Tuesday, February 23, 2010

Patients do not have access to modern treatment

I was on call this past weekend, and it was busy. Doctors in private practice work very hard. So I had 9 admissions from Friday evening to Monday morning. An average weekend at this hospital, so I'm told. Of that 9 patients, 4 had substance use problems. (Of note, even though I was the admitting physician, and addressed the treatment of patients' substance use disorders in my examination and treatment, the plan of action for all of them is still "CD assessment" by a counselor.) Yesterday and today I've seen three consults with serious substance use problems (mostly alcohol) and my clinic is now starting to fill as the word gets out. One common presentation is a combination of serious psychiatric disorder and substance use disorders, usually alcohol. Most have been through rehab a couple of times. I almost never encounter a patient like this who had never heard there were medications to treatment alcohol dependence. Occasionally I see patients who have been prescribed acamprosate (Campral) for their alcohol dependence. Campral is the med most likely to be prescribed by general psychiatrists because it was marketed to them. In the US, physicians tend to rely on pharmaceutical representatives too much, as opposed to reading the scientific literature themselves. Unfortunately, I don't think Campral works. Although a few of the first studies showed very strong effects subsequent studies have not. There now have been three large multi-site studies that have shown no effect of acamprosate, including one in Germany. (There had been speculation that acamprosate worked there because people drank more and they had a month of abstinence in the hospital before starting the drug.)

For patients with co-existing psychiatric and substance use disorder, psychiatric treatment is handled by a psychiatrist, and the alcohol dependence is handled by addiction counselors and AA. Just to be clear, I am not putting down or denigrating either addiction counselors or AA.  It's just that for every other condition such as anxiety, depression, bipolar disorder, eating disorders, schizophrenia and obsessive-compulsive disorder therapy is provided by at therapists with at least masters degrees and often doctorates, and medication management is provided by physicians. This should be the model we use with addiction too, given the state of the science, but it's not. The only thing offered to most patients and to the doctors and nurses working with them is another run through rehab. I've seen many patients who have been through rehab a dozen times most of whom could easily have run a rehab program. In fact, the way Minnesota Model treatment started was just that way. When I first started working at the VA Medical Center in Minneapolis, one of the counselors had been through the program twice and then stayed on as a counselor. I recently saw such a patient, who relapsed after a prolonged period of abstinence. What's the answer? Another run through rehab? Here's the rub: in all the years he had been exposed to treatment he had never been even told there were medications available to help him stay sober, he had never had cognitive-behavioral psychotherapy, and he had never been offered integrated, long-term treatment of his co-existing psychiatric and substance use disorders. All of these things are proven to work. We know what to do.

What if there were treatments available that would improve outcomes in leukemia or arthritis, but patients were only offered garlic and prayer? Would we stand for that?When parents deprive their children of modern treatments for diabetes or cancer on the basis of an ideology, they are charged with neglect. If the child dies, they are charged with murder.  If a family physician fails to prescribe an antibiotic because she doesn't believe in them, they are guilty of negligence and discipline by the medical board. Yet, that is precisely the situation with addiction treatment: suffering and dying people are deprived of scientifically based, modern treatment on the basis of ideology, in programs licensed by the states and accredited by national accrediting agencies. Why do we allow this to happen? It's time that everyone had access to truly integrated, professional, scientifically based treatment of addiction. In fact, it's way past time.


  1. I read about this drug as a treatment and am curious what you think about it.


  2. Yes, I completely concur with regard to addiction treatment. As it is, a year and a half of school here in Seattle will get you as Associate's Degree and will let you be a CDP. The education is basic, glosses over much of science, and many of the texts are written toward a 101 level of understanding. How is it that the primary text for the Law and Ethics class is published by Hazelden? It's so circular, and so addiction treatment is stuck in limbo.

    Yet, a CDP will tell you: "It's a disease. And I, somehow, with minimal training, and only rudimentary knowledge, know how to treat it."

  3. This is the most intelligent thing I have heard in a long time. It only makes sense. I personally do not believe that addiction is a disease. However, if I did, and I was told that I had a disease like cancer and diabetes which drug counselors tell you all the time, then why would I want treatment from a drug counselor who has limited skills and generally has had a problem with substances and only understands one approach to dealing with it? Why would I only want a sponsor, who is in many cases worse off then I am? Dr. Willenbring makes an excellent point when he suggests that we would not treat people with garlic and prayers for other ailments. Obviously like most things that don't make sense there are political and financial advantages that have been in place for decades which has maintained the system as it is. But, like Dr. Willenbring ends his comments, "Why are we allowing this to happen?"


Comments are welcome.