Wednesday, November 30, 2011

Good Medical Treatment Beats Rehab Any Day

Clinical practice is something of a roller coaster. One day, most of my patients are doing well, the next day, they're all crashing. Today was one of the good ones. Lots of folks doing well. Most doing better than they have in years. Many of my current patients I have picked up in the hospital, doing consultations. Almost all have been through 12-step rehab, most multiple times. The record so far is 43 times! I integrate behavioral treatment (psychotherapy seems to be a bad word in addiction treatment for some reason), medication management, family therapy if needed, and care management. I do this basically by myself (although I do have a couple of great nurses who help with fielding calls from patients and families, medication refills, etc.) Most of the psychotherapy I do takes 20-30 minutes. I try to see patients weekly for awhile and that works really well. Sometimes I've seen patients more often for stabilization but for the most part weekly seems to work well.

One of the first things I do with new patients is to tell them this: "I don't necessarily expect that my patients will never drink again. That is the aspiration [in most cases] and the goal. But clinical experience and scientific research demonstrates that for most patients achieving lasting recovery will take time and repeated efforts. Think of quitting smoking. How many times do most people have to make quit attempts before it sticks? Why would quitting drinking be any different. There is a destructive fiction that when people go to rehab, the clouds part, the light shines through, the angels sing and they never drink (or use) again. This is not typical. The most common outcome of rehab is improvement without remission. "So, if you drink (use) that's when I need to see you the most. Don't stay away because you're afraid I'll be angry or disappointed or because you feel guilty or ashamed. That's like staying away from the doctor when you have an asthma attack because you're afraid she'll be upset that her treatment failed. The goal of treatment is to reduce the frequency and severity of relapses. It will take work and time, and I'll be with you through the process."

Patients become much more engaged in their recovery if they don't fear being blamed for not instantly solving their problems. Finding a solution that works takes time and ingenuity. There is no treatment that always works no matter what anyone tells you. Would you trust a physician who said, "My treatment for breast cancer is 100% effective if you follow my directions?" I wouldn't either.


Sunday, November 27, 2011

Hope for Hospitalized Alcoholics?

A new study found that even severely alcohol addicted patients in the hospital responded to a 20 minute counseling session after leaving the hospital. This has not been found in all studies, however. As is the case with many medical or psychological treatments, some studies are positive, some are negative. In the end, it's the balance. This balance is determined in a synthetic process called systematic reviews and meta-analysis. These are techniques to examine the findings of multiple high quality randomized controlled trials (RCTs) to determine if a treatment is effective overall. I think the jury is still out on this one, but this study had some pretty impressive findings and a reasonably large number of participants. What's more interesting is what happens when you combine a brief counseling session in the hospital with ongoing follow up in an outpatient setting. That's what I am currently doing with the patients I see in the hospital - I start the treatment there and ask them to schedule a follow up in the my clinic. This is what's done in every other medical specialty. Why not addiction medicine? MW Brief interventions in dependent drinkers: a comparative prospective analysis in two hospitals. Cobain K., Owens L., Kolamunnage-Dona R. et al. Request reprint Alcohol and Alcoholism: 2011, 46(4), p. 434–440. In the north of England just a few (and often just one) counselling sessions by a specialist nurse had a remarkable impact on dependent drinkers seeking medical care at an accident and emergency department. Summary Unusually this study in England's north west region assessed the impact of relatively brief advice, not on adult drinkers selected to be at risk from their drinking, but those likely already to be dependent. As with studies of non-dependent drinkers, despite their heavy drinking they were not seeking treatment for drink problems but attending a hospital accident and emergency department for some other reason. Patients whose attendance was thought to be related to drinking were referred for assessment to specialist hospital or research nurses by emergency department triage staff in two hospitals in neighbouring cities. The assessments included the AUDIT questionnaire and for patients who scored as possibly dependent, the Severity of Alcohol Dependence Questionnaire. Patients indicated by both to possibly be at least mildly dependent were asked to join the study. In Liverpool the assessments were done by specialist alcohol nurses who immediately engaged possibly dependent patients in about 20 minutes of advice based on the FRAMES model, prioritising exploration of patients' perceptions of the link between their drinking and their hospital attendance. At the nurses' and patients' discretion, further sessions could be arranged. In practice, of the 100 patients recruited to the study, 46 attended typically four further sessions. In the other hospital in nearby Warrington, the same referral and research recruitment procedures operated, but instead patients were referred to a nurse who was part of the research team who did not offer any alcohol-related advice. Again, 100 patients were recruited at this site to act as a control group against which to benchmark any improvements associated with counselling. At both sites most patients were daily drinkers who consumed on average about 27 UK units (216g) of alcohol a day, tested as severely dependent, and were taking alcohol withdrawal medication. Typically they were single, unemployed white men in their mid-40s suffering from gastrointestinal or cardiovascular complaints. Six months later research nurses were able to reassess about half the patients to evaluate changed in their drinking and drink-related problems since they joined the study. Main findings Six months later the general picture was (despite some reductions) of continued severe drinking and drink-related problems in the control group, but substantial remission among patients who had been counselled by specialist alcohol nurses. The controls were still drinking on average 23 units (184g) of alcohol on nearly six days a week, while counselled patients had cut back to nearly four days a week and eight units (64g). These averages reflected the fact that none of the controls but 39% of the counselled patients had stopped drinking altogether. Also, just 17% of the counselled patients scored as severely dependent on the Severity of Alcohol Dependence Questionnaire compared to 56% of the controls chart. The greater reductions in drinking days and intensity and in scores on the two alcohol problem questionnaires were all highly statistically significant. Not statistically significant but almost so was the difference in the times patients returned to accident and emergency departments – about 90 times among the 50 control patients but only 34 times (or 36 extrapolated to 50 patients) among those counselled. The authors' conclusions The study demonstrates that treatment can be accepted and effective among dependent drinkers who have not come seeking treatment for their drinking. Generally it has not been ethically acceptable to deny treatment to dependent drinkers who are seeking it, complicating the evaluation of whether treatment works. In contrast, because patients were not seeking or expecting treatment, this study was able to compare structured treatment with no specific treatment. It showed that treatment is effective, and that even severely dependent patients can substantially benefit from relatively brief treatment. The patients in this study were usually medically ill; providing alcohol treatment in a general hospital offers a way to reach them even if they do not present to alcohol treatment clinics, and may reduce their need for further medical care. The greater drinking reductions among patients at the hospital offering counselling were due to the greater abstinence rate – 39% v. 0%. It seems likely that their medical conditions would have mandated advice to abstain for 8 in 10 patients and that this was the advice given by the specialist nurses, advice often well responded to. From previous research, it seems likely that planned follow-up counselling augmented the impact of the evaluated intervention. Though striking, the results have emerged from a study in which patients were not randomly allocated and attended different hospitals. On the assessed variables, the patients seemed similar but there may have been remaining differences between them and between how they were treated at the hospitals which contributed to the findings. Moreover, the research nurse who conducted the follow-up assessments was not always 'blinded' to whether patients had been counselled. Despite its general brevity, it is a moot point whether the open-ended treatment could be called a 'brief intervention'. Half the patients could not followed up, potentially biasing the findings. These impressive results are weakened somewhat by the low follow-up rate. But even if we assume bad outcomes (severe alcohol dependence, death or imprisonment) in all patients not followed up, at most 60% of the counselled patients met these fates compared to 88% not counselled. Similarly, assuming continued drinking among patients not re-assessed, the abstinence rate would be 19% among counselled patients but zero among those not counselled. Yet on average these patients drank at least as much as those at specialist alcohol clinics in the UKATT trial in England and Wales, who were seeking treatment and offered what was intended to be a full course of psychosocial therapy in addition to medical treatments like detoxification and anti-relapse medications. In that study, 12 months after starting treatment a minimum of 12% of patients had sustained abstinence over the past three months, compared to 19% at six months (over an unspecified period) in the featured study. Despite its successes, for most patients the intervention was not enough. If abstinence is the yardstick of success, 8 in 10 could not be shown to have achieved it; if not being severely dependent was the yardstick, the corresponding proportion was 6 in 10. Whether more extended or intensive intervention would have been accepted by the patients and helped reduce the failure rate is unclear. The main limitation on delivering it might have been staying in touch with the patients. Few were homeless, yet two letters and two phone calls were unable to recall half for follow-up assessments. As the authors speculated, it could be that the nurses and perhaps ward staff were in a position in most cases to credibly counsel abstinence on medical grounds, helping bolster the results. Few patients were there because of injuries which could be avoided by continuing to drink but taking greater care to avoid getting drunk in dangerous situations. Instead, most seemed to be suffering from chronic conditions which would be aggravated by continued drinking. They were also generally the type of people research suggests are most receptive to abstinence as a goal of treatment and least able to sustain non-problem drinking. Among the issues raised by the study are whether extended treatment is always required before dependent patients – especially those with the disadvantages shared by most of the study's sample – can attain non-dependent drinking or abstinence. Along with other research, it clearly indicates that this is not the case for many patients. More generally, added benefits from longer versus shorter treatments (as opposed to post-treatment aftercare) has yet to be adequately established. Another issue is whether brief interventions will only benefit non-dependent patients. Again this study along with other research strongly suggests this is not always (but sometimes) the case. What makes the difference may be whether the patient makes (or can be led to make) a link between their drinking and the medical misfortune which led them to the emergency department. These issues are explored in greater detail in the background notes. Perhaps the most serious of the limitations acknowledged by the authors is that the hospitals may have differed not just in the availability of specialist alcohol counselling, but in how drinking was addressed by other medical staff. With counsellors available to handle the aftermath, in Liverpool they may have been more willing to expose the need for counselling by assessing and discussing alcohol problems with their patients. A hospital which hosts four specialist alcohol nurses is likely to have a different and perhaps more serious attitude to drinking than one which hosts none. But even if this were the case, it would not affect the strength of the intervention's impact, just relocate a greater part of that intervention to usual medical staff

Tuesday, November 22, 2011

Prometa or Promota? Hope You Didn't Spring for It

A new study just released found that Prometa, a proprietary combination of currently available drugs and nutrients, was no better than placebo in the treatment of methamphetamine addiction. This parallels the negative finding in treatment of alcohol dependence (although most subjects in the alcohol study did worse on Prometa than placebo.) Prometa contains two drugs widely prescribed among people with alcohol dependence, gabapentin (Neurontin) and hydroxyzine (Vistaril.) The third drug, flumezanil, is widely used to reverse the effects of benzodiazepines (such as alprazolam or lorazepam.) However, it can only be given intravenously so it is primarily used to help wake people up after procedures such as colonoscopy where "conscious sedation" is used instead of putting the patient to sleep. The folks at Hythium, Prometa's parent company devised a series of intravenous infusions of these drugs followed by oral medication. They also added various nutrients. Underwritten by wealthy investor Terren Peizer, Hythium hyped Prometa very successfully and in the complete absence of any credible evidence. Prometa is very costly, in the range of $12,000-15,000 or more per month, but enough people addicted to alcohol, methamphetamine or cocaine coughed it up out of desperation, driving the stock very high initially. Those of use who know something about psychopharmacology always knew this was a bunch of horse manure but that doesn't matter much in the addiction treatment world. Prometa wasn't greeted with universal acclaim to say the least. A headline on in 2007 read: "Unproven meth, cocaine ‘remedy’ hits market. Researchers debate quick fix: Is it good medicine or just marketing?" It took 4 years, but now high quality studies have debunked any claim to efficacy for alcohol or methamphetamine. The meth study, by Ling et al. (Addiction, published online in advance of print, 11/15/11), randomly assigned 120 meth addicts seeking treatment to either the Prometa protocol or a similar set up (with the iv infusions and all) but using placebo instead. As expected, Prometa was no better than placebo. At least it did better in this study than in the study by Anton et al. (J Clin Psychopharmacol 2009;29:334-342,) where for most study subjects, those receiving Prometa had significantly worse outcomes than those receiving placebo! So does this take the wind out of their sales? Of course not! Hythium has the nerve to quote these studies on their website as though they prove than Prometa works, when they show the opposite. That takes real chutzpah. But then again, it's no different than all the treatment centers who offer nutritional supplements, yoga, life coaching, equine therapy etc. as effective for treating addiction. And people keep flocking to them, and paying for them. So until consumers (and payers) wise up, I guess they'll keep selling their snake oil as long as people are buying it.