Wednesday, December 26, 2012

Can Suboxone Induction Be Done at Home?

This recent article investigated whether heroin addicts could make the transition from heroin to buprenorphine at home, rather than in the office. Office-based inductions have been preached as the standard of care. But in this study, most addicts did fine. I've been doing this way for some time now, without a problem. 


 Home- versus office-based buprenorphine inductions for opioid-dependent patients.

Sohler N.L., Li X., Kunins H.V. et al.
Journal of Substance Abuse Treatment: 2010, 38, p. 153–159.
Unable to obtain a copy by clicking title above? Try asking the author for a reprint (normally free of charge) by adapting this prepared e-mail or by writing to Dr Sohler at You could also try this alternative source.
Is is safe and will heroin-dependent patients complete the process and stay in treatment if they start buprenorphine maintenance at home rather than being observed and doses adjusted at the clinic? This US study suggests this is feasible, saving time for all concerned, but also hints at possible (in this case, rare) complications.
Summary This US study from the Bronx district of New York documents the induction safety and retention record of a primary care health centre providing buprenorphine/naloxone maintenance treatment for addiction to heroin or other opioids. After two years of offering this treatment, the clinic switched from requiring all patients to start treatment under supervision at the clinic (entailing two to four hours during which the dose was adjusted), to allowing the doctor and patient between them to agree instead that the patient would be given a 'take-home' induction kit to enable them to start their treatment at home. The kit contained enough buprenorphine/naloxone pills for patients to themselves build up their doses over three days so they no longer felt withdrawal symptoms, other medicines to help control withdrawal symptoms, plus instructions. They were scheduled to return to the clinic within the week to discuss longer term treatment.
In the first two years 28 patients were inducted on to buprenorphine/naloxone at the clinic. In the next two, 51 patients opted with their doctors for home-based inductions and 36 were inducted as before at the clinic. The study compares initial experiences of all those inducted at the clinic with those inducted at home, 115 patients in all. About 70% had been using heroin, nearly all were Hispanic or black, and over two thirds were unemployed.

Main findings

In the second two years when home inductions were available, patients who with their doctors opted for these were more likely to have had previous experience of buprenorphine treatment. Those who opted to be inducted at the clinic were more often of Hispanic descent, unemployed, had only state-provided health insurance, and had recently used cocaine or sedatives or benzodiazepines.
Across all the patients, about 17% experienced difficult inductions regardless of whether inducted at home or at the clinic. Only one patient (in the home-based induction group) was hospitalised immediately following induction. This was due to complications secondary to benzodiazepine abuse which the patient had not fully disclosed. Tests did not reveal any clinically significant disturbance of liver function following inductions. A month later virtually the same proportions of patients (78%) remained in treatment regardless of the induction site. This result was essentially unaltered when differences between patients who opted for induction at home versus at the clinic were taken in to account.

The authors' conclusions

In a health centre that serves an economically disadvantaged community, people treated for opioid dependence with home-based buprenorphine inductions were as likely to be retained in treatment for 30 days as those with traditional clinic-based inductions. There was also no indication that either induction type was associated with greater difficulties with the induction process. The implication is that both office- and home-based buprenorphine inductions are feasible in the primary care setting.
The findings reflect the ability of patients and providers to select the induction type best suited to the patient's needs, abilities, and beliefs about health care. Given the importance of the induction process for longer term opioid addiction management, these data should be encouraging providers to consider treating opioid-dependent patients in primary care.

Monday, December 24, 2012

Do relapse rates rise around the holidays?

Many people assume that the time between Thansksgiving and the winter solstice holidays are the most difficult time of the year for people in  recovery. Temptations are harder to avoid, what with office and holiday parties, family gatherings, and so forth. Many people with alcohol dependence come from families with many heavy drinkers, so alcohol may be flowing freely, and there may be others who are intoxicated. (Ever notice how boring and obnoxious intoxicated people can be if you're not intoxicated yourself?) So cue-induced craving is certainly an issue, whether your cues are visual, smells, other being surrounded by others who are drinking. How can someone protect themselves, what are the best strategies?

Another major trigger for many are negative or painful feelings. The constant drumbeat and ceaseless streaming of happy families enjoying their time together is very different from what most of us experience. Especially in early recovery, loneliness is common, and made so much more painful as we imagine all the other people surrounded by relatives and friends, all enjoying themselves and each, celebrating their good fortune. And that's how families usually are right? (Wrong!) Interactions with family members are often their most difficult and painful during the holidays. Young adults home for the holidays fall into acting like 15 year-olds, and parents play along. Having to endure another holiday with your obnoxious brother in law from the other political party or religious group seems like it will make you explode.

Finally, we all get knocked out of our normal rhythms of self-care and self-regulation during the holidays. We get swept off our feet, we lose our ground. Our work-out routine gets disrupted. If we travel our time clock gets out of whack. If we're working a 12-Step program, our home group and sponsor may be back home while we're visiting relatives in Seattle. If we're in therapy or seeing a psychiatrist, those appointments are harder to find. And then there's Seasonal Affective Disorder (SAD,) so in temperate climes, we may become more depressed. Most people with Major Depression or Dysthymic disorder have seasonal sensitivity, making depression worse in the winter. We eat too much, sleep too much (or too little), get lazy. It's a wonder any of us make it through sometimes.

One basic strategy for managing the holiday season comes from cognitive behavior therapy (CBT.) The principles are: Recognize, Avoid and Cope. Recognize a high risk situation before you're in it. Anticipate it. Ruminate about it. How might you be affected? What are your triggers? How solid are you feeling in your recovery right now? Main principle: don't test yourself. If you're feeling shaky, pay attention. Second principle: take care of yourself. No one else will. Then, if you can, Avoid the high-risk situation completely. Don't let guilt or a sense of obligation push you into a high risk situation. Your recovery is more important than anything or anyone else. Finally, if you cannot avoid the situation, Cope with it. Devise strategies for managing it. Talk to your therapist, support friends and family members, psychiatrist, or sponsor. Consider using an anti-relapse medication over the holidays, even if you usually don't. Antabuse, which makes you ill if you drink, is a particularly useful one, but naltrexone is also good. Topiramate is less so because it takes a long time to ramp up on the dose. If you are in a 12-Step program, schedule your meetings, being specific about when and where. Decide what your emergency strategy is is you are in a situation and don't trust yourself to drink. For example, get out of there, go for a walk, excuse yourself and go to a meeting or meet up with a friend, or call a supporter. Can you identify supportive people at the gathering? Or, better yet, bring your own! Make sure you pay attention to sleep and exercise and alone time. Meditate or have a relaxation training session. Get a massage. Well, you get the idea.

So, do relapse rates go up during the holiday season? Here's a graph from a fascinating study by Mark Goldman and colleagues, who tracked drinking for 365 days in young adults. (Goldman M, et al., Psychol Addict Behav. 2011 March; 25(1): 16–27.)

As you can see, the major peaks for young adults are Spring Break, New Years, Halloween and July 4th. Thanksgiving ranks about the same as the Super Bowl. Christmas is, like, nada. On the other hand, a study in Finland found that alcohol poisoning fatalities were greatest there during Mayday, Midsummer and Christmas celebrations. A 1989 study by the CDC found increased rates of alcohol-related traffic crashes and fatalities during the holiday season, but with the changes in DUI laws, it is hard to extrapolate. But I couldn't find one study in PubMed examining relapse rates among recovering alcohol dependent persons over the holidays.

So what's the answer? Well, we don't have good scientific evidence one way or another. In my clinical experience, alcohol dependence, like other serious chronic illnesses, often have a pattern of their own. Serious depression and suicide don't go up over the holidays. (Suicides peak in the spring.) My own impression is that there is no big jump in relapses in general, although specific people may struggle more during this time. But it always helps to be prepared. Recognize, Avoid, Cope, and have a great solstice celebration!


Friday, December 21, 2012

Gender Specific Treatment Reduces Recidivism by 67%

Here's the abstract from a new study that used random assignment in prison (a nearly impossible task in itself) and found that trauma-informed, gender-specific care served female inmates better. Not very surprising but the authors are to be commended for their methodological rigor. Even more impressive, though was a whopping 67% reduction in reincarceration within 12 months after parole. Wow!

Read more about it here.


 A randomized experimental study of gender-responsive substance abuse treatment for women in prison

UCLA Integrated Substance Abuse Programs, 1640 S. Sepulveda Blvd., Suite 200, Los Angeles, CA 90025, USA
Received 1 July 2009; received in revised form 26 August 2009; accepted 20 September 2009. published online 16 December 2009.


This experimental pilot study compared postrelease outcomes for 115 women who participated in prison-based substance abuse treatment. Women were randomized to a gender-responsive treatment (GRT) program using manualized curricula (Helping Women Recover and Beyond Trauma) or a standard prison-based therapeutic community. Data were collected from the participants at prison program entry and 6 and 12 months after release. Bivariate and multivariate analyses were conducted. Results indicate that both groups improved in psychological well-being; however, GRT participants had greater reductions in drug use, were more likely to remain in residential aftercare longer (2.6 vs. 1.8 months, p < .05), and were less likely to have been reincarcerated within 12 months after parole (31% vs. 45%, respectively; a 67% reduction in odds for the experimental group, p < .05). Findings show the beneficial effects of treatment components oriented toward women's needs and support the integration of GRT in prison programs for women.

Tuesday, December 18, 2012

Why Don't We Have New Treatments for Addiction?

I just got back from a meeting of the American Academy of Addiction Psychiatry, and one of the most striking things was the lack of anything new in the treatment of addiction. There was a lot of tweaks of existing modalities, both behavioral and pharmaceutical, but nothing groundbreaking. As a clinician, I encounter this every day. We have a handfull of psychotherapeutic and pharmaceutical treatments available, but it is no where near enough.

Far too many patients respond modestly or not at all to available treatments of all kinds. Don't drink the Kool-Aid of 12-Step programs that tell you that their approach is 100% effective among those who truly want sobriety and work the program. It's simply not true, and most older AA'ers will admit that. There are very few treatments that even approach that level of efficacy. In most of medicine, we are simply slowing the rate of deterioration, if that.

I believe that talking therapy approaches have reached the point where further refinement of them will not improve outcomes, or at least not much. There are two areas of research that may eventually transform care: more direct approaches to reprogram the preconscious or unconscious mind, and pharmacotherapy. I'll leave the former for a later blog, but today I'd like to address concerns about the lack of medications in the medication development pipeline.

This is not a problem that only afflicts addiction treatment. It's true throughout health care. With a few notable exceptions, very little progress has been made in the past 10 years on developing new medications for our most vexing and common disorders: heart disease, depression, addiction, high blood pressure, cancer, arthritis, pain. And the pipeline looks so dry it's almost scary.

It's not because Big Pharma isn't investing in R&D either. According to, the industry website, industry investment in R&D has not dropped, either as real dollars or as percentage of revenue.  For example, in 1990, Pharma spent $8.4 billion on R&D, but in the past few years, it's been hovering around $50 billion. And yet, as this chart in an article by Scannell et al. (Nature Reviews Drug Discovery 11, 191-200) shows, the number of new drug approvals as a function of R&D investment has been dropping for 60 years. Why? Tune in tomorrow for the next blog!

Monday, December 3, 2012

Potential New Treatment for Cocaine Addiction?

In a recent article, Mariani and colleagues reported on a pilot study of a combination of mixed amphetamine salts (MAS; most commonly known as Adderall) and topiramate (Topamax) in the treatment of cocaine addiction. Their study appeared in the journal Biological Psychiatry (the reference is Mariani et al., Volume 72, Issue 11, 1 December 2012, Pages 950–956.) In the study, subjects were randomized to receive either a combination of MAS and topiramate, an anticonvulsant used for epilepsy and migraine prophylaxis and which is also effective for treating alcohol dependence, or placebo. They found that the proportion of subjects able to achieve 3 consecutive weeks of abstinence from cocaine was significantly better over a 4-week period. The figure below, from the article, shows the difference between the two groups over the course of the study. By study end, 4/13 of subjects receiving the medication combination had complete 3 weeks of abstinence, compared to 0/11 of the control group receiving placebo. No conclusions can be drawn from such a small study, but the results are intriguing. They point to the potential importance of therapies that provide some low potency, long-term stimulation of the receptors involved in a specific addiction. These agonist therapies include current medications such as methadone and buprenorphine (Suboxone) for opioid addiction and varenicline (Chantix) for smoking cessation. Agonist therapies are likely to provide the most effective treatments in the future, as opposed to antagonist therapies that block the receptors and thus the effects of the drug. A current example is naltrexone (Vivitrol) for opioid addiction. Some effectiveness if external coercion is used, but much less or no effectiveness in other circumstances.


Wednesday, November 28, 2012

Health Care Changes Important to Addiction Treatment

Among the various things I do, I work about half time for a large health care organization (HCO) in Minnesota called Allina Health. Currently Allina is the largest HCO in Minnesota, but it is likely to become the second largest due to continuing consolidation in HCOs. HealthPartners and Park Nicollet, two other HCOs in Minnesota desire to merge, and it does not appear that there will be any barriers from either the MN Attorney General or federal agencies. So it is likely to proceed, which would produce a larger HCO than Allina. Consolidation in health care is almost a torrent right now. It's happening very rapidly. In the Twin Cities area in Minnesota, there are almost no independent primary care practices; they've all been purchased by large HCOs. The health plans like Blue Cross/Blue Shield and HealthPartners are working very closely with the large HCOs to create products that maximize value to the consumer. So the future of health care is one dominated by a few large HCOs that dominate a market. Unfortunately, this is all to familier. Witness the consolidation in airlines and in cable television, internet and wireless services.

But there are important changes in perspective that will drive a much more pronounced and determined effort to deal with behavioral health issues, including both mental health and addiction. The most important of these is the movement from fee for service to capitated approaches. In fee for service, a clinician is paid a specific amount for providing a service, such as a primary care visit or an addiction counseling session. This rewards providing more services for fewer people, and it drives up costs without regard to quality or outcomes. Increasingly, health plans are moving towards a different model where the HCO is accountable for outcomes, not just whether the service was delivered. In a capitation model, a HCO is given a single fee for treating someone with a given diagnosis. It is up to the HCO to figure out how to do this efficiently and effectively.

This is a good thing. Here's an example. Someone with an addiction goes to a time-limited, intensive rehab program, which is the current standard of care. Let's say that this intensive outpatient program costs $2400. Someone else who was able to produce equivalent outcomes for $1800 would be attractive to a health plan, not to mention someone paying out of pocket. Similarly, a $15,000 or $20,000 residential treatment program would go out of business if it could not produce substantially better outcomes than someone providing office-based treatment for a third of that amount. I think this is quite possible to do, since there is no demonstrated benefit to residential treatment. There is room here for innovation, for modernizing our approach to addiction treatment. It's time for addiction treatment providers to take responsibility for the outcomes of their treatment. It's time to end the idea that treatment failures are the patient's fault. In the future, this isn't going to fly. One of my goals is to make sure this happens. We can generate better outcomes at much less cost.

What if, instead of being paid $30,000 for a residential treatment lasting 28 days regardless of whether that actually produced a good outcome, HCOs were only paid for treatment that worked? What if payment was based on outcomes rather than the treatment provided? I can tell you, that would change the addiction treatment world in a heartbeat. Give patients that same treatment over and over even though it's already proved ineffective? No way! Give everybody the same treatment whether they need it or whether it's been shown to improve outcomes? Forget about it? Changes in how payment is made for services will force change in the treatment delivered. And it's about time.

What's the silver lining? We can lead the way. Many of the very high utilizers of health care have addiction and mental health problems. We have to figure out ways to improve their care and outcomes. That's our challenge and our opportunity.


Tuesday, November 27, 2012

Change: Continuous and Discontinuous

Recently I have several patients who have made remarkable progress in a short time. I would call this discontinuous change. That is, there is a prevalent notion that change occurs gradually, step by step. And sometimes that's how it happens. But then there are times when people change in multiple ways, on multiple dimensions, all at once. Change can be continuous or discontinuous. Now, in some ways this distinction requires some kind of arbitrary decision about what those terms mean. Ultimately, it's an issue of measurement. So, "continuous change" occurs at a smaller scale than the current measurement can detect, while "discontinuous change" occurs in a way that is distinct, a detectable change. Or, one could define it quantitatively or qualitatively. For example, "discontinuous change" could be defined as a change of a certain magnitude, or changes of a certain magnitude on multiple levels or in multiple scales.

But clinically, there are times when I'm simply blown away. A patient comes in who is hardly recognizable, and not simply because of cosmetic or clothing or grooming changes, although they may be a part of it. It's more that a different person walks through the door. Someone who thinks, speaks and otherwise behaves in multiple ways they have not previously. This happens with both substance use disorders and with psychiatric disorders. All of a sudden, everything is different. And no one, least of all the person who just transformed, has any idea why this happened now, at this moment in time. These events are not predictable with current knowledge and scientific methods. They may never be. (A part of me hopes and, of course, therefore predicts, that they never will be.) Anyway, in the past several weeks I have been completely blown away by progress in some of my patients.

What causes the change? There may be environmental events that have powerful effects, such as a DUI, hospitalization, serious medical illness, interpersonal experience, and so on. But these are not very reliable predictors and are not always present. I have patients who have had a DUI and then stopped drinking, and I have others where it doesn't seem to make a difference. Most often, my changed patients report to me that they have either "gotten sick and tired of being sick and tired," or "just decided," or "I just woke up and felt different." We don't have insight into how or why we make the most important decisions in our lives. Our reasons, by and large, are constructions designed to continue a cohesive narrative of our lives. We decide and then construct the reasons. Now sometimes it is the other way around. A slow, rational deliberation (System 2 in Daniel Kahneman's scheme) often plays an important role. But more often I think it's the other way around.

Here's my working hypothesis: complex dynamical systems (including us) tend to configure into a number of discrete, finite states, rather than an infinite number of slightly different ones. We tend to flip from one state to another, much like a tornado suddenly forms out of a certain set of optimal circumstances (but not always, and not easily specifically predicted.) And for us, these states include cognitive, affective (emotional), perceptive, behavioral, genomic, metabolomic, organ, organ system, organismal and social components that may all change at once on multiple levels.

And the thing is, there is only one thing happening even though it is happening at multiple levels. This is a hard one, an idea I finally developed when I was at NIH. In complex dynamical systems, an event occurs on many levels at once. Of course, there may be an instigating event, let's say an adverse social interaction that sets off a crusade of processes ending in severe depression and extremely heavy drinking. The response of a particular person (organism) involves all different levels of analysis essentially at once, because there are millions or billions or trillions of extremely rapidly interactive events that make up the whole. Everything happens on all levels at once: from particle physics up to global and beyond. However, we cannot examine the whole, we need to examine a part of it. We may talk to the involved person, ask them about their experience, perhaps ask them to fill out some scales. We may examine their social interactions and networks, or patterns of communication. We might put them in an fMRI or PET scanner to examine brain blood flow and metabolism, we might measure the output of a stress hormone such as cortisol in the blood, and so on. But we delude ourselves if we think that by looking at one level of analysis, we can say much about the system's behavior. It's not simply linear: A causes B which causes C. It requires a different type of mathematical modeling to help predict the behavior of the system as a whole. But this science is new and will take a long time to mature.

What about therapy or treatment? Sometimes, I think that by creating a safe, therapeutic environment and providing straight, often difficult, but always compassionate feedback, I may make a change like that possible. It often feels like a lifeline - I provide a secure support and anchor for taking chances and making changes. Some patients volunteer this information - that having me in their corner allowed them to make changes they were previously afraid to make, or that I provided a direction they had not seen before. Other times, I have no idea. A patient changed suddenly to the better, and I don't feel I had much if anything to do with it. This isn't false modesty; I'm talking about people I may see every 3 months for medication checks, but who suddenly undergo a big positive change. Most of the time, it's pretty hard to tell. Maybe I made a difference, maybe not. But it's enough to keep going, doing my best, trying to help people in any way I can. And I'm grateful for that opportunity. People let me into their lives in the most intimate ways imaginable, trusting me not to betray them, not to hurt them. I feel very privileged and humbled by that trust and I do my best to be deserving of it.


Monday, November 26, 2012

Naming Contest for Blog!

Recently, I've become more aware of search engine optimization. These are strategies to increase the likelihood your site or blog will come up sooner rather than later in a search on a given term. For example, "addiction." Although I am personally attached to the name Substance Matters, it doesn't necessarily come to mind (or search engine) when someone enters a search term related to the use of intoxicants and substance use disorders.

So it needs a new name, and I need your help. So... I'm open to suggestions for a new name that will maximize visibility on the web. It may end up having to be boring, for example, it may have to have addiction in the title. But, let's see what we can come up with.

Thanks to my followers and contributors, and thanks for helping me out with a new name.

So please send your suggestions, and then I'll give you all a chance to vote on the best 3 names submitted. How about that?

Hmmmm..... Intoxiblog? Addiction and More? Addiction 21? Alltyr Addiction Blog? 21st Century Addiction Blog? Lindsey, Dr. Drew and Mel Blog?


Friday, November 16, 2012

NIDA/NIAAA Merger Called Off!

This morning, Francis Collins, MD, PhD, the Director of the National Institutes of Health announced that he had decided to reverse his earlier decision to proceed with the merger of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA). This is a cause for celebration, as the merger was a solution in search of a problem right from the start.

For most of us at NIAAA (this process started when I was still there) it always looked like a simple power grab by NIDA and a relatively small but influential group of researchers and policymakers closely affiliated with it. The White House Office of Drug Control Policy (ONDCP; the Drug Czar), former NIDA Director Alan Leschner (who coveted NIAAA when he was at NIDA,) and current NIDA Director Nora Volkow all pushed very hard to make this happen. The "problem" it was supposed to solve were "missed opportunities" to pursue research involving both alcohol and drug disorders, but that's actually never been a problem in reality. The two institutes collaborate on multiple initiatives, and both alcohol and other drug disorders are frequently studied together, if only because they often occur together. But few of us involved with this ever thought there was a problem with the two institutes.

At any rate, without getting into details right now, I think this is very good news indeed.


Thursday, November 15, 2012

How Will the Election Affect Treatment for Addiction?

Here's a blog from a guest blogger, Ian McLoone, who is a student in the Integrated Behavioral Health Master's program at the University of Minnesota, as well as a Graduate Research Assistant at the new MN Center for Mental Health, which is focused on treatment for people with co-occurring mental and addictive disorders. Welcome Ian!


P.S. Anyone else want to volunteer? I'm open to blog submissions.

Why the Election Results Are Good News for Addicts and the People Who Treat Them

As Tuesday’s election results trickled in, addiction and mental health professionals throughout the country breathed a collective sigh of relief. President Obama’s re-election means that the Affordable Care Act - affectionately termed, “Obamacare” – is safe from the Romney/Ryan campaign promise of “total repeal” of the law (1). This means that President Obama will have the opportunity to oversee the implementation of his signature first-term accomplishment. What’s more, addiction research will see, at minimum, modest funding increases and the National Institutes of Health (NIH) will avoid the devastating cuts outlined in the Romney/Ryan 2013 budget proposal.

The ACA increases patient access to behavioral health services in several ways. By expanding Medicaid coverage to those at 138% of the federal poverty level, as well as the creation of state-run insurance exchanges, as many as 30 million new people will have access to health insurance (2). Health insurance providers will also be subject to several new provisions which are meant to improve the quality of the care they receive. For example, preventative care and interventions will be emphasized, and in many cases fully covered. The ACA has already awarded upwards of 100 million dollars for the implementation of an evidence-based prevention measure known as SBIRT – Screening, Brief Intervention and Referral to Treatment (3). Prevention efforts can improve outcomes for all people, but those with mental illness and substance use disorders are disproportionately affected with other health problems like diabetes, high blood pressure, asthma, heart disease and stroke (4). This, in addition to guaranteed coverage for patients with preexisting conditions, more coverage for prescription medications, and the carrying-forward of the 2009 “parity” law (which mandates that insurance companies cover treatment for mental health like they would any other condition), means those with addiction or mental illness, and those who treat them, will no longer need to question whether or not these services will be available in the years to come.

Mitt Romney, and his running mate, Paul Ryan, ran on a platform of significant cuts in government spending (“non-defense discretionary spending”), exemplified in Paul Ryan’s 2013 budget proposal. In addition to eliminating the ACA’s Medicaid expansion, their plan included provisions which would have resulted in 14 million more people losing their Medicaid insurance over the next 10 years – an estimated 31 million people, in total (5). While many have criticized Paul Ryan for the lack of specifics within his budget plan, the White House estimates of the impact on NIH-funded grants are sobering: 1,600 fewer grants in 2014 and 16,000 fewer over the next 10 years (6).

While we cannot yet say for certain exactly what the impacts of the ACA will be, we can expect some significant improvements in behavioral health coverage for all Americans. Expanded coverage means more patients seeing doctors, more clients with access to therapists and counselors, and more money to pay for drug and alcohol abuse treatments. Certain states have indicated an interest in “opting-out” of the Medicaid expansions, and their right to do so was recently upheld by the Supreme Court. Voters in these states will have to hold their lawmakers responsible for ensuring that they have the same access to healthcare that the rest of the country does. In the meantime, President Obama has an opportunity to do even more for the behavioral health community over the next four years. It will be important to remind him that we expect investments in addiction and mental health research. He has the chance to encourage innovations that could change the way we see addiction and its treatment throughout the 21st century.


Tuesday, November 13, 2012

Living With Success and Failure in Treating Addiction

A number of my recent postings have focused on chronicity, treatment-resistant disease, and staying connected with people who are not doing well no matter what. These are important principles to me and to others who are dedicated to helping people with addictions overcome them if possible, but to continue to work with them if it is not. It is so important to talk about this, to advocate for this, because too often people who have addictions unresponsive to current treatment are condemned, abandoned by their families and friends in the guise of "tough love," prosecuted for crimes and imprisoned, unemployed and homeless because background checks reveal a criminal history. They deserve our care and compassion in spite of, indeed because of, their plight. This service is informed by our humility in the face of a difficult, complicated problem that too often defies effort, faith and science.

However, I witness a lot of successful outcomes, and I need to share those too. As an addiction psychiatrist, I don't see run-of-the-mill patients, I see those with multiple, usually chronic, addictive, mental and physical disorders who have failed to respond to multiple rehabs, or to other approaches. Many patients are referred from hospital based physicians who are seeing the most treatment-refractory group of patients with addictions.

But most of the time, a change in antidepressants, treating a previously undiagnosed disorder, or changing pain medication makes positive difference. Sometimes it is dramatic. I've had patients with chronic pain who were on the edge of despair, even suicide, whose lives turned around dramatically by simply changing the pain medication. Others have depression, anxiety, post-traumatic stress disorder or borderline personality disorder, but where a sophisticated diagnosis and change in treatment results in dramatic improvement.

For most of us, I think our challenges are more salient, bothering us. We fell short. We didn't solve the problem. We failed our patients. But in the majority of cases, we can make a difference. Sometimes that difference is relatively small but meaningful. For example, one patient was able to pick up her grandchild for the first time because of adjustments in pain medications. Another one was able to establish and maintain long-term sobriety for the first time because of a combination of psychotherapy and anti-relapse medications over a 3 year period (but not without some early recurrences.)

Last week, a colleague of mine, a very compassionate family physician called me. He is seeing a patient who has several ongoing chronic illnesses, one of which is alcohol dependence. In spite of everything he and others, including his physician, have tried, he continues to struggle with his drinking. My colleague called to ask, "Am I enabling? Should I send him away, somewhere else?"

My answer came from my own experience more than 25 years ago: "Who is better situated than you to stay with him, and continue to work with him to overcome his disease? Do you discharge people with diabetes, heart disease or arthritis because their disorders don't respond to treatment? How would it help him get better if you were to abandon him? Isn't he demoralized enough by his own 'failure' to respond to treatment?"

He was grateful for my advice and support, and then he added, "I feel like I'm all alone out here [in my primary care clinic.]" I told him I understood, I felt the same way.

Friday, November 9, 2012

New Anne Fletcher Book!

Anne Fletcher, author of Sober for Good, Thin for Life, and other books about how people overcome destructive health behaviors, recently commented on my blog about Hazelden's historic shift to (finally, and belatedly) embrace Suboxone maintenance for opioid addiction. She wanted me to add that she hopes those with a public voice who've spoken out against maintenance treatment, including Dr. Drew Pinsky and Russell Brand, will come along, too. (They seem to subscribe to ideology or opinion or hot air, not science). Please visit her website at for more info. Her newest book chronicles the stories of people who have been through rehab, 12-Step and others. It is a great read! (Full disclosure: I served as an informal and unpaid consultant on the book, offering opinions about various evidence-based topics. But I don't have any financial connection to Anne or the book.) This book offers an unparalleled view of the "real" world of rehab, and who benefits, and the many who do not, or are harmed by the cookie-cutter approach used by most rehabs in the country. I highly recommend it. It's due out in Feb 2013. Look for it!


Tuesday, November 6, 2012

Hazelden Starts Suboxone Maintenance!

Many of you may already have heard that Hazelden is starting a pilot project involving Suboxone maintenance treatment. This landmark shift is primarily due to the skill and persistent effort of Marv Seppala, MD, Hazelden's Chief Medical Officer. Marv and I go way back. I was on the faculty in the Department of Psychiatry at the University of Minnesota when Marv was a resident and then, subsequently, an addiction psychiatry fellow. He and I have stayed in touch ever since, and he and I and Carol Falkowski, another member of the old guard in Minnesota get together for lunch every few months. Marv is a great guy in addition to being a top-notch physician and psychiatrist. He is one of the few people who could make something like this happen. He is widely respected in the 12-Step and addiction treatment worlds, yet he is also a true professional who reads the research and believes in science. When he returned here to Minnesota from Oregon (where his true home still is) to work at Hazelden the second time (he was Chief Medical Officer for a period of time, then left due to disagreements with the then-CEO of Hazelden, then came back to work under a new CEO) we had dinner one night. I argued that not providing Suboxone and/or methadone maintenance treatment to opioid addicts was negligent given how strong the support was in the literature, and at that time, he said that their outcomes for opioid addicts was similar to those of other patients. More recently, as we discussed this new initiative, he told me that one of the primary forces driving the Board to adopt this shift was the number of poor outcomes from strictly abstinence-based 12-Step treatment. (No news to me, some of my Suboxone patients have completed multiple 12-step treatments including at Hazelden.)

Hazelden's new approach is a seismic shift that is likely to move the entire industry in this direction. I told Marv that it was like the Vatican opening a family planning clinic! However, although this is a major positive step, they continue to be wedded to a strictly 12-Step approach along with the medication. I don't see this ever changing. Hazelden has always seemed to operate like a Catholic hospital: science was ok as long as it didn't conflict with ideology, and when it did, ideology won out. It is still pretty much like that I think, but to their credit they have been prescribing anti-relapse medications for alcohol dependence for some time. To those rabid, fundamentalist 12-Steppers who consider anti-relapse medications a "crutch" (in a negative way), my reply is that when you break your ankle, a crutch facilitates healing, and anti-relapse medications do so as well. Rather than "weaken" recovery, they can help some people achieve long-term recovery who would otherwise fall by the wayside. It will be interesting to see how this all plays out in the 12-Step community. My patients tell me that in Narcotics Anonymous there has been increasing acceptance of Suboxone in particular, in contrast to methadone maintenance, which is still regarded as "using" by many because you can still get high while taking it.


Thursday, November 1, 2012

Don't Believe Me, Believe Those Affected!

It's interesting that in response to my talking or writing about research on addiction treatment, I'll get anecdotes in return: "I don't care what the studies show, I got sober without medication!" So we've got to get the stories of people who have benefited from modern treatment methods out there too. I reader wrote an email to me recently, and gave me permission to publish it with identifying info deleted. If you don't believe in research, or believe me, perhaps you'll believe what the people directly affected have to say. Here's the email, and thanks again to the reader who allowed me to publish it. .

Hi Dr:

I have been reading some articles on you as my interest in Suboxone has come about because my 31 year old heroin addict son is trying it.  He has been in detox 4 times, holdings 3 times, 8 months of sobriety in the last year and currently got kicked out of a holding after waiting two months for a halfway house (for smoking).

He is now with his "clean" girlfriend and has gone on Suboxone.  He is going to NA meetings and the doctor is distributing the medication in small amounts, recommended my son see a therapist and of course, go to meetings.  I am hopeful but only "cautiously optimistic" but he feels good and looks good and has hope.

I don't understand all the negative publicity over addiction medications as if there is something out there that works, I don't care if he is on it the rest of his life.

I do believe in the 12 steps and the concept but I don't understand why addicts are punished for relapses and put back out on the street.  It is the worst thing for them.  I have gone the enabling route (didn't work) and now do not enable and have practiced tough love when needed.  I think it helps.  He no longer asks for anything and is truly hopeful.

I just wanted you to know that your information is good to read and necessary to educate all of us that there are alternatives out there.

Keep up the good work... You are saving lives.

Thank you for listening.

PS:  Have you ever heard of

It is a fabulous support group for family members of addicts.  it is a lifesaver for us parents and if you haven't heard of them, you might want to take a look. 

Wednesday, October 31, 2012

The Inadequacy of Mental Health Treatments

I've written about treating addiction in its chronic or recurrent form much like we treat other chronic illnesses. Arguably the most painful part of doing so is accepting the limitations of our current treatments. It does not diminish the progress we have made to acknowledge that our current treatments are far from ideal. They fail too many people. (Yes, fellow treatment providers, treatment does fail people, we can't keep blaming our patients for not responding.) Addiction has a significant mortality rate. Cigarette smoking alone kills close to half a million Americans a year, and hundreds of millions globally. Alcohol addiction kills 85,000, and other addictions perhaps another 10,000. It is hard to live with this, to work so hard with people only to see them struggle in spite of everyone's efforts.

But as time goes on, and as I've done more clinical work again, I'm finding that mental illness is at least as hard if not harder to treat. Depression and anxiety are the most common mental illnesses, and they frequently co-exist with addiction. One thing I've learned is that the more chronic illnesses you have, the harder it is to manage any of them well. And our treatments for depression and anxiety are far from adequate. Between the two, anxiety is the most difficult, because for most people none of the treatments are very effective. Psychotherapy done well is probably the most effective, but it is hard to access good therapy and many patients are ill suited for it. (On the other hand, lousy psychotherapy can be had on every street corner it seems.) Antidepressants are the primary medications used to treat anxiety, but although some people respond very well, most do not. Benzodiazepines such as alprazolam (Xanax), clonazepam (Klonapin), lorazepam (Ativan) and diazepam (Valium) are extremely effective in the short run, but often become ineffective over time, leading to ever escalating doses. Unfortunately, one of the more common alternatives to the "benzos" is a second-generation antipsychotic, such as quetiapine (Seroquel) or aripiprozole (Abilify.) Sec-gen antipsychotics are effective for treating schizophrenia and bipolar disorder, and may be useful as adjuncts to antidepressants for depression, but they come with a lot of baggage and risk. They are terribly expensive, and they frequently lead to substantial weight gain, diabetes and heart disease. And they don't even work very well. Antihistamines such as hydroxyzine (Vistaril, Atarax) and diphenhydramine (Benadryl) don't really work at all in my experience. Anticonvulsants such as gabapentin (Neurontin) are usually not helpful. Most of the time, we struggle to find anything that works. And an uncontrolled panic or generalized anxiety disorder in an individual with an addictive disorder is a prescription for chronicity of both.

Depression is a little, but only a little, better. In the STAR*D trial, going through multiple iterations of medications yielded a remission or recovery rate (not at all depressed, or normal mood) in about 50% of participants. This rate is as good as it gets, because participants were screened out if they had addictive disorders or serious medical problems, or were homeless or did not have transportation, and they had sterling follow up and pharmacotherapy focused on adherence. In real life the figure is likely to be substantially lower. A majority, even in real life, do eventually show a response although in most people there are residual symptoms such as low energy, pessimism or irritability. However, finding a medication that works is trial and error, because the science is not yet available for us to predict who will respond to which drug. Thus, it may take weeks or months, trying multiple medications for several weeks each before finding something that works. So, many patients are left struggling with a serious depression that is not responding well to treatment, even while they are trying to establish recovery from a substance use disorder.

Bipolar disorder, schizophrenia and other psychotic disorders respond to acute treatment, but the long-term course does not appear to have changed significantly as a result of modern treatments. Compared to these diseases, addiction has a much higher rate of recovery. It is ironic indeed that the chemical dependency treatment industry has been highly successful in convincing people that treatment outcomes are poor because they defined success as complete and permanent recovery. Meanwhile, the pharmaceutical industry and, yes, psychiatrists, convinced the public that success rates for treating depression, anxiety, bipolar disorder and schizophrenia are much higher than they are in practice.


Tuesday, October 30, 2012

George McGovern Understood the Cost of Addiction

I once heard George McGovern speak at a meeting of addiction psychiatrists. He spoke so movingly of the futility of efforts to save his daughter from alcohol dependence. Tragically, she froze to death in a snowbank. As a father of now adult sons, I can imagine but not really understand how painful this must have been. His daughter took advantage of all available treatments. Many, many attempts at rehab. "Worked the program." All to no avail. The disease killed her. This is the reality that people avoid at all costs. Addiction kills people. And they cannot help it. And neither can we, not yet.

I've dedicated my career to developing ways to help people with severe addictions, people who often have other severe chronic illnesses. People on whom everyone else has given up , especially rehab programs and counselors, doctors and social service agencies. And yet, inevitably, if I talk about the limitations of current treatments, someone will accuse me of "giving up on them." Underlying that accusation is the assumption that "anyone can overcome addiction and recover, if they really want to."

This is arguably the cruelest thing about current treatment approaches. People are blamed for the inadequacy of available treatments. This doesn't only apply to addictions, it applies to chronic or fatal illnesses in general. Especially here in the West, we are uncomfortable with death. In the US, perhaps more than anywhere else in the world, we fear not feeling in control of our lives, or deaths. In order to maintain the illusion of control, we criticize others who have "lost control," believing that they could have prevented it, except for their laziness, moral depravity and/or lack of motivation. This helps us fend off our fears, but it is devastating to those whose lives fall apart around them, no matter what they do. Too often, when they turn to others for help, they encounter condemnation, criticism, and rejection.

Even worse, the belief that those who succumb are somehow responsible, that effective treatment was available but those affected rejected it, leads to the idea that we don't need more effective treatments. We just need more availability (and payment.) That's one reason that families and people with addictions aren't effective advocates for more research. Today, I bought something at Walgreens. After I swiped my card through the machine, I was asked if I wanted to contribute to the Susan G. Komen Foundation for breast cancer. It seems like every other week, there is some sort of "pink ribbon" campaign on this topic. And what do breast cancer advocates want? More research. They don't ask for more availability of current treatments, because they are not anywhere good enough. What's required is more research and scientific breakthroughs.

Is this what the addiction and recovery communities advocate for? No, they don't. They typically advocate for more treatment, and more support for funding available treatments. Are treatments for addiction that much better than for breast cancer, or heart disease? No they aren't. In fact, there have been very significant advances in the treatment for and survival of people with those disorders. Advances that came through scientific research.

How do you think we are going to achieve better outcomes in the treatment of addictions? If not through scientific research, then what? More 12-Step meetings? Imprisoning more addicted people? Making it even more difficult to recover by closing off access to school loans, jobs, health care, housing and other benefits? I for one believe the only way forward is through scientific research. If we are going to increase funding for research, we have to compete with the advocacy groups for autism, Alzheimers's Disease, heart disease, cancer and many others. Without the advocacy of people with addictions and their families and loved ones, we don't stand a chance. And without more research, we'll still be referring people to support groups 20 years from now, and just as many will die.

Family members: have you been satisfied with the response to addiction from available treatments? Do you just want more of the same? Who is going to organize and sponsor the first national campaign to raise funds for addiction research?


Monday, October 29, 2012

Can We Trust Scientific Research?

A comment from a Twitter follower (@AddictionDrW) asserted that studies supporting the effectiveness of opioid maintenance therapy for opioid addiction must have been funded or supported in some way by "Big Pharma" and therefore cannot be trusted. He rejected all the research, saying that we should be listening to recovering addicts instead, or that "evidence is mixed." Is that true?

Methadone was invented in Germany as an analgesic during WWII. The first study of methadone maintenance, by Vincent Dole, Marie Nisswander and then-resident Mary Jeanne Kreek, was funded not by Big Pharma (who wanted nothing to do with "junkies"), but by the Health Research Council of New York City, due to the failure of abstinence-based approaches in the face of a growing heroin problem (Joseph et al., 2000). To my knowledge, it's never been a significant money maker for a large pharmaceutical company. Subsequent studies have for the most part been funded by government organizations such as the National Institutes on Health (NIH). The most recent large study of Suboxone maintenance for prescription opioid addicts, was funded by the NIH.

If NIH funded research, conducting in a rigorous way, is not trustworthy information, then what is? In my mind this is a way of asserting, in essence, that whatever one wants to believe is true. There are no objective methods to determine whether one assertion is true and its opposite is false. Therefore, there can be no accumulated knowledge, and we are all on our own, depending on whatever we wish to believe, or have heard from others. We can simply reject information we don't like or agree with and accept evidence that supports what we believe.

I don't think that is a supportable position, because it leads to the radical conclusion that there is no objective truth, only subjective opinions. Please, folks, how besides through scientific research are we going to improve outcomes for addiction treatment? And if we choose only to believe results that support our pre-existing ideas, how can we progress?

I understand that we all operate that way to a significant degree, because these biases are built into our brain structure and function, and are almost completely unconscious  Why is not clear, but then traits that nature selects through evolution seldom have immediately clear rationales. As my colleague, Steve Gilbert, argued in a previous blog, we make decisions and then rationalize them after the fact. We weave a coherent narrative of our lives because we need to. We need reasons why things happen, we need to feel in control, and we need to feel like a specific person with a specific history and characteristics. We need be able to explain how we arrived at a decision, and to simply say, "My gut told me so," is seldom adequate. Imagine a presidential debate where that was the rationale for political positions: "It just feels right to me."

On the other hand, it is because of these biases that the scientific method was devised: to minimize bias, to constrain interpretation, and to reveal the precise basis for arriving at a specific conclusion, so that others could replicate the study. Although single large trials may be provide evidence so strong that it changes thinking and practice, more often it is an accumulation of evidence from many studies conducted by multiple independent scientists. Evidence from multiple studies is then collected into systematic reviews, and if there are enough high-quality studies, are then subjected to an obscure procedure called meta-analysis. Meta-analysis is a systematic statistical method for combining findings across studies in order to determine whether, overall, a particular treatment is more effective than its alternative. Two famous examples are aspirin and beta-blockers for prevention of heart attacks after a first heart attacks. It wasn't until the meta-analyses were done that it became clear that these are effective approaches. Sometimes, it takes multiple meta-analyses before a conclusion can really be drawn.

Recent history is littered with examples of approaches that were fervently held and promoted prematurely. How many thousands of women underwent a horrendous and often fatal procedure, bone-marrow transplant, to treat end-stage breast cancer, before it was shown to be ineffective? At the time, women were lobbying legislatures around the country to mandate insurance coverage for it. Those of us who said, "Wait for the research before moving ahead," were shouted down, with tragic consequences for the unfortunate women who received the procedure and their families. Hormone replacement after menopause is another example, being strongly recommended and widely prescribed in the past, to prevent osteoporosis and heart disease, only to learn through meta-analyses, as well as very large well-done trials, that the treatment is actually harmful.

Perhaps the best recent example is that of PSA testing for prostate cancer in men. It was never clear that PSA testing was a good idea, but it became extremely widespread, if not universal. Millions of men have had  prostate biopsies (a very unpleasant procedure,) radical prostatectomies, radiation that scarred their rectums, and other treatments that left them incontinent and impotent. However, two large randomized controlled trials, one in the US and one in Europe, determined that almost all the tumors being treated were slow-growing and probably would never require treatment if left alone. In one trial, there was no difference in mortality, while in the other, there was a slight advantage to PSA testing, but 50 men would have to be treated in order to save one life. I know I don't want to be one of the 49 treated who didn't need it.

However, PSA testing is still popular in the US. Why? Because we are terrified of cancer, and we have been told that "catching it early and getting it out" is the best way to avoid dying of it. Many urologists refuse to believe the studies, based I would guess on their experience treating men with advanced, fast-growing tumors. (It's not even clear that treating fast-growing tumors alters survival.) I don't believe this is because of their financial interests in performing procedures; I know physicians too well to believe they don't have their patients' best interests in their minds and hearts. But they suffer from biases as well. We whack out prostates not because it is beneficial to most men undergoing surgery, we do it because it "feels like the right thing to do."

One of the reasons our health care costs so much is because of our refusal to stop funding ineffective or harmful medical procedures and treatments because "people want them." Here's another example: people presenting to the doctor with back pain were randomly (like the toss of a coin) assigned to either 1) receive regular XRays of their spine, or 2) to get an MRI. After one year, what was the result? In terms of function and pain, there were no significant differences. But there was one significant difference: people getting an MRI had more surgery. The fact is, most people over the age of 35 have abnormal MRIs of their spines, but the correlation with clinical symptoms is very low. And yet, people traipse into the doctor's office demanding an MRI of their back "because I want to know what it is." And the US does more back surgery than any other country in the world, probably more than the rest of the world combined, with highly dubious results. We also consume more prescription opioid pain medication than the rest of the world combined. So biases of this type are not limited to the field of addiction treatment. However, there is one difference: urologists and other physicians are obligated to advise patients of all alternative treatments and to do so in an unbiased way. The patient needs this information to make an informed decision.

A footnote about the "the evidence is mixed" strategy. This approach is not new, having been used by tobacco company executives and climate change deniers for many years. It is always possible to find one of 6 scientists in the world who reject climate change, and then present their opinions as equivalent to the 95% of scientists who are convinced of the evidence. This is a problem with current media, an obsession with presenting two sides to the story without providing the context of the overwhelming majority opinion or of the research itself. In the case of opioid maintenance treatment, the evidence is simply overwhelming in showing that it reduces relapse to addictive use, improves health and function, and reduces crime, and that abstinent-based approaches do not. If you choose to believe something else, that's up to you, but a professional in my opinion has en ethical responsiblity to accept scientific findings and act accordingly. In similar vein, anti-relapse medications for smoking and for alcohol use disorder are not home runs, but they improve outcomes consistently. To say otherwise is to filter the evidence according to preference, to see only what one wants to see. Treatment programs and their professional staff members who deny people with a devastating and often fatal illness access to these treatments, or even to information about them, are imposing their own biases and beliefs on their clients, in violation of the basic tenets of informed consent.

Joseph H, Stancliff S, Langrod J. (2000) Mt Sinai J Med 67:347.