the mission of newstart is to provide a comprehensive...

1A P R O G R A M O F H E A L I N G F O R A L C O H O L A N D D R U G U S E D I S O R D E R S

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A P R O G R A M O F H E A L I N G F O R A L C O H O L A N D D R U G U S E D I S O R D E R S

The Mission of NewStart is to provide a comprehensivenetwork of treatment, education, and referral services forpersons with alcohol or other substance use disorders, andothers affected by the patient’s substance use.

IN THIS ISSUE…Directory of Services ..........................................1NewStart’s Scope of Treatment .............................1September is Recovery Month! .............................1Alcohol Screening Event Gets NewStart Touch..........2NewStart and Meriter Complete JCAHO Accreditation Survey .................................2WisSAM Elects New Officers.................................2Staff Profile...................................................2-3Passages ..........................................................3Fall Substance Abuse Conference ..........................3Advocacy Training for Physicians ..........................3Welcome New Employees ....................................3Marijuana: Health Effects.................................4-5Guest Article: Carbohydrate Deficient Transferrin ...................6-7Medical Director Active in Medical Organizations.....7NewStart Physicians Attend ASAM Medical-Scientific Conference .............................7NewStart Adolescent Services Updated ..................7ASAM 50th Anniversary Gala .................................8

NEWSTART’S SCOPE OF TREATMENTNewStart is the sole remaining hospital-

based treatment program for alcohol and druguse disorders in South-Central Wisconsin.NewStart continues to offer a full continuumof services including outpatient, intensiveoutpatient, and full-day treatment;detoxification; and inpatient rehabilitationservices. NewStart remains one of the fewlocal providers which accepts fee-for-serviceMedical Assistance patients. NewStartcounseling staff are all certified to provideaddiction treatment services through theWisconsin Certification Board, and all areMasters-prepared. In our current two-physician model of care, 24-hour coverage isavailable for emergency room and hospitalconsults and inpatient coverage while allowingfor consistent availability of physician servicesin our outpatient clinic every week.

SEPTEMBER IS RECOVERY MONTH!Recovery from alcohol and other drug

dependencies happens every day, to thousandsof persons nationwide. Long-lasting recoveryis enjoyed by millions. While alcoholism anddrug addiction can be progressive and evenfatal illnesses (almost 150,000 prematuredeaths per year in the USA, excludingnicotine-dependence deaths), recoveryhappens—and this is noted and celebratedeach year by the federal Center for SubstanceAbuse Treatment (http://recoverymonth.gov).

Wisconsin also recognizes Recovery Month.A major event each year is the Rally forRecovery on the grounds of the State Capitol,sponsored by the Wisconsin Association forAlcohol and Other Drug Abuse (WAAODA), theleading advocacy organization in our state forAODA issues. The third annual event is sched-uled for 11:00 to 1:00 on Saturday, September18. This year’s event will not focus on legisla-tive advocacy as in the past: it will simply bea celebration of the recoveries of thousandsof Wisconsin citizens. Music and food will beprovided. Recovering persons need to ‘puta face on recovery’ for the many people whodon’t understand that addiction can happento anyone, in any community, in any family,and that being diagnosed with alcohol or otherdrug addiction is not a ‘death sentence’, butinstead often leads, through recovery, to notonly restoration of health but an enrichedlevel of functioning and serenity for individu-als and their loved ones. Recovering personsare encouraged to join the state effort ofWAAODA called Alliance for Recovery Advocates(AFRA) and the national effort, “Faces andVoices of Recovery (FAVOR).” More informa-tion is available through www.waaoda.org andwww.facesandvoicesofrecovery.org.

DIRECTORY OF SERVICESAddiction Medicine Consultationand Evaluation Services (AMCES)

202 S. Park StreetMadison, Wisconsin 53715

(Ph) 608-267-6291(Fax) 608-267-6687

• Addiction Medicine Consultation and Evaluation

• Information and Referral• Chemical Dependency Assessment

• Emergency Services• Medical Inpatient Detoxification

• Nursing Evaluation• Referral Services

Outpatient Services and Adolescent Program

1015 Gammon LaneMadison, Wisconsin 53719

(Ph) 608-271-4144(Fax) 608-271-3457

• Assessment and Referral Service• Adolescent Intensive Outpatient Program

• Adult Intensive Outpatient Program • Adult Day Treatment

• Individual, Group, and Family Counseling for Chemical Dependency

and for Family Members• Chemical Awareness Programs

Inpatient ServicesUnit 1 East

202 S. Park StreetMadison, Wisconsin 53715

(Ph) 608-267-5330(Fax) 608-267-5334

• Adult Inpatient Rehabilitation Services

VOLUME XXV FALL 2004

ALCOHOL SCREENING EVENT GETSNEWSTART TOUCH

Anyone who passed through MeriterHospital’s Atrium on April 8 had anexcellent chance to learn more aboutalcohol and its effect on health, thanks toNewStart’s participation in NationalAlcohol Screening Day activities.

NewStart manager Michael Gerst andother counselors were present throughoutthe day, providing information aboutalcohol and health, and offering freescreenings to those who approached andrequested one. Screening included theAlcohol Use Disorders Identification Tool,the same questionnaire used by theWorld Health Organization (http://whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6a.pdf), and one easilyused in any primary care medical setting.

Additionally, NewStart Medical DirectorMichael Miller, M.D., was featured speakerat a noon community education talk on“Alcohol and the Workplace” in Meriter’sCommunity Health Education Center.

Alcohol Screening Day (www.nationalalcoholscreeningday.org/alcohol.asp) is a program of screeningfor mental health, and conducted incollaboration with the National Instituteon Alcohol Abuse and Alcoholism and theSubstance Abuse and Mental HealthServices Administration of the U.S. Depart-ment of Health and Human Services.

Meriter, Madison’s community hospital,is dedicated to improving the health ofour community, and participates in severalscreening events such as this every year.For a list of activities at Meriter’s Commu-nity Health and Education Center, contact(608) 267-5900, or go to our Web site atwww.meriter.com and click on the tab thatreads “Register Online for Classes & Events.”

NEWSTART AND MERITER COMPLETEJCAHO ACCREDITATION SURVEY

The Joint Commission on Accreditationof Healthcare Organizations has accreditedMeriter Hospital and all its services,including the NewStart Program, foranother three years. A survey team fromJCAHO visited Meriter for a full week inMay, 2004, with a special surveyor spend-ing a day with NewStart alone. This will beour last scheduled triennial on-site survey.

Our next survey will occur in approximatelythree years, but will be unannounced,which means that we must maintain con-tinuous readiness at all times. In addition,organizations must complete and submitto the Joint Commission a Periodic Perfor-mance Review (PPR) and plan of action andidentify appropriate measures of success atthe 18-month point in the accreditationcycle. The hospital participates in a con-ference call with Joint Commission staffto discuss plans to address standardsidentified as being not in compliance.

Only recently did the federalgovernment change from a ‘certification’to an ‘accreditation’ process for licensingmethadone facilities. In May, a separate one-day JCAHO survey for NewStart’s ‘OpioidTreatment Program’ was conducted andNewStart received a three-year accreditationcertificate for this small service.

Meriter/NewStart does not offermethadone maintenance services; MadisonHealth Services (608-242-0220), a for-profitfree-standing clinic, is the only licensedprovider of methadone maintenance treat-ment in the Dane County area. However,Meriter does maintain a license which allowsit to use methadone as the treatment agentfor selected in-patient cases of opioid detoxi-fication. Several times a year, there is a casein which use of first-line opioid detox agents,such as clonidine or buprenorphine, is notfeasible; in those cases, Meriter physicianshave the ability to prescribe methadone fordetox purposes—for inpatients only.

WISSAM ELECTS NEW OFFICERSThe Wisconsin Society of Addiction

Medicine (WisSAM), the state chapter ofASAM, held an organizational meeting inDelafield on August 12. President LanceLongo, M.D. ended his term by hosting anenthusiastic meeting. The new president ofWisSAM is Michael Bohn, M.D., of AuroraBehavioral Health in Milwaukee. ElectedVice President is Randy Brown, M.D., of theUW Department of Family Medicine inMadison, and a NewStart Panel physician.Re-elected as other officers are DeanWhiteway, M.D. of Gunderson-Lutheran inLaCrosse, as Secretary, and Randy Kieser,M.D., of Madison Health Services andMetaStar, as Treasurer. Dr. Whiteway willcontinue as WisSAM Delegate to the Wiscon-sin Medical Society. Dr. Brown was named

chair of the new Membership Committee ofWisSAM. Dr. Mike Miller, WisSAM’s found-ing president, was named chair of the newPublic Policy Committee of WisSAM.

STAFF PROFILE:KATHRYN CURIO, RN, MSN, AMCESNURSE

I applied for graduate school in commu-nity mental health-psychiatric nursing inmy early twenties, hoping to figure myselfout. Well, THAT hasn’t happened, but I’vehad some interesting experiences and hope-fully have done some good because of thatdecision. I’ve been a staff nurse and a headnurse, an administrator, an assistant pro-fessor and a sexual assault nurse examiner;I’ve worked at PACT (a psychiatric patientcommunity service provider which wrapsits services around the client, thus allowingthem to remain in the community), andin forensics (patients found not guilty ofa felony because of mental illness or defect)at Mendota. I found academia “meetingmad and conference crazy” (ViktorFrankel). And inpatient forensic psychiatryI found to be like anaesthesiology: periodsof boredom interspersed with terror.

Throughout my career I’ve worked withthe addicted: dually diagnosed patients onthe VA psych unit, in PACT, in forensics.I studied at the Summer School of AlcoholicStudies at Rutgers University. And now I amwith New Start. Essential to my work withour patients, I think, is that I’ve had yearsof honing communication skills, experi-menting with what does and does not workfor me, playing with different techniques.In this work I have to connect quickly inthe emergency room or on Meriter’snursing units, and I’ve found “mirroring,”a neurolinguistic approach, helpful. Forexample, a detox patient is angry becausethey’re not allowed off the medical floor fora cigarette. After stating what the limit is,I will reflect back the feeling (anger) in thepatient’s voice tone (loud) in the same speed(fast), perhaps using their own words.“You’re mad because you’re not allowed offthe unit for a cigarette!” They may stillleave AMA, but they will feel understoodand that will make it easier for them toreturn to be treated for their illness whenthey are ready.

Attitude too is crucial in helpinga patient. I do not see myself as separate,different from the patient. Our challenges

N e w S t a r t V o l u m e X X V • F a l l 2 0 0 4 2

for NewStart’s former Medical ManagementUnit at Meriter Capitol’s 5-West for fiveyears, and her last position at NewStartwas back at the eventual successor to thatservice, our Adult Inpatient Program andDual Diagnosis Program on the new adultpsychiatry unit at Meriter-Park’s 1-East.In between, Bonnie has touched the livesof countless patients and families, servingpersons of all ages: as an inpatient counselorat the CBRF following Pat Sweeney, as a coremember of the NewStart Adolescent Programdoing individual and family intakes andcounseling plus the Intensive OutpatientProgram, and as an individual counselor atour Gammon Lane clinic (among the clientgroups she enjoyed were senior citizens).Bonnie will remain an on-call NewStartcounselor.

The number of people who appreciativelyremember Steve and Bonnie as no-nonsensecounselors who would ‘tell it like it is’ whileclearly respecting and having warm fond-ness for them and the challenges of theirrecoveries, is countless. Their colleaguesand supervisors at NewStart will missthem as well, and look forward to theirtales of retirement.

Also, NewStart Secretary MelissaCarpenter has moved on since our lastNewsletter, taking a nice promotion withinMeriter Hospital.

Passages for Jennifer Schoff: The BIGnews is that Jen and her husband are‘expecting.’ The OTHER news is that Jen,who has been a great member of theNewStart team, filling in in a variety ofroles as a 0.0 FTE counselor in the adoles-cent and adult programs, has accepted aposition as a permanent counselor on ourstaff. Her primary responsibilities will beon the Adult Inpatient Program on 1-East,filling the role of Bonnie Allen. Like Bon-nie, Jen will job-share the 7-day-per-weekcounselor coverage on 1-East with counselorPeter Laubach.

STATE CONFERENCE: OCTOBER 13-15The Wisconsin Bureau of Substance

Abuse Services (now the Bureau of MentalHealth and Substance Abuse Services) willhold its 10th Annual Fall Conference thisyear at Kalahari Resort in Wisconsin Dells,October 13-15, 2004. This outstanding educa-tional opportunity is recommended for anyphysician, nurse, social worker, psycholo-gist, or counselor interested in learning

more about addiction treatment, and eachyear the Bureau reaches out to others(including educators, public health profes-sionals, child welfare and criminal justiceprofessionals, and others) through itsannual conference.

ADVOCACY TRAINING FOR PHYSICIANSAt this year’s Bureau Conference,

physicians from around the state interestedin learning more about how to advocate forpatients and for improved treatment, willget together for a ‘primer’ course to befacilitated by NewStart’s Medical Director,Dr. Mike Miller, former Chair of the PublicPolicy Committee of ASAM and now chairof the new Public Policy Committee ofWisSAM. The political process has significantinfluence on what does or does not happenin both public sector and private sectorfunding streams and delivery systems foraddiction care. Parity for mental health andAODA benefits is but one legislative topic ofimportance to addiction professionals. TheTIP (Treatment Instead of Prison) bill bySen. Roessler and the medical marijuanabill to be introduced by Rep. Underheim areother examples of bills that could affectpatients and families. Thursday evening,October 14 has been set for this meeting ofthe WisSAM Public Policy Committee.

WELCOME NEW EMPLOYEESJane Edwards has accepted a position

as Secretary at the NewStart OutpatientClinic. She started September 16 and wewelcome her to our staff on Gammon Lane.

Jennifer Weiss is a student at UW-Madison and she will be working with thesupport staff at the Gammon Lane this yearas a work-study student. We are pleased tohave her, and the support staff is lookingforward to the help she will provide!

Bobbie-Jo Nichols “BJ” is a second-yearstudent in the Masters of Science in SocialWork program at the UW-Madison. Shehas accepted a field placement at NewStartas a Social Work Intern, and will beworking with our Adolescent IntensiveOutpatient Program.

A P R O G R A M O F H E A L I N G F O R A L C O H O L A N D D R U G U S E D I S O R D E R S 3

may be different, but we are all in thiscosmic dance together. Martha Rogers,a nursing theoretician, describes each of usas a bundle of energy interacting with eachothers’ bundles of energy—very Buddhistin that she views us all as interconnected.Newton and Descartes may see us each asindividual machines, but some scientistsare now studying our interconnectednessand creating new knowledge: nonlocalityin quantum physics, electromagnetic cellcommunication, biophoton emission in thehuman body, biological effects of the layingon of hands, menstrual synchronization.

In nonwork time, I wife and I mother;I sail in the summer. I write (I had my firstessay published in a literary journal inSpring, 2004); I volunteer (I was namedWisconsin NAMI [National Alliance for theMentally Ill] Volunteer of the Year this pastspring); I exercise, knit, cook, and I walkmy Rottweiler at the dog park; I read andI study. And daily I pray to be worthy ofmy work, my life.

PASSAGESTwo of NewStart’s finest and longest-

serving counselors, familiar to many of you,have begun the AARP phase of their lives.

Steve Hansen joined NewStart in 1984.After a career in business, his personalrecovery led him into the counseling field,and he received a master’s degree, workedat the former DePaul-Madison, then joinedthe staff of our then-brand-new NewStartResidential Center on Raymond Road. Stevehelped hundreds of persons into recoveryat the CBRF where he was one of the corestaff including his colleagues David Back,Kim Rice, and Pat Sweeney. He moved withthe CBRF staff to the inpatient/day treat-ment unit at Meriter Capitol’s 2-West in1996, and then went into semi-retirementin 2001, doing outpatient assessments, indi-vidual counseling, and coverage duty in ourintensive outpatient programs. Steve’scommitment to recovery was unflagging(and still is!), and his perspective as arecovering person himself was invaluableto his co-workers and his patients alike.

Bonnie Allen also pursued counseling asa second career. She received her Masters ofSocial Work from U.W. Madison in 1987,beginning at NewStart as an intern. Sheand her colleague at that time, SherriMartin, served as the inpatient counselors

September is Recovery Month

Marijuana:Addiction and OtherIssues Michael M. Miller, M.D.

This is the first in a series of articles by NewStart’sMedical Director, the second of which will appearin the next issue of the NewStart Newsletter,and is entitled: “Marijuana: Health Effects.”The final article will be entitled “Marijuana:Health Benefits?”

Marijuana has an interesting historyin the United States. Though used withinminority groups (e.g., urban Blacks, includ-ing musicians, artists, and the generalpopulation) in the first half of the 20thCentury, it wasn’t until majority youth(White college students, then high school-ers, from suburban and even rural areas)began smoking ‘pot’ in the 1960’s and after,that marijuana gained the attention ofmedical researchers, parents, governmentofficials, and the media. By 1979, more than60 percent of 12th-graders had tried mari-juana at least once in their lives. From thispeak, the percentage of 12th-graders whohad ever used marijuana decreased formore than a decade, dropping to a low of33 percent in 1992. However, by 1993, first-time marijuana use by 12th-graders wasagain on the upswing, reaching 50 percentby 1997. Marijuana is the America’s mostcommonly used illegal drug—more than1/3 of the U.S. population ages 12 andolder have tried marijuana at least once.According to the 2001 Monitoring theFuture Study, an annual survey of drug useamong the nation's middle- and high-schoolstudents, 22 percent of 12th graders—kidswho had not dropped out of school—werecurrent users.

Marijuana has always been a ‘politi-cized’ subject—as are all ‘controlledsubstances’ that are regulated by the gov-ernment. It is common knowledge thatmarijuana is a plant that grows wild inmany parts of the country, but to possess itor distribute is a crime. There is a currentpublic debate about decriminalization ofdrugs, especially marijuana. A frequently-used argument in such debates is that mari-juana is relatively harmless, so prohibitionof its use is illogical. One thing which

distinguishes marijuana from other illegaldrugs is that there are significant advocacygroups whose sole purpose is to legalize thissubstance: cocaine and heroin never hadtheir version of NORML (the NationalOrganization for the Reform of MarijuanaLaws). Some of the appeal of such advocacypositions has come via their reaction togovernment scare tactics used to discouragemarijuana use (in fact, the film ‘Tell Your

More recently, pharmacologists have beenstudying potential health benefits of THC.With this has come a movement to legalizemarijuana for use by ‘patients’ to relievevarious medical conditions or symptoms.

Key issues about THC and marijuana areas follows:

1. There are indeed several documentedhealth benefits to pharmaceuticalTHC, taken orally by patients, incapsule form, under a physician’sprescription.

2. Smoked marijuana is not identical toTHC, and health benefits from smok-ing marijuana leaf have not beendemonstrated to date in clinical trials.

3. For any agent to be approved as a‘medicine’, it must undergo review(e.g., by the Food and Drug Adminis-tration) to confirm that it is both safeand effective—and though it is fairto assume that since the active ingre-dient (THC) is effective in relievingsome symptoms of illness, then thebiological product that contains thatingredient (marijuana leaf) will alsobe effective, the issue of safety is ofcritical importance. How safe is it tosmoke marijuana leaf? What toxicitiescan occur?

4. To what extent is marijuana truly‘addictive’? Does the syndrome ofchemical dependency develop in somepersons who smoke marijuanaregularly? And would this occur inpatients using marijuana leaf for‘treatment’ of an approved medicalcondition or symptom?

‘The Addiction Question’ is one of themost intriguing issues. The majority ofmarijuana users do not develop addiction:they do not experience ‘loss of control’,they use when they choose to, in theamounts they choose to, getting theresults—in general—that they intend toget. Parents of today certainly recall manyacquaintances from college in the 1960’s or‘70’s, or from high school in the 1980’s or‘90’s, who smoked marijuana regularly,without long-term negative consequences.Similarly, the vast majority of alcohol usersdo not develop alcoholism: only 10 percentof regular drinkers develop ‘loss of control’and other features of addiction. Even


Children’ from 1938, later renamed ‘ReeferMadness’, was actually purchased by thefounder of NORML and shown to collegekids as a mockery of propagandized posi-tions opposing marijuana smoking). Becausemarijuana use has been so widespread inthe cohort of Americans who are now ages35-55, and because is was the experience ofthe vast majority that one can smoke mari-juana, even frequently, and not suffer long-lasting harm, it is counter-intuitive even forparents and civic leaders to believe thatmarijuana can be harmful.

Marijuana was originally placed in thesame drug class as hallucinogens by medicalresearchers, since heavy use is able to pro-duce some of the same effects as LSD andpeyote. Researchers have been studyingthe behavioral effects of THC, the activechemical in marijuana, for decades, as wellas the health effects on various organ sys-tems of chronic smoking of marijuana.

regular cocaine use can proceed in a phaseof a person’s life and then fade away with-out life-long addiction taking hold of theuser. But just because addiction doesn’toccur to all users, or even most users,doesn’t mean that addiction doesn’thappen—to any user.

Addiction to marijuana has the samefeatures as addiction to other substances:after a period of regular but controlled use,the person gradually develops an inabilityto consistently use within the limits thathe or she has set for themselves. Use won’tjust result in ‘fun’ or ‘getting high’; it willlead to problems, with job performance,school performance, interpersonal relation-ships, or even health. Others will commentthat there is a change in the user—andthe user will at first deny or rebut suchconcerns. Use will continue despite theproblems caused by use. Larger and largeramounts of the substance are used, consum-ing money that could go to other purposes,and the person may spend more and moreof the day or the week either using, orthinking about using, or conniving to getmore supplies of the drug, or planning onhow to connive. The substance use takes ona central place in the person’s life, withother activities—including major liferesponsibilities—falling by the wayside.Despite the pleas of friends or family toexamine one’s behavior, or to change thebehavior, substance use continues on,causing distress to others before the addictexperiences the distress him/herself. Thisis the cycle of addiction, and it does hap-pen to many pot smokers. Eventually, theperson may seek help, or at least agree toa professional assessment at the behest offamily, school or employer.

The fact is that for persons under age 18, the Number One substance usedisorder for which persons seek the helpof NewStart is a marijuana problem.Cannabis Abuse is just as common asCannabis Dependence among patients inthe NewStart Adolescent Program. ‘Depen-dence’ is a term equivalent to ‘Addiction’in this context, and involves preoccupa-tion, inability to consistently control theamounts used, and unsuccessful efforts tocut down or persistently eliminate use, asdescribed in earlier paragraphs. ‘Abuse’,as defined by the DSM Criteria, involvesrecurrent use despite legal, occupational,

or academic problems (e.g., recurrent useafter an arrest for impaired driving or awork suspension because of a positiveurine drug test), or recurrent use after com-plaints from others (parents, school person-nel) that they have observed an impairmentof functioning associated with persistentmarijuana use. This relatively less severesyndrome, ‘cannabis abuse’, certainly cre-ates distress for loved ones (family) andinterested parties (teachers, social workers,co-workers or supervisors), and by defini-tion involves an observable downturn in theuser’s performance of some important lifetask. NewStart offers individual and grouptreatment for persons with Cannabis Abuse,including a Chemical Awareness Programfor adolescents which has a health-education focus. But, when indicated,we also refer youth with a diagnosis ofCannabis Abuse into our IntensiveOutpatient Program.

Now it is known, as reflected in the DSM-IVcriteria, that tolerance or withdrawal mayoccur in individuals with ‘dependence’or ‘addiction’, but that the condition ofaddiction can exist without there beingany sign or tolerance or withdrawal. Still,a common question of interest is, doesmarijuana produce ‘physical dependence’,that is, tolerance or withdrawal.

By the 21st Century, the answers to thesequestions are clear. Tolerance does developto THC, and the neurochemical details ofhow this occurs, and to which cannabinoidreceptors, is well known. Tolerance is dueto cannabinoid receptors becoming lesssensitive to THC’s effects over time. Toler-ance to marijuana is not due to changes inTHC metabolism over time. Interestingly,there is some cross-tolerance betweencannabinoids and opioids (see the futurearticle on ‘Health Benefits?’). Moreover,withdrawal definitely occurs in some users.The effects are generally the opposite of theeffects of intoxication: anxiety and insom-nia instead of relaxation, loss of appetiterather than hunger, excess salivationinstead of dry mouth, decreased pulse,irritability, and even tremor. Much hasbeen written on the relationship betweenanger and marijuana use. It is likely thatin some individuals, THC decreases theexperience and the expression of anger,and that after cessation of marijuana use,the person can not only be irritable, butcan have an increase in mood swings andanger and even an increase in aggressivebehavior.

A Final Comment

Even though marijuana use has beencommon in many segments of the Americanpopulation for two generations, and manyadults and teenagers know marijuana userswho have not developed addiction to evenprolonged use, the potential for the devel-opment of addiction is almost certainlygreater today than in the 1960’s or 70’s,because the marijuana of today is different.It’s not just that it’s much more expensive;it’s that the THC content of today’s ‘pot’is several times higher than even strong‘weed’ from the original Flower Power era.This makes it more rewarding, but alsomore likely to induce tolerance and trueaddiction.


How do some users of marijuana developimpairment in their functioning? This willbe the focus of the article in our next issue,entitled "Marijuana: Health Effects."

Tolerance and Withdrawal

Two decades ago, addiction medicinedoctors and counselors believed that thedifference between the syndrome of‘substance abuse’ and the syndrome of‘substance dependence’ was whether or nottolerance and withdrawal were present.

In giving patients feedback on their lev-els of CDT, the clinician should present theinformation objectively, yet empathetically.It is also important that the information begiven in a manner that is fully understand-able and compelling to the patient. Use offigures and graphs showing where thepatient’s CDT test results fall (relative to thelaboratory reference range of the test, orin comparison with the general population)should assist in this. Showing the patienta plot of his or her test values during thecourse of treatment should also reinforcechange efforts or, if the tests reveal a pattern of rising scores, elicit discussionof a relapse event and its precipitants.

How frequently should CDT-testing beperformed during treatment andcontinuing care?

CDT testing has been used for years bythe life insurance industry in the UnitedStates, but is just now becoming used inclinical settings. In Europe, it is used inclinical settings, but even more so by thelegal system, to monitor abstinence inpersons convicted of driving while intox-icated. In treatment settings, CDT testingshould be done more frequently early inthe recovery process, the period of highestrisk for relapse. As the patient’s recoverystabilizes, testing frequency can diminish.One recommended strategy is to testpatients every two weeks for the first threemonths in recovery and then reduce testingto once a month during the later monthsof follow-up and continuing care if thepatient otherwise appears to be doing well.

How should CDT results be interpreted asindicators of likely relapse?

Two strategies have been used foridentifying relapse based on a review ofCDT results. The first involves simplylooking at ongoing CDT test values to see ifthey exceed the cutoff value of the test(i.e., 2.6%CDT). The second approach, whichis becoming more popular and is probablypreferable, involves examining the patternof test scores for each patient across time.If the current value exceeds by 30% or morethe lowest value observed for that patientup to that point in time, then the patient isassumed to have relapsed.


Guest Article:

Carbohydrate DeficientTransferrin: an emergingtool to identify and treatindividuals with alcoholuse disordersPamela Bean, Ph.D., MBA

What is CDT?

CDT stands for ‘carbohydrate-deficienttransferrin.’ Transferrin is a glycoproteinthat transports iron in the bloodstream tocells where it is needed. For reasons thatare not yet fully understood, drinking inthe range of four or five drinks a day for atleast two weeks results in this glycoproteinlosing its carbohydrate content: thetransferrin is thus referred to as being‘carbohydrate-deficient.’ If the person whohas been drinking like this for two or moreweeks stops drinking, CDT returns towithin the normal range in three to fourweeks. Interestingly, CDT has also shown a“sensitization effect.” This refers to the factthat levels of CDT often rise dramaticallyand rapidly in patients who have beenabstaining from alcohol for a while andthen return to drinking, even if in fairlylow amounts. This apparently uniquecharacteristic of CDT makes it an especiallyuseful early indicator of relapse in patientswho are in alcohol treatment.

Although there are several other usefulbiological markers of heavy drinkingavailable – such as the liver enzyme gammaglutamyl transferase (GGT) and the meancorpuscular volume (MCV) of the red bloodcell – the unique advantage of CDT is thatvery few conditions, other than alcoholconsumption, cause CDT to rise. Otherbiological markers tend to reflect dysfunc-tion in body organs that, while often dueto heavy drinking, may also be caused byother common physical problems. Further-more, whereas testing for blood or urinealcohol concentration measures very recentalcohol consumption, the CDT test measuressustained alcohol use, and CDT valuesremain elevated for several days afterdrinking has stopped.

The standard way of measuring CDT is tomeasure it as a percentage of circulatingtransferrin that is carbohydrate-deficient.In 2001, the FDA approved a single kit thatclinical laboratories can use to detect trans-ferrin levels and calculate the percentageof circulating transferrin which iscarbohydrate-deficient. The cutoff value forthe %CDT test is 2.6% and is the same formales and females.

Why is CDT particularly useful?

There are many good self-reportingquestionnaires to aid in identifying peoplewith drinking problems – such as the CAGE,the Michigan Alcoholism Screening Test(MAST), and the Alcohol Use DisordersIdentification Test (AUDIT) – but someindividuals who drink at risky levels or aredependent on alcohol may not be able orwilling to admit their level of alcohol intakeor the problems that alcohol is causing them.As an objective biological measure, CDT canassist in identifying these individuals, thushelping them enter the alcohol treatmentservices they need. In addition, measuringCDT values over time is helpful to givefeedback to patients with the aim ofenhancing their motivation for change.CDT performs very well as an indicator ofrelapse in patients who are receivingabstinence-oriented alcohol treatment.

How can CDT results be used to motivate change in patients with alcohol problems?

Providing feedback to patients has beenrecognized as a key element in enhancingmotivation of patients to modify theirdrinking behavior. The treatment manualfor Motivational Enhancement Therapy inProject MATCH provides recommendationsfor doing this. One of the earliest studies ofbrief intervention illustrated the benefit ofusing feedback based on a biochemicalmarker. During a five year follow-up,patients who had had high levels on GGTand who had been given feedback onsubsequent GGT levels revealed significantreductions in alcohol consumption, sickdays, hospitalization rates and mortality.Since GGT levels can also be elevated fromnon-alcohol related conditions, the use ofa biomarker such as CDT that is specific toalcohol consumption, is expected to provideeven better results. (Continued on page 7)

How can CDT be used in the workplace?

A recent study (U. Hermansson et al,Occupational Medicine [London]. 53(8):518-26. 2003) in a large workplace settingdescribes the use of CDT to screen dayworkers and shift workers for high-riskalcohol consumption. In a similar study bythe same group, CDT was used to examineabsenteeism due to sickness over a periodof 36 months; absenteeism data wasobtained through the company’s payrollsystem. In both studies, employees whoattended a regular routine health screeningwere offered voluntary screening with theAUDIT and CDT. Almost 1000 employeesparticipated in this study and 20% screenedpositive by either the AUDIT or CDT.Accordingly, the studies concluded thatworkplaces have a good reason for usinga more systematic approach to alcoholscreening.

How can I use and learn more about theCDT test?

Meriter’s General Medical Laboratoriesis now performing CDT tests for outpatientsas well as inpatients. Physicians can orderCDT tests for outpatients as well as in-patients from Meriter’s GML. GML sendsthese tests to an outside laboratory. In2005, GML hopes to be performing CDT testsin-house. For more detailed information,see the review article by N. Montalto andP. Bean, “Use of contemporary biomarkersin the detection of chronic alcohol use,” inthe international journal Medical ScienceMonitor [, Vol. 9(12):RA285-90, 2003] orcontact Dr. Bean for reprints (Phone: 608-829-1973; E-mail: [email protected]).

Dr. Bean is Executive Director for Research atRogers Memorial Hospital in Oconomowoc, WI.She has a Ph.D. in Experimental Pathology fromthe University of Southern California and hasreceived many awards including the YoungInvestigator Award from the American Society ofAddiction Medicine in 1997. She serves as a con-sultant for several companies developing new bio-markers to detect alcohol consumption includingAxis Shield in Dundee, Scotland, Alcohol DetectionServices in Big Bend, Wisconsin and U.S. DrugTesting Laboratories in Des Plaines, IL.


NEWSTART ADOLESCENT SERVICESUPDATED

Times are changing, and so has theNewStart Adolescent Program. TheNewStart Adolescent staff has beenworking on changes to update and improvecare. New educational materials have beenadded, to include updated videos,worksheets, games, art activities and morehands on experiences. These changes havebegun and the adolescents and theirparents are enjoying and benefiting fromthese new therapeutic experiences.

One notable change is the hours thatAdolescents and their Parents meet for theAdolescent Intensive Outpatient Program.The Adolescents now participate in theirtherapeutic groups on Tuesdays andThursdays from 5:00 to 8:00 pm.Adolescents and their Parents participatetogether on Mondays from 5:00 to 8:00 pm.This change has been made to have moreflexibility when developing a therapeuticplan for each family. This allows for moreadolescent individual sessions andindividualized family therapy.

Also, a Phase System has been developedto allow the adolescent to progress throughtreatment at their own individualizedpace. The adolescent is encouraged by thePhase System to take more responsibilityfor his or her treatment. They progress bycompleting goals to move into a lessintensive level of care. Subsequent Phasesof their therapy with the intensivetreatment program may includeindividuals, support groups and/orfamily sessions to be scheduled.

We’ve also involved additional staffmembers in our Adolescent Program.Joining Lori Brattset, Jeanne Kinney andNancy Millard in our Adolescent Programare counselors Christopher Henry andPatrick Nichols.

The NewStart Adolescent Team ispleased with how these changes haveenhanced the treatment experiences ofthe Adolescents and their families. TheAdolescents have taken more responsibilityfor their own progress. Their progressdetermines the length of time it takes forthem to complete the Phases of IntensiveOutpatient Treatment.

If you have any questions about theAdolescent Services at NewStart, please feelfree to contact any of the Adolescent Teamat 271-4144.

Carbohydrate Deficient Transferrin(Continued from page 6)

MEDICAL DIRECTOR ACTIVE INMEDICAL ORGANIZATIONS

NewStart Medical Director Michael M.

Miller, MD, served as a Delegate from the

Dane County Medical Society to the Wiscon-

sin Medical Society House of Delegates at

the WMS Annual Meeting April 2-3 in Madi-

son. At that meeting, Dr. Miller was re-

elected to serve on the WMS Nominating

Committee from District 2, and was

re-elected to represent the WMS as an

Alternate Delegate to the AMA House of

Delegates. He has been a member of the

WMS Delegation to the AMA since 2001.

Dr. Miller has been nominated by the

Nominating and Awards Committee of

ASAM to be candidate for President-Elect

of the American Society of Addiction

Medicine for 2005-07. He previously served

as Secretary of ASAM, and chaired ASAM’s

Public Policy Committee from 1999 until

April, 2004.

The Wisconsin Society of Addiction

Medicine also recently named Dr. Miller

chair of its new Public Policy Committee.

NEWSTART PHYSICIANS ATTEND ASAMMEDICAL-SCIENTIFIC CONFERENCE

All three of NewStart’s physicians

participated in ASAM’s annual meeting in

Washington, DC, at which ASAM celebrated

its 50th Anniversary with a major gala (see

pages 4-5). At the gala, Randall T. Brown,

MD, was honored for presenting the

Abstract of the Year for the Medical-

Scientific Conference. A new feature for

this year’s 35th Annual Medical-Scientific

Conference was a Plenary Session focusing

on Public Policy. Michael M. Miller, MD,

gave a presentation at the plenary on

how ASAM develops and makes use of

its Public Policy Statements

(http://www.asam.org/ppol/Table%20of%20

Contents.htm).

Drs. Miller and Brown also attended

a workshop on buprenorphine treatment in

office-based settings, for which Dr. Miller

served as a panelist.

ASAM 50TH ANNIVERSARY GALAThe American Society of Addiction Medicine held a 50th Anniversary Gala to celebrate ASAM’s first half-century. The Gala took place

in Washington, D.C., April 24, 2004, as part of ASAM’s 35th Annual Medical-Scientific Conference. ASAM is the largest national medicalspecialty society devoted to addiction treatment, education, research, and advocacy. NewStart’s Medical Director, Michael M. Miller, M.D.,FASAM, attended the celebration.

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Dr. Miller, outgoing Chair of ASAM’s Public Policy Committee,with Dr. Bob Dupont (the first Director of the National Insti-tute of Drug Abuse – NIDA – and the second Director of the

White House Office of National Drug Control Policy (ONDCP –the ‘Drug Czar’s Office’) and Dr. Mark Kraus, MD, FASAM ofConnecticut, incoming Chair of the Public Policy Committee.

James F. Callahan, D.P.A., Executive Vice President/CEO ofASAM from 1989-2002, and David Mee-Lee, MD, FASAM,

creator of the ASAM Patient Placement Criteria, enjoy the evening.

Anne Geller, MD, FASAM, President of ASAM 1993-95. Stu Gitlow, MD, ASAM’s Delegate to the AMA. Gail Jara,Executive Director of the California Society of Addiction

Medicine 1973-1999. Michael Miller, MD, FASAM, Past Delegate to the AMA from ASAM.

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