Saturday, December 12, 2009

Military Service Members, Veterans and Their Families

This past week, I spoke at the 2nd Annual Trauma Spectrum Disorders Conference, which is a scientific conference on the impact of military service on families and caregivers, held on the National Institutes of Health campus in Bethesda, MD. Many government agencies collaborated, including NIH, the Department of Defense, the Veterans Administration, the Department of Health and Human Services and others. I applaud these agencies in their efforts on behalf of those who have borne the burden of our recent military campaigns in Iraq and Afghanistan. The focus of the conference was on translation of research findings into clinical care and policies and identification of priority areas needing additional research. This conference offers a good example of the challenges of evidence-based medicine (EBM).
The fact is that using research findings to guide care is seldom straightforward. Most areas of medical care do not have high level research evidence underlying them. Even where high-level evidence is present, applying it is not easy. Most high-quality studies are highly controlled efficacy trials in academic health centers. In order to isolate the question being investigated, study participants are carefully selected. People with other serious medical, psychiatric or substance use disorders are often excluded, as are people with no transportation or who have to work two shifts a day to make ends meet. Studies are usually time-limited, although most diseases are chronic. The level of care provided in efficacy trials is almost always higher than that in usual care. Thus, generalizing findings from efficacy trials to community care is difficult, because patients in the community differ in systematic ways from study participants and community care necessarily lacks the rigor present in efficacy trials. For example, in an excellent NIH-funded study comparing different treatments for attention deficit disorder (ADD), stimulant medication was found to be a highly effective when rigorous medication management procedures were employed, but was not at all effective as used in common practice where systematic follow-up and careful medication treatment protocols were absent.
A related problem is that clinical research is very expensive and time-consuming. Thus, clinical realities often race ahead of the research. Neither clinicians nor consumers feel they can wait for the next study before acting. This is certainly the case for military service members and their families. Many medical advances, especially in trauma care and surgery, are made on the battlefield out of desperate necessity. Exposure to battlefield conditions may lead to previously unknown disorders, such as Gulf War Syndrome, that nevertheless require treatment (and determinations regarding disability.) It has taken a long time to address Post Traumatic Stress Disorder (PTSD), Traumatic Brain Injury (TBI) and the disorders that often accompany them such as substance use and other psychiatric disorders. Management of chronic pain remains controversial and difficult. Spouses, children and extended family members of those who are serving also experience serious stress including financial strain, prolonged absence of their loved one and having to care for a veteran with service-related injuries including PTSD and TBI. In none of these areas is there a strong evidence base providing guidance. Yet, we have a responsibility to do what we can. That’s what I spoke about today, and I’ll discuss that more in a future post.

Friday, December 4, 2009

What's Needed to Transform the Treatment System?

Today I heard a presentation by Tom McLellan, PhD, the Deputy Director of ONDCP, outlining the priorities of the Obama administration concerning “demand reduction,” i.e. prevention and treatment. Dr. McLellan and those he works with are to be commended for developing a thoughtful and comprehensive approach. You can read more about it here:

At the same time, I have some concerns about their approach. My overarching concern is that it may not fundamentally alter the care system in the country but instead attempt to incrementally improve the existing one. I think the existing one, based on a now outmoded idea, is so flawed that it cannot be sufficiently improved. Instead, we need to move in a more transformative way, offering a completely new way of thinking about and treating substance use disorders.

One particular concern is that their approach seems unlikely to close the largest treatment gap there is: the people lying between at-risk users (the target of SBIRT) and people with severe, chronic or recurring dependence (the target of traditional treatment programs.) Between lie all the people with mild to moderate dependence who remain highly functional even though they are concerned and are struggling with their use. They primarily have symptoms of compulsive use: using larger amounts and for longer times, persistent desire to quit/down and being unable to do so, and using despite psychological or physical symptoms caused/exacerbated by use, such as hangover or insomnia. Serious functional impairment only occurs in a relatively small minority of users. For this group, addiction is seldom a chronic disease. This is demonstrably so for alcohol dependence. I suspect the same is true for other substances (especially cannabis) but the proportions may vary (there may be fewer functional cocaine, meth or opioid users relative to functionally impaired addicts.) These functional dependent persons are the people who “do not perceive a need for treatment.” I strongly believe, however, that there is an interaction between perceived need for treatment and what that treatment is or is perceived to be. Don’t you think if treatment for alcohol dependence meant going to your primary care doctor or psychiatrist and receiving a medication and brief behavioral support that it would change perceptions about “need” for treatment?

The only way I can see to offer this group attractive, accessible, affordable care is through existing healthcare and mental healthcare systems. In ONDCP’s approach, treatment still seemed to be something that occurs in special places and that is done by special people (i.e., in rehab or opioid treatment programs.)

Finally, we need a robust medical addiction specialty sector to make any of this happen, and we need to define and disseminate a model of medical/psychiatric treatment for addiction. (By “medical” I mean a biopsychosocial approach, not just medication.) For example, most treatment for depression is done by non-psychiatrists, but I think that few doctors would try to treat depression if they didn’t have a psychiatrist to refer the difficult cases. Similarly, I think it is essential that there be sufficient, well-trained addiction psychiatry and addiction medicine physicians available to provide the chronic care management for complex, chronic disorders.

Transforming Treatment for Addictions in America

On October 31, I left NIH and and returned to St. Paul-Minneapolis, MN to rejoin my family. I'd like to share what my next project is: Transforming Treatment for Addictions in America. Of course it sounds grandiose, and perhaps it is. (If so, I'm sure I'd be the last to recognize it.) However, I think that the time is right for transformative change in this field, and that given the right effort and some luck, it could actually happen very rapidly.

Here's why. First, nearly everyone agrees that the current system of care is not meeting anyone's needs very well. Many people have difficulty obtaining access to treatment. Treatment is often of low quality and effectiveness yet can be very expensive. Treatment centers are able to offer just about whatever they want, regardless of whether there is scientific research or expert consensus concerning effectiveness. For example, at licensed treatment programs around the country, you could get hypnosis, yoga, meditation, treatment with nutritional supplements (which the program sells), treatment based on brain scans, and equine therapy (riding horses). It is almost certain that the treatment recommendation will be whatever that program offers, and there seems to be no felt ethical obligation to educate consumers about alternative treatments that may have better efficacy. Programs may offer seven days of treatment or six months. Thus, consumers are often confused about how to decide about where to go and what treatment is effective.

Second, consumers do not have any meaningful choice in the type of treatment available (except for the flaky stuff.) With the exception of methadone and Suboxone maintenance, more than 90% of US treatment programs offer group counseling and referral to AA. Period. Consumers don't like our programs, thus the majority have to be coerced into treatment. I often ask people what it would take to make them walk into a rehab program tomorrow and the nearly universal answer is: I'd have to have no other choice. Unfortunately, too many providers have become complacent, not needing to provide good customer service because their clients have no choice but to comply. Most importantly, there is very little access to newer treatments that are based on solid scientific studies. Every time I have had a national media interview in the press, I have received calls and emails from patients and families: where can I find a doctor to prescribe these medications [for alcohol dependence] that you were talking about?

Third, there has been a revolution in understanding of substance use and addiction that has radically altered our view of the spectrum of substance use and associated problems. This new understanding has significant implications for configuring a system of care. We now have the knowledge and tools to offer risk reduction and individualized treatment for a much broader group of people than ever before. Most people who drink more than is medically advisable have relatively mild dependence and remain highly functional. They have a much better prognosis than the more severely affected people who enter rehab programs. They can respond to less intensive and more discreet treatment if it were made available, and the only way to do that is through the existing system of health care. In the future, most people who develop alcohol dependence will go to their primary care doctor or psychiatrist and receive medications and brief behavioral support. This is the way we treat depression now, and although it's not perfect it has made treatment more accessible, affordable and attractive. Those with severe, recurrent disorders require care that is set up to manage the addiction and the co-existing health conditions over years to decades, not weeks or months. Chronic care management by physicians, nurses, and other professionals is needed and makes more sense than expecting a few weeks of group counseling to induce permanent recovery. The prognosis is much better than most people think, but it often takes several years to finally achieve recovery.

I am in the process of forming an initiative to transform treatment for addictions in America in the next five years. It is called the ALATYR Initiative. In the coming weeks, I will be describing this in detail, and sharing our progress.