Saturday, February 27, 2010

Medications -1

I've recently received a number of questions about medications used to treat alcohol dependence. The use of medications is a crucial concern. Treating alcohol or other drug dependence represents the transition from lectures and AA to modern, professional treatment. It is a symbolic as well as a concrete advance that can help many people with substance use disorder to recover. So, I'm going to devote several blogs to this topic. It deserves more, but there are so many other important topics that it will have to take it's place.

The primary concerns among consumers are: do drugs work? are there harmful side effects or other downsides? how does taking a medication fit with 12-step programs? isn't taking a medication to stay sober a "crutch?" shouldn't I be able to stay sober without taking a medication?

OK. Let's take them one at a time. Do these drugs work? Yes. Without question, yes. One might debate whether it is "right" or not, but the answer from dozens of studies is this: certain medications (currently naltrexone and topiramate) reduce the number of people having relapses in early recovery by 20-40% and increase the number who embrace ongoing abstinence as their goal. The latter statement might be news to people, because of the way that research study findings are reported. But it's true: these medications increase the number of people who are able to recover. Keep in mind that these are people who otherwise would not recover but instead would relapse and have another failed quit attempt. When looking at results like these, there are essentially two types of people: those who don't care about the results, but are focused on intention, and those who focus on the results, as long as getting there was ethical and where the benefit/burden ratio was positive. As you might expect, I fall into the latter. Pragmatists, as opposed to idealists, who don't care if you fail as long as your motives are pure. Pragmatists are primarily interested in the outcome, whether the method comports with your preconceptions or not. That's me. Results are more important than intentions alone. Just because this point seems to get so easily lost: for some people who are trying to quit, medications make the difference between successful recovery or continued suffering, injury and even death.

The bottom line is that these medications offer people a greater chance at success. Why should they be deprived of the option of using them? Who should make that decision for them? Some people will prefer to not take medications, and others will opt to do so. That is the same way it is for every other disease: take an antidepressant or try therapy, take a medication for high blood pressure or lose weight and exercise more. My point is this: consumers should have the choice, and no matter where they enter the system, they should be informed of all available scientifically supported approaches and empowered to decide for themselves. In other words, whether or not a particular professionals "believes" in a particular approach should be secondary to whether there is evidence in support of it. One of the key principles of being a professional is that one has a fiduciary duty to the client/patient/consumer. That means putting the well-being of the client ahead of one's own needs, be they financial, ideological, religious, ethnic, or otherwise. In this case, it means that full disclosure is an ethical and legal requirement for any licensed professional irrespective of their own beliefs or preferences.

As another way to bring this home, let's assume you notice a lump in your armpit. You go to your neighborhood oncologist, who performs a biopsy and determines your worst fear: you have a lymphoma, a cancer of the lymph glands. However, this particular oncologist has recently been really into the benefits to health of radical dietary changes. So, in spite of the fact that her professional community and the published research support radiation and chemotherapy, the doctor recommends a macrobiotic diet and some nutritional supplements, without informing you of the other options. You like this doctor, and she is very persuasive, so you follow her recommendations. As you lay dying a year later, you learn that the other treatments have a cure rate of 50%, while there is no support for nutritional treatment. And now, it is too late for you. How would you feel? How would your family feel? How long would it take them to consult a lawyer and sue this doctor for malpractice? How is this different from what happens every day in almost every treatment center in the country?

Wednesday, February 24, 2010

The New York Times Consults Blog

Here's my answer to a question in the New York Times Consults blog. I'll either comment on the comments there or here soon.

More debunking of easy assumptions

Here's a recent new item from Reuters Health. This among many similar studies shows how easy it is to assume certain "obvious" truths, when in fact there is little or no evidence for them. Professionals, families and patients often look to drug or alcohol use as a factor to explain things for which their may be no easy explanation, and those assumptions are seldom challenged. 


Drinking may not worsen bipolar symptoms

2010-02-18 (Reuters Health)

By Joene Hendry

NEW YORK (Reuters Health) - Among people with bipolar disorder who strictly followed their medication plan, drinking alcohol did not appear to worsen their mood symptoms, hint findings of a small study from the Netherlands.

Bipolar disorder can cause extreme mood swings that require medication to control, and among those with the disease about half abuse alcohol and other drugs, Dr. Jan van Zaane, at University Medical Center Amsterdam, and colleagues note in the Journal of Clinical Psychiatry.

Other studies in patients with bipolar disorder have looked at substance abuse overall rather than just drinking.

To better understand specific effects from alcohol, van Zaane's team examined daily mood symptoms and alcohol intake over one year in 137 community living men and women with bipolar disorder but no other serious physical illness.

The study group was 23 to 68 years old. About half were women and about half lived with a partner and held a job.

The investigators describe 44 as "incidental" or non-drinkers, and 49 as moderate drinkers (21 and 14 or fewer drinks per week for men and women, respectively). The remaining 44 reported drinking more than moderate amounts.

A total of 104 kept diaries for the entire year. About half who stopped said they tired of the daily records and monthly monitoring required for study participation, while others did so due to worsening bipolar disease, alcohol dependence, and other reasons.

Still, all 137 participants kept daily mood diaries for at least two months, providing investigators with 44,808 days of mood data (about 327 days per participant).

The researchers were surprised to find the group of heavy drinkers did not have greater numbers of depressed days, number or severity of mood swings, or any other bipolar disorder symptom than the occasional or moderate drinkers.

More than 90 percent of the current participants reported taking prescribed bipolar disorder medication as directed. This, and the monthly clinical assessments required for participation in this study, likely partially explain the current findings, the researchers note.

However, this study compared groups, not individual patients, who should each monitor, with their doctor, how daily drinking affects bipolar mood symptoms, van Zaane said in an email to Reuters Health.

The investigators also call for confirmation of the current findings in further long-term evaluations of larger groups of patients with bipolar disorder.

SOURCE: Journal of Clinical Psychiatry, published online January 26, 2010.

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.

Thursday, February 18, 2010

The Variety of Substance Involvement

I've been surprised at the variety of patients I'm seeing. They range in age from 18 to 75. I'm seeing patients for depression, anxiety, bipolar disorder, ADHD and many other problems. But many of my patients have some problematic involvement with alcohol or other substances. Use of intoxicants is of course very common, even here in the US, where we have the highest rate of abstinence from intoxicants of any other developed country. But these intoxicants "tickle" our reinforcement and pleasure centers in the brain enough that many are drawn to them and subsequently, some become overly attached to them. Either to cope or simply for the pleasure. We experience potentially "addictive" experiences daily: donuts, candy bars, soda, ice cream, orgasm, alcohol, other drugs, etc. A long time ago, I concluded that from an evolutionary basis, we are not far from ancestors who had no self-consciousness. They may have had language and culture, but not reflective self-awareness. Reflective self-awareness is both a blessing and a curse, but once it's there, it can't be undone. So I guess it's "get over it." At any rate, the ability of some self-reflective consciousness to assert control over more basic impulses, urges and patterns is quite new and relatively undeveloped. So it's no surprise that it's partial in all of us, and that self-regulation often fails.
Everything I encounter in practice tells me the direction I'm headed is the right one. Saw yet another person today with alcoholic pancreatitis who I had not previously met someone who understood both how difficult it is to cope with the really awful chronic pain of pancreatitis, as well as her alcohol dependence and recent relapse and her bipolar disorder. I like being back in a hospital, getting to know the nursing staff, the hospitalists, and of course, the patients I see. I'm surprised at how many people I'm seeing in private practice who have very serious problems with substance use. There is such a stereotype that people who have substance problems are low-lifes who can't cope. Of course, I've always known better, but this experience is reinforcing it. To my mind, it's astonishing how few people have had access to truly competent addiction psychiatry. For these folks, another run through rehab is not the answer. I've seen several patients recently who are actually quite good at managing their various chronic medical and psychiatric conditions but who have had a slip or relapse of their substance use disorder in response to severe environmental stress. As I explained to a nursing student today, relapse in any chronic disease can be understood as the place where each of us has a breaking point. Under severe stress, some of us will lose control of our heart rhythm, our mood, our glucose control or our chronic pain. Where each of us loses control differs primarily by genetics and our particular situation. There is no point in condemning those with some chronic illnesses (depression or bipolar disorder, addiction or schizophrenia) and not others (asthma, heart failure, cancer, or arthritis.

Over and over, everything I'm encountering in general psychiatry practice is affirming the need to offer updated, scientifically based treatment for people who overuse or become dependent upon intoxicants.

Tuesday, February 16, 2010

Medical/Psychiatric Treatment of Addiction

The past two 6 weeks I've been in the process of practicing in a new environment, learning all the rules (official and unofficial), the technology (not simple or quick), and of course, the nurses, administrative staff and patients I work with on a daily basis. I've been having a lot of fun. Practicing general and addiction psychiatry is very gratifying, in part because I'm offering other medical staff and patients services they've never experienced before. People are baffled, befuddled. They are so used to the idea that treatment for addiction is education, group counseling and 12-step programs that the idea of the medical and psychiatric treatment of addiction is completely foreign to them. They are intrigued; I'm concerned about the deluge as word gets out. They've been truly desperate for it; they've had to do what they could on their own. Obtaining a "chemical dependency" consultation essentially consisted of two options: yes and no. That is, yes or no to rehab. Or, there had been so many runs through rehab that they weren't eligible for another "run." At any rate, treatment for addiction was not medical or psychiatric; it was social and spiritual. I don't denigrate peoples' spiritual experiences, they seem to be profound and uplifting experiences for many people. At the same time, when a medical condition is treated by spirituality, it suggests that there is no actual medical treatment for it. This is the history of medicine: when all else fails, pray. The problem is this: medical/psychiatric treatment of addiction is possible, feasible, cost-effective and has an excellent empirical base for it. The evidence base for treatment of addiction is better than for most medical specialties. In some cases, patients are lucky enough to find me in time, in others, tragically, they are not. They only obtain access to scientifically based treatment after suffering devastating consequences of their substance use. This is nowhere more apparent than in the treatment of chronic pain. The treatment of chronic pain in the US is extremely limited and ineffective. Patients are routinely labeled as "drug-seeking," a term that is not actually descriptive, but a value judgment.  I'll have a lot more to say about that in the future. In the meantime, I'm interested in hearing about either living with chronic pain or professionals who are treating chronic pain.

Wednesday, February 10, 2010

DSM-V: How Does It Stack Up?

The American Psychiatric Association has come out with the proposed fifth revision of its Diagnostic and Statistical Manual (DSM-V). The biggest news is the elimination of the two-category diagnoses of abuse and dependence. They are proposed to be folded into one diagnosis, substance use disorder, with accompanying dimensional criteria estimating severity, lethality and so forth. Is this an advance? In my view, yes. Unequivocally yes. Here's why: the abuse and dependence category have never worked the way they were intended and the have added to a lot of confusion about diagnosis. Newer research has demonstrated that substance use and its consequences exist along a single continuum. What were criteria for abuse in DSM-IV are mostly found in late-stage severe addicts. Things like role failure (inability to perform as a parent, student, employee, professional) and legal problems. DSM-IV Dependence criteria, on the other hand are among the first symptoms experience, and the most common symptoms among those with milder forms of the disorder. Things like going over self-imposed limits, a persistent desire to quit or cut down, and continuing to use in spite of physical or psychological symptoms caused by substance use, like insomnia, dyspepsia or hangover. The most common form of alcohol dependence is characterized by mostly the "internal" symptoms experienced as impaired control, in the absence of serious life disruption. Unfortunately, we keep focusing on the most severe chronic or recurrent forms of the disorder, rather than the much large group of people with milder disorders that usually remit without recurrence.

So I think the overall direction is positive, that is, a single substance use disorder diagnosis that can range from mild to moderate to severe. What do you think?

The future of addiction treatment

I'm just back from ICTAB, the International Conference on Treatment of Addictive Behaviors, held each year in Santa Fe, NM. Established by Bill Miller, this is the 12th annual conference. As you might expect, the participants are devotees or at admirers of Motivational Interviewing, the set of techniques that Dr. Miller and colleagues developed at the University of New Mexico. Dr. Miller has retired (although he was at the meeting and very present) and now Barbara McCrady, PhD, is the Director of the Center for Alcoholism, Substance Abuse and Addiction (CASAA) at UNM. Terri Moyers, PhD, was the organizer for the conference, held at the ElDorado Hotel. 

I found many kindred spirits there, professionals who had been working for years to provide scientifically based treatment for addictions. Treatment that provided highly professional, individualized treatment in an environment of respect, confidentiality and consumer choice. But so far, there's been nothing to bring them together to advocate for a comprehensive, accessible and affordable alternative to existing rehab programs. There were many senior scientists there as well. People who had been working for decades to improve the outcome of addiction treatment, to understand the basis of it, and to justify the expense of treatment. And they were excited too. They have seen their hard-won research findings sit on the shelf, not being implemented by treatment programs, not available to consumers. 

More than ever, this meeting energized me and strengthened my commitment to change the way we do business in the treatment of substance use conditions. I really think the time is ripe for change. And I am beginning to understand the power of people coming together in a common goal. There is a groundswell building that includes scientists, treatment professionals, payers, health care organizations, county, state and federal health care organizations, employers, family members, and most of all, people suffering from addiction, who desperately want access to new therapies and approaches, flexibility, professionalism, and better outcomes. I don't know a single person who believes the current system of care serves anyone very well. The time for change is now.

A caveat: sometimes, in my enthusiasm for change, I may be perceived as putting down addiction counselors and others who are currently providing treatment, or as saying that current treatments are ineffective. I know how dedicated treatment providers are, and how much they want their clients to respond and have better lives. But most are working within a framework that is 50 years old and that does not incorporate current scientific understanding of addiction and its treatment. Change may be disruptive for some providers, especially those who have been working in the field the longest. There must be sensitivity to those concerns. But we also cannot let those concerns override the need to provide the best treatment, grounded in science, to people who need it. I think there are ways to make the transition work.

I also agree that there are several approaches to behavioral treatment that are approximately equally effective if delivered skillfully. I use them myself and have experienced how helpful they are to me (helping to provide care) and to my patients and families. My concern is that those treatments, delivered individually by skillful, well-trained therapists (as is the case in the studies) are not available to most people. And, most current rehab programs don't offer that quality of therapy. The studies published by Tom McLellan, currently Deputy Director for Demand Reduction at the White House Office of Drug Control Policy (ONDCP) found that more than 90% of rehab programs in the US offer group counseling and AA, and nothing else. Together the research budgets for the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) amount to almost $2B per year. It's time the American taxpayer had access to the fruits of this investment.