Wednesday, January 4, 2012

A Routine Day for an Addiction Psychiatrist

Today I had a fairly routine day in my practice. On a typical day, I encounter a wide range of people, problems, challenges and successes. I suppose it's not much different from any medical practice that way. But all of my patients are pretty complex and challenging. They all have multiple problems that are intertwined and that cannot be fully teased apart. The most common problems I encounter are addiction, pain, depression, anxiety, insomnia, brain injury, ADHD and PTSD. Relationship, marital and family problems are very common, as are various social and economic problems such as unemployment, disability, poverty, lack of health insurance and homelessness. These are all common problems, and they usually occur in some combination of two, three or more of them. Often there are significant other medical problems as well, including arthritis, heart disease, cancer, multiple sclerosis, lung disease and many others. I have to say it's enough to scare a person once you realize what fate can bestow on you. Most of my patients feel very alone and isolated. They often think they are the only ones who experience what they are experiencing and there is therefore something wrong with them. This isn't true of course. The experience of suffering from these problems is pretty similar across different people, which is not to diminish the importance or meaning of suffering for each person. But most of us don't meet others who are confronting the same or similar issues we are so we feel alone. Those around us who are well almost never understand, and all too often are judgmental. I think some of that is redirected anger at the inconveniences and losses that they experience when a loved one becomes disabled. Most of us think it isn't ok to feel angry with a loved one who becomes ill or disabled, but anger along with sadness and empathy are almost universal. But for someone who has never experienced depression or chronic pain or addiction, it can be very hard to understand why their loved one isn't responding better, isn't getter better or well, or requires ongoing medication to function. I spend quite a bit of time with friends, partners, spouses, children, parents of my patients explaining the illness(es) and treatment(s). It usually makes a difference, sometimes to the point of saving a marriage or preventing rejection from a family. Every day, however, I feel privileged that these people, my patients, let me share their lives in a pretty intimate way. A lot of whatever effectiveness I have comes from simply sharing the path and doing my best to understand what someone is going through without judging them. If nothing else, at least I can give them that.

Monday, January 2, 2012

Revolutionizing Health Care Related to Alcohol Use

My current organization, Allina Hospitals and Clinics, has embarked on an ambitious and to my knowledge unprecedented effort to rationalize our approach to alcohol throughout the system. (The Veterans Health Administration has been addressing alcohol use in primary care for several decades and is as usual way ahead of private care, yet another example where government beats private care by a wide margin. However, their system is so unlike private practice that what happens in the VHA is difficult to translate.) I am leading Allina's effort and we've developed an ambitious agenda and a very aggressive timeline. If we're successful it will be almost a revolution across a large HCO (health care organization.) Allina consists of 11 hospitals, about 60 primary care clinics and many speciality clinics. Last year, there were more than 1 million hospital admissions and almost 4 million clinic visits within the Allina system.

I'm excited about this. It is nothing short of amazing that a large HCO would choose alcohol as a major focus across the organization. So far, the response has been enthusiastic. Physicians and other clinicians are very frustrated with the lack of consistency across parts of the system. They are frustrated that there seem to be so few options for patients admitted to hospital. Even if someone has been through 12 step rehab a dozen or more times, that is still the only option available: another run through rehab. They are desperate for something new. Clinicians are realistic. Most of what we do in medicine is care for chronic incurable conditions. Although we sometimes make people completely well, more often we help mitigate the ravages of an incurable condition. And sometimes we are pretty poor at even that. In cases with really severe, progressive illness we are often pretty helpless, along with the patients and families. So health care professionals are comfortable with care that is less than curative but is at least comforting, and perhaps that slows the rate of deterioration. And they want to be involved and active in managing chronic diseases.

Allina's initiative is remarkable in that it will address alcohol across an entire HCO. This includes emergency departments, primary care, hospital and ICU care and specialty addiction treatment. The goal is to create a fully integrated system that addresses alcohol wherever a heavy drinker interacts with the system and that coordinates the flow of care across boundaries such as inpatient/outpatient care and primary/specialty care. All of this is intended to be as fully evidence based as possible, which is always a challenge but it's an important aspiration. The vision is very ambitious and I am unaware of any other quite like it. If it succeeds, it can serve as an example for other HCOs.

Translating the science to practice is a daunting challenge. Allina is to be commended for choosing alcohol as a focus for such an effort. I'll keep you updated as this progresses.

Sunday, January 1, 2012

Do Scientists Know Nothing About Addiction?

Here's a comment I received yesterday from someone who didn't identify him or herself:

Anonymous has left a new comment on your post "ALLTYR™ Is Born!": 

From this short introduction it is very apparent that despite your credentials you know very little about recovery from substance abuse or its underlying causes.

This comment illustrates a fundamental problem we face in trying to bring addiction treatment into the 21st century and to advance the cause of addiction research and treatment. 

I wonder what it is that I don't know? I've treated thousands of patients with addictions of all sorts and run a treatment program. I've conducted research on various kinds of treatments, on AA, and on implementing evidence based practices in addiction treatment. I co-edited the first version of the VA/DOD clinical practice guidelines for the management of substance use disorders. Many of my patients tell me that I understand them and their struggles more than anyone else they've encountered. So what is it that I don't know? (I won't address how so many other people could be wrong about me.)

Since this writer didn't identify him or herself, I can't ask for clarification. I suspect my commenter has a specific idea or theory about what addiction is and how to overcome it, and sees other theories or ideas as a threat, almost as blasphemy. Perhaps even as destructive, because having a plurality of approaches might dilute the "true"message. So I suppose that I don't "know" that this one true way is in fact, the one true way

But what is it about what I write and speak about that triggers this response? I suspect it is my focus on scientific research. Science is famously viewed with suspicion by true believers. Gallileo was imprisoned for presenting scientific findings that contradicted theology. Science doesn't discriminate either. Many a pet theory scientists have been proved wrong, dashing hopes and ruining careers. So it goes. The scientific method is not perfect but it is structured precisely to minimize scientists' ability to bias the results. In recent years, new research has shown us that much of what we thought we knew about substance use and addiction was wrong or only partially right. This includes many dearly-held notions. For example, addiction is not necessarily chronic or severe or progressive. Most people recover, and most of them do so without treatment or 12 step participation. There are multiple routes to recovery. Spiritual transformation is not necessary for recovery. Multiple different types of behavioral therapy approaches work about equally if delivered well. And the list goes on.

But I worry about the schism this comment suggests, which I encounter frequently. At a recent conference, I talked about treatment for opioid addiction. I said that there was only one treatment that had been proved to be effective for opioid addiction and that was opioid agonist therapy with either methadone or buprenorphine. One of the participants challenged me, saying that the problem was that opioid addicts treated in a 12 step program didn't do well because they didn't do what they were told. Well, I suppose you could say they were told to abstain and they didn't. But I find this kind of argument distressing. For one thing, the same argument could be used for any treatment that didn't work, because treatment failure is the patient's fault, it's not that the treatment is ineffective. What this means is that a treatment could never be proved to be ineffective, because "it would be effective if they did what they were told." 

But what concerns me most is how much this schism reduces the effectiveness of our advocacy and efforts. I think this is why there is so little activity on the part of the recovering community to support more addiction research. With other diseases, research is seen as the way towards improved diagnosis and treatment, but in addiction, far too many view research only as a way to validate what they already "know." In this view, it's not that our treatments are not effective enough, it's simply that there isn't enough money for current treatments. So there may be advocacy for treatment accessibility but not for research. Furthermore, new treatments emerging from research are most often viewed with suspicion rather than embraced and widely implemented. Opioid agonist therapy and anti-relapse medications for alcohol dependence are prominent examples.

I find it very discouraging that someone would conclude based on a "short introduction" that "in spite of my credentials" I know very little about addiction or recovery, not because I'm the grand global expert but simply because it simply cannot be true on its face. I can understand disagreeing on various ideas, having a different take on certain findings or experiences. But this tendency to completely dismiss those we disagree with is a major barrier to advancing the cause of improving our understanding and treatment of addiction. Until we find a way to bridge this gap, we will continue to lose out to more integrated and better organized groups advocating for research on heart disease, Alzheimer's disease, or breast cancer.

The time is long overdue for the recovering, treatment and research communities to stop fighting and join together to promote addiction research and treatment.