiative, 5 of the 7 programs implemented tobacco free grounds. Results indicated that client smoking prevalence decreased from 54.2% to 26.6% from pre to post intervention. Current smokers and those who quit while in treatment also reported an increase in NRT/pharmacotherapy (11.9% vs. 25.2%) from pre to post intervention. These data suggest that an intervention to promote tobacco-free grounds implemented in residential SUD treatment programs was associated with a significant reduction in client smoking and an increase in NRT/pharmacotherapy. These findings directly supported the enactment of California AB 541, which now requires all California substance use treatment programs to assess and treat smoking among patients in these programs. The Tobacco Free for Recovery Initiative serves as a model for how substance use treatment programs may adhere to requirements of AB 541 while addressing smoking prevalence within their programs.”

Here are two resources for additional information:

McCuistian, C., Kapiteni, K., Le, T., Safier, J., Delucchi, K., & Guydish, J. (2022). Reducing tobacco use in substance use treatment: An intervention to promote tobacco-free grounds. Journal of substance abuse treatment, 135, 108640, 1-8.

https://doi.org/10.1016/j.jsat.2021.108640

Campbell, B. K., Le, T., McCuistian, C., Hosakote, S., Kapiteni, K., & Guydish, J. (2022). Implementing tobacco-free policy in residential substance use disorders treatment: Practice changes among staff. Drug and Alcohol Dependence Reports, 2, 100033. https://doi.org/10.1016/j.dadr.2022.100033, 1-8.

*The UCSF Drug Use Research Group (DURG) is a city-wide seminar attended by faculty, postdoctoral fellows, graduate students, and other investigators with a focus on and for persons who use drugs. Started in 2005 after a friendly debate between an epidemiologist and anthropologist on the merits of quantitative versus qualitative research methods, the DURG monthly seminars provide a community platform for new and established investigators to present their work, formulate research questions, and prepare for grant applications, conferences, and publications in a supportive environment. The seminar has been successful in cultivating new collaborations and mentorship and in sustaining interdisciplinary and interprofessional dialogue between those engaged in basic sciences, epidemiology, clinical research, and qualitative methods.  

By: Chwen-Yuen Angie Chen, MD, FACP, FASAM, Communications Committee Chair

In 2025, that’s only two more years from now, the American Board of Preventive Medicine – Addiction Medicine Practice Pathway Certification process will sunset. In 2026, board certification in Addiction Medicine will require ACGME accredited fellowship training.

For your reference, below is the information provided directly from the ABPM website and we hope you plan accordingly if you intend on becoming board certified in addiction medicine through this practice pathway. As part of your preparation resource, CSAM continues to offer their popular annual Board Review Course at their Scientific Meetings, the next one will be held in San Diego from August 30-September 2, 2023. Seating is limited and super early bird registration at a discount is available until April 24: Register for the Annual Review Course Here

Direct from American Board of Preventive Medicine:

“Practice Pathway* (open through 2025)

The practice pathway is the mechanism for physicians to meet eligibility requirements for certification in Addiction Medicine without completing an ACGME-accredited fellowship in Addiction Medicine. Additional requirements include either minimum time in practice or completion of non-ACGME-accredited fellowship training in Addiction Medicine.

Two options are available in the Practice Pathway:

• Time in Practice: Applicants must submit documentation of a minimum of 1,920 hours in which they were engaged in the practice of Addiction Medicine at the subspecialty level; this minimum of 1920 hours must occur over at least 24 of the previous 60 months prior to application. The minimum of 24 months of practice time need not be continuous; however, all practice time must have occurred in the five-year period preceding June 30 of the application year. Practice must consist of broad-based professional activity with significant Addiction Medicine responsibility. Applicants must also demonstrate a minimum of 25% (or 480 hours) as Direct Patient Care. Addiction Medicine practice outside of direct patient care, such as research, administration, and teaching activities, may count for a combined maximum of 75% (or 1440 hours). Only 25% (480 hours) of general practice can count towards the required hours for the Practice Pathway, and the remaining 75% must be specific Addiction Medicine practice. Fellowship activity that is less than 12 months in duration or non-ACGME accredited may be applied toward the practice activity requirement. The actual training must be described for any fellowship activity. Documentation of Addiction Medicine teaching, research and administration activities, as well as clinical care or prevention of, or treatment of, individuals who are at risk for or have a substance use disorder may be considered.

• Non-Accredited Fellowship Training: Credit for completion of training in a non-ACGME-accredited Addiction Medicine fellowship program may be substituted for the Time in Practice option in i) above. The applicant must have successfully completed an Addiction Medicine fellowship of at least 12 months that is acceptable to the American Board of Preventive Medicine. The fellowship training curriculum as well as a description of the actual training experience must also be submitted. Fellowship training of less than 12 months may be applied towards the Time in Practice hour requirements of the Practice Pathway. The non-ACGME-accredited fellowships are those currently accredited through the American College of Academic Addiction Medicine (ACAAM), formerly known as The Addiction Medicine Foundation (TAMF).

Documents and Verifications

• CV/Resume
• Medical License Verification (ABPM will confirm after application)
• Current ABMS Board Certification Verification (ABPM will confirm after application)
• Practice and Training Verification, if using practice activity
• Fellowship Verification, if using credit from a fellowship
• 1 Letter of Reference from a physician who is certified by one of the ABMS Member Boards

*The Addiction Medicine Practice Pathway will expire in 2025. Beginning in 2026, all applicants for certification in Addiction Medicine must successfully complete an ACGME-accredited Addiction Medicine fellowship program. This subspecialty certifying exam will be given annually throughout this period.”

See you this Summer, August 30 – September 2!

By: Randolph P Holmes MD, FAAFP, DFASAM, Government Affairs Committee Chair
with Chwen-Yuen Angie Chen, MD, FACP, FASAM, Communications Committee Chair

CSAM’s Public Policy Committee has a new name, the Government Affairs (GA) Committee. We are early in the legislative session and have been reviewing several bills related to substance use disorders care. There are several bills concerning fentanyl, some of which are more about the old “war on drugs” thinking and do not align with CSAM’s mission. We have several bills that seek to license drug and alcohol counselors and it is likely CSAM will support. Most bills are still in committee so it will be another month or two before the GA Committee will have the final products. CSAM was represented in Sacramento on April 19 for Legislative Day. We will be hearing from our legislators and meeting with staff to elicit support on bills we want to see passed.

When the Section Chief of Special Programs and Utilization Management Branch from the Department of Health Care Services, Steven T. Kmucha, MD JD MMM reached out to CSAM’s President Dr. Karen Miotto with an inquiry for advice and guidance about “best policies” and clinical evidence pertaining to the update of Medi-Cal policies related to Voluntary Inpatient Detoxification (VID), CSAM News Editor and Chair of Communications, Dr. C.Y. Angie Chen connected CSAM Member Dr. Cheryl Ho, Director of Hope Clinic and Co-Founder Valley Homeless Healthcare Program of Santa Clara Valley Health and Hospital System with GA (HPPC) committee for support in crafting a letter, signed by 14 physician-leader colleagues of Dr. Ho who practice addiction medicine within Santa Clara County, outlining the paucity of Medi-Cal funded services for medically supervised withdrawal management in the face of our fentanyl crisis, where ASAM Placement Criteria 3.2 level programs are providing services that would more appropriately fall between 3.2 and 3.7, however, the funding for this level of treatment remains at a level 3.2. We are awaiting a response, and welcome others who are interested in VID reform to reach out to CSAM.

Among the many things that CSAM does as part of our advocacy efforts is submit amicus briefs in support of SUD related legal cases before various courts. CSAM recently signed on to two cases. In the first case (Carpenter), a pregnant woman gave birth and the baby died in San Diego. She is being charged with murder because her urine tested positive for drugs; the submitted brief states why it is wrong to weaponize drug use in pregnancy and the reasoning behind opposing a punitive response to perinatal drug use. In the second case, a man was denied visitation privileges with his child because he tested positive for drugs. Our key arguments include a) substance use, even in high amounts or with high frequency, is not equivalent to a substance use disorder b) The DSM-5-TR distinguishes between substance use and SUDs which should not necessarily be equated c) The frequency, duration, and amount of substance use alone have never been diagnostic criteria in the DSM, because those metrics do not correlate with a lack of control d) A positive drug test alone is not an indicator of a substance use disorder and e) substance use disorders are clinical conditions that should only be diagnosed by trained professionals and not the courts. This latter amicus was filed with CSAM as a lead, with our input on crafting it, and is currently before the State Supreme Court.

CSAM continues to work hard to have our voices heard as the subject matter experts on substance use disorder issues.

JOIN US FOR THIS EXCITING WORKSHOP AUGUST 30, 2023 in San Diego!

with Ingeborg Schafhalter, MD, IASC Committee Chair

How did the idea for CA Bridge come to life?

The idea for CA Bridge began in 2017 when we realized that the emergency department was this incredible 24-7 access point for people in crisis from substance use disorders. The emergency department is the only place in the healthcare system that federal law guarantees access to treatment no matter your insurance or citizenship status, and our patients know that. There is a tremendous amount of trust and reliance on the emergency department particularly by people facing social challenges. It might be busy and loud, but you can trust it. Unfortunately, that’s not true in most other settings in healthcare, even safety net systems often maintain standard workflows that block access to treatment or create onerous eligibility tests and delays.

From an access standpoint the emergency department is ideal, the problem has been that most healthcare leaders both on the medical side and on the administrative side have not considered substance use disorders a legitimate medical condition on par with cardiovascular disease. That means the general treatment expectations have been only the most basic interventions to keep a patient alive with little to no attention paid to the treatment of addiction. As a group, people suffering from substance use disorders have had very little advocacy, their voice is typically just not impactful at the stakeholder tables where large scale decisions around funding and resource allocation are made.

The abject horror of the overdose epidemic has been a catalyst to at least begin the long project of treating people who are suffering from addiction with dignity as any other patient. Through the incredible advocacy and powers of persuasion of people like Dr. Aimee Moulin, Dr. Hannah Snyder and Arianna Sampson, (co-founders of the CA Bridge Program), and support from the California’s Department of Healthcare Services (DHCS: https://www.dhcs.ca.gov/), the CA DPH (https://www.cdph.ca.gov/) and California Hospital Association (https://calhospital.org/) we have been given some space to explore this vision of what if you combined the access capacity of an emergency department with competency in the medical treatment of addiction to provide high-quality care 24-7 for substance use disorders. It’s so simple yet so ambitious, if we can get this done it will save thousands of lives and just become part of healthcare…like strokes, heart attacks, and all the other things we treat in the emergency department every day.

Are there latest findings or practices? 

The big finding is that emergency department staff WANT to do this. The response from clinicians has been incredible. It’s incredibly thrilling to see over 280 hospitals, in California alone, sign on and commit to a fairly rigorous implementation project that up-trains their emergency departments to provide high quality care. With this reach, you start to see population scale impacts that I believe will start to move the needle on overdose deaths–we have seen over 70 thousand emergency department visits for buprenorphine treatment just in the last few years. Many of these people arrived in high-risk crises, either in withdrawal, having overdosed, or just been released from prison. 

How has the program grown? 

CA Bridge began with focus on just getting buprenorphine into standard medical practice at emergency departments in California and grew rapidly to take on all substance use disorders and creating treatment pathways that integrate emergency medical services and hospital inpatient units. Again, nothing we do is particularly innovative, it’s just building out the same care infrastructure that we do for victims of trauma or stroke. For so many reasons leaders in medicine, healthcare, and public policy decided that people suffering from substance use disorders did not merit the same care–the system we have today is very much by design. Hopefully, we can sustain and grow the outrage against this dominant belief and continue to drive progress. 

The future is going to center on deconstructing the current behavioral health system that was conceptualized, designed, funded, and implemented without any serious involvement of medical science. We currently have two largely separate and often oppositional systems–the healthcare system and the behavioral health system. That is a very wasteful and unfortunate situation. The future involves building an integrated system of care from the ground up that applies medical interventions and knowledge in partnership with behavioral health models of care. Cognitive behavioral therapy, contingency management, and medications like buprenorphine should be offered together with social support. Splitting everything up has never made any sense at all. I’m very hopeful we can break through the inertia and special interests and build a commonsense system appropriately scaled to meet the needs of California.

What do you most look forward to presenting at the CSAM WORKSHOP? 

I’m a pharmacology nut, so probably treatment of buprenorphine precipitated withdrawal, but in terms of impact I really think it’s within our grasp to leverage technology to create a statewide network of telehealth enabled Bridge Clinics that provide on-demand treatment (including buprenorphine) that are vertically integrated with 24-7 emergency department care and closely partnered with high-risk touchpoints–jails, syringe services programs, behavioral health residential centers–to create an always available resource. I understand we can’t snap our fingers and fix the overdose epidemic, but we can fix access to medications like buprenorphine, it’s very doable.

Dr. Andrew A Herring graduated from Harvard Medical School and completed his residency in emergency medicine at Highland Hospital—Alameda Health System (AHS) in Oakland, CA where he continues as an attending emergency physician and Director of Research. At AHS he is Division Chief of Addiction Medicine and Medical Director of Substance Use Disorder Treatment and the past Medical Director of the AHS Functional Restoration Pain Clinic. Dr Herring has led national efforts to transform hospital-based care for substance use disorders and his work has been featured in local and national press including the New York Times, Los Angeles Times and National Public Radio. Dr. Herring co-founded and is a PI at CA BRIDGE, one of largest state level efforts to promote access to medication for opioid use disorder in the hospital settings. Dr. Herring’s research has been funded by the National Institutes of Health (NIH) and the Patient-Centered Outcomes Research Institute (PCORI) and has been published in numerous journals including JAMA Open and Annals of Emergency Medicine; his work focuses on treatment of substance use disorders and pain management. He is a co-investigator NIDA CTN 0099 (ED-INNOVATION), and principal investigator for the Public Health Institute CA Bridge Outcomes Study. He has conducted health policy research as a Fulbright Scholar in Central America. Dr. Herring is board-certified in Emergency Medicine, Addiction Medicine, and Pain Medicine, and is Associate Clinical Professor of Emergency Medicine, at UCSF.

The CSAM News was recently published! Featured articles include Conference Photos, Like Minded Docs, President’s Message, CSAM 50th Anniversary Bash & More!

Spring 2021

By Ken Saffier, MD, FASAM, President, Medical Education and Research Foundation (MERF) for the Treatment of Addiction

What is MERF?

MERF was established in 1981 “to increase and improve the education of physicians about alcoholism and other drug dependencies” – specifically about the evidence, the science, and how to apply it to patients with substance use disorders (SUD’s). We particularly stress the clinical continuum of diagnosis, treatment and recovery for patients and their family members. As CSAM and the addiction medicine discipline have grown, we include other health professionals to receive our scholarships and we have evolved to destigmatize use disorders with our language and approach to education.

Progress despite the COVID Pandemic

In spite of social distancing and many changing schedules due to COVID-19, we funded a total of 85 MERF Scholars, the most ever. Forty seven were funded by the CA Department of Health Care Services (“MATES” – Medication Assisted Treatment Expansion Scholars) and 38 were our ”Traditional” Scholars composed of residents, fellows and faculty from graduate medical education programs. We increased our diversity of Scholars – 12 of our MATES were from the CA Department of Corrections and Rehabilitation and there were representatives from CA tribal communities. Most clinicians were employed in clinics from underserved communities. Due to the remote conferencing, we had Zoom orientation sessions for facilitators 2 weeks before and an orientation for all Scholars 1 week before to provide background and context for the conference activities. The “silver lining” for this new normal of COVID social distancing was that we were able to use remote conferencing economically, dramatically reducing the cost of our program per Scholar and admit more learners than ever before.

How does a MERF Mentored Learning Experience enhance Scholars education?

MERF activities are designed to immerse Scholars in an augmented learning environment emphasizing interactive educational with addiction medicine (ADM) experts and facilitators for maximizing meeting individual and program goals.

We started off our activities with a well-received “Motivational Interviewing for Busy Clinicians” pre-conference workshop via Zoom by Ken Saffier, MD and Karena Frances, LCSW, with 95 registrants and 17 small group MI facilitators. Then, during the CSAM conference, our Scholars participated in case discussions and sessions to empower future clinical and curricular change in their home programs and clinics. On the last day, all Scholars met in small groups, discussed and then shared their refined future educational and clinical goals.

We embellished the first series of CSAM plenary sessions by inviting Eric Hargis, DO, and Sharone Abramowitz, MD, speakers on the first day to guide a case study, “The world inside and outside the walls – :A journey of survival to recovery” involving incarcerated patients with SUDs, In their overall evaluations, a surprising number of comments thought their #1 take home point from the whole conference was learning about incarcerated patients’ needs and treatment strategies.

For the second year, we also offered optional ADM coaches who are CSAM members with special or general ADM interests. Some Scholars met with their coaches outside of our scheduled activities for informal discussions and exploration of mutual interests. This contributes to networking, continued clinical education and active, self-directed learning.

As in past years, we continued our quarterly journal clubs with presentation of an article written by the discussant. Our first session was attended by 56 Scholars, another record, to hear Jose Maldonado, MD, our superb SOA plenary speaker, “Novel Algorithms for the Prophylaxis and Management of Alcohol Withdrawal Syndromes – Beyond Benzodiazepines.” And more recently, in March, with 47 attending, we hosted Tauheed Zaman, MD, who presented on another important ADM topic, a review of micro-dosing buprenorphine protocols.

Another first is our new www.MERFposters.org website where all peer-reviewed posters can be placed before and after our annual conferences. We will expand this in the coming year with designated times for authors to present their pre-recorded description of their research, or programs, or cases as a means of promoting scholarly activities for MERF and CSAM.

Looking into our future

We are accepting applications for our MERF mentored learning experience at the upcoming CSAM Review Course. Because we are repeating a virtual conference, we hope to accept Scholars from residency and fellowship programs as well as practicing clinicians. However, without DHCS funding this year, we are reaching out to all CSAM members, prior MERF Scholars and other possible grants to promote our work.

What you can do

Please consider making a donation to MERF by going on our website, www.merfweb.org which also can be accessed from the CSAM website. Your $200 donation will fund 1 MERF Scholar. Please give generously.
We thank you in advance for making a tax-deductible donation today. Hope to “see” you at the review course!

Spring 2021

By Cathy McDonald, MD

Consider using ICOVIDQUIT.com to encourage those with TUD to quit

ASAM president-elect Brian Hurley, MD has renewed the commitment to “standardizing the delivery of individual addiction care, particularly including smoking cessation, and…adequate health insurance coverage for individuals with substance use disorders, particularly tobacco use disorders.” He was speaking at a press conference that reported a 27% drop in calls to state tobacco quit lines during COVID-19. The conference announced a new resource to help individuals with behavioral health conditions to quit smoking, which was developed under the leadership of the UCSF based Smoking Cessation Leadership Center. The site, Icovidquit.com features four diverse individuals with lived experience of behavioral health conditions who quit smoking. The site offers downloadable posters/videos for your office or for posting on social media.

Inform others that a YES VOTE is a vote for a flavored tobacco/menthol BAN on upcoming Tobacco Industry Sparked referendum

Prepare to inform others about the need for ACTION on SB796 (Hill), the menthol and flavored tobacco ban which CSAM supported and Governor Newsom signed. Because the ban on flavored products is being held up by a tobacco industry sponsored referendum, it will be important to inform patients, colleagues, friends and others that THEY MUST VOTE YES on the referendum in order to enact the ban that has been delayed, resulting in the loss of thousands of lives and recruitment of thousands of teens to smoking and vaping. This referendum will likely appear on the ballot in November 2021 with the recall election for Governor Newsom although the exact date has yet to be announced. A menthol ban will begin to address the years of targeting African Americans to buy menthol. You can begin to educate folks by posting something like this on your website or social media:

“Menthol cigarettes are killing Black people, and the @NYTimes just wrote all about it. Californians have the chance to finally end Big Tobacco’s dangerous scheme of hooking our kids on nicotine with candy flavors by voting YES to #ProtectCAKids
https://www.nytimes.com/2021/03/22/health/methol-smoking-ban.html”

The referendum does not affect the ability of local communities to ban the sale of flavored tobacco products and menthol which over 100 communities in California have done either partially or completely. See list here: https://www.tobaccofreekids.org/assets/factsheets/0398.pdf

Let colleagues know Addressing Tobacco Use in Substance Use Disorder (SUD) Treatment Facilities likely to pass the legislature soon and be required

Last but not least CSAM is co-sponsor of AB541 (Berman) which passed by consent in the CA Assembly Health Committee. Despite a smoking rate of 11% in CA, SUD programs in California ranked 41st of 50 states in asking about tobacco use and 32nd in providing tobacco treatment counseling according to an MMWR report. AB541, if passed, requires substance use disorder facilities to assess clients for tobacco use, inform patients how continued tobacco use can affect their recovery, and offer treatment or referral for treatment of tobacco use disorders. Assemblyman Berman’s bill also requires incorporating data on tobacco use amongst SUD clients into the existing SUD database system which will help the state track the magnitude of this issue currently estimated at an incidence of 70% of patients in SUD treatment are tobacco dependent.

To support tobacco related advocacy for CSAM contact Cathy McDonald, Dr.CathyMcDonald@gmail.com or Chwen-Yuen Angie Chen, MD, csameditor@yahoo.com.

Spring 2021

By: Randolph Holmes, MD and Robert Harris, CSAM Public Policy Advisor

The Legislature in Sacramento is slowly moving out of COVID-19 restrictions and getting on with the work of government. There have been limitations placed on the number of bills a Member from one house can carry over to the other side so some of CSAM’s bills have been moved to the 2022 calendar. Here are some important bills CSAM is sponsoring for 2021:

1. CSAM is supporting an appropriation of $40 million to continue a pilot program started in 2019 to grant hospitals $100K for the purpose of hiring behavioral health counselors and peer navigators in ED’s. These people help patients with addiction and behavioral health needs start treatment in the ED and continue it after leaving the hospital. This is included in the budget proposal from the Senate and the Assembly.
2. SB 57 (Wiener) this is the bill that will allow pilots for Overdose Prevention Sites (formerly known as Safe Injection Sites) to be started in San Francisco City and County, the City of Oakland, and the County of Los Angeles. It has passed out of the Senate and we anticipate it passing the Assembly. We will need a campaign to encourage Newsom to sign.
3. SB 110 (Wiener) this is a bill that would allow Contingency Management to be used at a treatment modality in publicly funded treatment programs. It is an evidence-based treatment for stimulant use disorders, but federal regulations prohibit its use with federal funds (Medi-Cal). It is currently out of the Senate and in the Assembly. We will need help from our friends in Washington (ASAM and others) to change federal rules.
4. AB 541 (Berman) originally required SUD treatment centers collect data on client smoking in addition to assessing and offering treatment for tobacco use disorder. It has passed unanimously in the Assembly and is now in the Senate. Unfortunately, the data collection requirement was removed in the appropriations committee. However, the bill still requires programs to do the assessment and offer treatment. Programs must demonstrate compliance with those provisions during their relicensing reviews.
5. Newsom has proposed $3.5 billion for youth behavioral health, this would include substance use treatment as well.