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.
MW
Wednesday, October 31, 2012
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?
MW
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?
MW
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.
References
Joseph H, Stancliff S, Langrod J. (2000) Mt Sinai J Med 67:347.
Thursday, October 25, 2012
Determinism, Neuroscience and Free Will: A Conversation
I've recently been having a conversation with a colleague about implications of recent neuroscience research and free will (and therefore blameworthiness, or responsibility for our actions.) Thought you might be interested. My colleague is Steven P. Gilbert, Ph.D., ABPP, LP. He is married to Anne Fletcher, who recently published a wonderful new book (more on that in a later post) called "Inside Rehab." If you haven't read it, you'll want to. There's nothing else like it on the planet.
MW
Mark,
Anne sent me your blog below about the frustrations of appealing to reason in argumentation. I thought you might be interested in both the column I've included below entitled "Reasons Matter (When Intutitions Don't Object)" and the attached PDF, both by psychologist Jonathan Haidt.
I think Haidt's work is brilliant. He demonstrates how evolutionary-based instincts shape our morality and thus our politics (see also How Evolution Has Turned Us Into Liberals and Conservatives<http://blogs.
It all fits perfectly with Benjamin Libet's classic research in neuroscience which found that unconscious neuronal processes precede and potentially cause volitional acts which are retrospectively felt to be consciously motivated by the subject (disturbing research because it challenges the notion of free will).
Steve
Steve, I couldn't agree more. I've always been an "intuitionist," as Haidt puts it, and I've always found much of academic psychology to be sterile and meaningless, in part because of the emphasis on rationality as the basis for decision-making. But my time at NIH is what really convinced me, as I became intimately acquainted with Kahneman's work, among many others, concerning Systems 1 and 2. Many years ago, I concluded that determinism is fundamentally correct, but irrelevant, because we still have to reason and act accordingly, it's how we're made. Also, it's irrelevant because quantum physics tells us that you can't know the precise location, mass and trajectory of every particle in the universe, because there isn't one. Therefore, you can't predict the future, although you could suggest probabilities of various outcomes (50% chance of showers today.)
MW
Mark,
Anne sent me your blog below about the frustrations of appealing to reason in argumentation. I thought you might be interested in both the column I've included below entitled "Reasons Matter (When Intutitions Don't Object)" and the attached PDF, both by psychologist Jonathan Haidt.
I think Haidt's work is brilliant. He demonstrates how evolutionary-based instincts shape our morality and thus our politics (see also How Evolution Has Turned Us Into Liberals and Conservatives<http://blogs.
It all fits perfectly with Benjamin Libet's classic research in neuroscience which found that unconscious neuronal processes precede and potentially cause volitional acts which are retrospectively felt to be consciously motivated by the subject (disturbing research because it challenges the notion of free will).
Steve
Steve, I couldn't agree more. I've always been an "intuitionist," as Haidt puts it, and I've always found much of academic psychology to be sterile and meaningless, in part because of the emphasis on rationality as the basis for decision-making. But my time at NIH is what really convinced me, as I became intimately acquainted with Kahneman's work, among many others, concerning Systems 1 and 2. Many years ago, I concluded that determinism is fundamentally correct, but irrelevant, because we still have to reason and act accordingly, it's how we're made. Also, it's irrelevant because quantum physics tells us that you can't know the precise location, mass and trajectory of every particle in the universe, because there isn't one. Therefore, you can't predict the future, although you could suggest probabilities of various outcomes (50% chance of showers today.)
Another body of work that convinced me of that, although I'm not truly familier with it, is that of social psychologists, who repeatedly find that our "freely made decisions" are strongly affected by our social, internal and external environments, although we are almost never conscious of that.
That said, I'm concerned about the popularization of what is essentially another metaphor for the id, ego and superego, the idea that we have to tame the reptilian monster through reason and religion. Hair shirts, anyone, or flogging, perhaps?
Mark
Mark,
Your observation the indeterminism of quantum mechanics (which has outsed Newtonian determinism) opens the door to free will –– is really interesting, though at the outer limits of my conceptual abilities in both physics and philosophy! Does knowing that God does in fact play dice, i.e., that there is always the possibility of Heisenbergian uncertainty (that no one can "determine" how I will act), really mean I have free will? If our actions are caused by chance, we lack control and if we lack control, then we don't have free will, do we?
Re taming the reptilian monster, my readings in evolutionary psychology suggest that emotions are merely "evolution's executioners," to quote Robert Wright. That is, emotions are essentially motivational dispositions which impel us to behave in adaptive ways, i.e. in ways which increase the likelihood of survival and reproduction (i.e., of having our genes replicated.) Lust (more specifically, male desires for a partner with physical characteristics that signal health and fertility and female desires for a partner with physical and psychological characteristics which signal skill at resource acquisition and a willingness for commitment), maternal love, drives to understand the world, all are in the service of our "selfish genes." Admitedly reductionistic, but true nonetheless, I think!
Steve
Your observation the indeterminism of quantum mechanics (which has outsed Newtonian determinism) opens the door to free will –– is really interesting, though at the outer limits of my conceptual abilities in both physics and philosophy! Does knowing that God does in fact play dice, i.e., that there is always the possibility of Heisenbergian uncertainty (that no one can "determine" how I will act), really mean I have free will? If our actions are caused by chance, we lack control and if we lack control, then we don't have free will, do we?
Re taming the reptilian monster, my readings in evolutionary psychology suggest that emotions are merely "evolution's executioners," to quote Robert Wright. That is, emotions are essentially motivational dispositions which impel us to behave in adaptive ways, i.e. in ways which increase the likelihood of survival and reproduction (i.e., of having our genes replicated.) Lust (more specifically, male desires for a partner with physical characteristics that signal health and fertility and female desires for a partner with physical and psychological characteristics which signal skill at resource acquisition and a willingness for commitment), maternal love, drives to understand the world, all are in the service of our "selfish genes." Admitedly reductionistic, but true nonetheless, I think!
Steve
Steve,
Re your first paragraph:
My primary point was that IMO the question of free will is moot, because we have to act as if we have it even if we don't in theory. That is, accepting determinism, how does one make a decision? "I" still have to "make a decision," and since no one can predict or understand all the pre-determinants, even if "my decision" was pre-determined, it doesn't change anything. Even trying to implement determinism doesn't work. For example, you could say, "It doesn't matter what "I" think because "my decision" is already determined. Therefore, I will flip a coin for every "choice" that "I" have to make" still doesn't help, because that is a "choice" itself, and "my mind" can (and probably will) change. I don't think there's a way out of this loop. If that's so, then we have "no choice" but to act as if we do have choice and make decisions. I think the recursive nature of consciousness and rational thought (system 2) is an evolutionary development. We don't need consciousness to have language, make calculations, or do anything else. So it could be argued (and has, by Skinner) that consciousness is simply an epiphenomenon, perhaps something that came along for the ride with some other more essential evolutionary development, and that we simply respond to reinforcement. I suspect that consciousness evolved because it does have evolutionary value, probably by monitoring System 1 and allowing non-instinctual decision-making. However, it also unleashed the uniqueness of human evils, by freeing us of the constraints of purely instinctive behavior. Wolves will typically fight fiercely for dominance, but when one of them surrenders, the dominant wolf will generally not kill the other one. Humans feel humiliation and shame, and go on killing sprees to punish those perceived as causing the humiliation. So whether consciousness will turn out to be advantageous in the long run remains to be seen.
Along those lines and pursuant to your second para, I've also come to believe that we are motivated to maintain homeostasis in our interoception, our awareness of our internal state, and that this drives all behavior. Emotions are combinations of thoughts and physical sensations, and there are other internal states This appears to be localized in the insular cortex, but it's not an area we hear much about in terms of research.
Mark
Friday, October 19, 2012
Informed Consent: The Best Way to Promote Evidence-based Practice?
Yesterday, I was one of three experts participating in a new Huffington Post initiative called HuffPost Live. This one was on medications for SUDs, and it can be viewed here. What caught the attention of the producer of HuffPost Live was the Salon.com article, which was picked up from TheFix.com (thanks again to Sacha Scoblic, the author of the article.)
It was an interesting interchange. I got pretty incensed when one of the "experts," Justin Hewitt, who runs a sober living facility in Los Angeles, said that the evidence about the effectiveness of maintenance treatment for opioid addiction was mixed, that there was evidence on both sides. I don't think I handled it especially well from a communications standpoint, since the moderator then ignored me and went on to ask about his personal "story" about recovery from addiction. I also re-learned that talking about studies seems to put people to sleep, but anecdotes carry real power (see: election, Presidential.) I think I redeemed myself at the end, adopting a more measured tone, and I was able to get the point across that most people with addiction eventually get well, a positive note that the moderater ended the program with.
But I no longer have any patience with treatment professionals who ignore the overwhelming evidence that abstinence based approaches simply do not work for most people with opioid addiction, or worse, distort the evidence. People are dying because of this every day. We lament the fact that deaths from opioid overdoses are up, and then we fail to provide easy and cheap access to live-saving treatment with Suboxone or methadone. Patients and families (and insurance companies, that is, us) spend hundreds of thousands of dollars repeatedly going through 12-step rehab, only to relapse within weeks or months after program completion. And people are dying because of this. In one study in the UK, the death rate among people discharged from methadone programs shot up as high as 8 fold in the following months.
The program also reinforced an evolving belief of mine, that the best way to advance evidence-based treatment of addiction is to focus on the professional duty to provide full informed consent, something lacking in most treatment facilities. Addiction treatment providers are not held to the same ethical standards of other health care professionals. Justice Cordozo, in a frequently cited landmark court case, Schloendorff v. Society of New York Hospital (1914), stated that "Every human being of adult years and sound mind has the right to determine what shall be done with his own body..." Using that principle as a basis, the current obligation for providing informed consent was established by the D.C. Court of Appeals in another landmark case, Canterbury v Spence (1972). Prior to Canterbury v Spence, the standard had been physician-oriented, based on what the local standard of practice was for informing patients. This led to the common practice of failing to disclose a diagnosis of cancer to a patient, while often informing a spouse, because the physician decided it was in the patient's best interests not to know. In Canterbury v Spence, the court established the principle that a physician's obligation was to give the patient information about a proposed medical treatment, based on what a reasonable person would want to know, in order to make a fully informed decision. They also found that the "the patient's right of self-decision shapes the boundaries of the duty to reveal." Subsequent rulings in other jurisdictions have refined this to find that failure to inform the patient about risks, benefits and alternative treatments violated ethics and law even if the treatment provided was not done negligently. That is, providing competent treatment that the patient may have rejected had they been fully informed was also wrong and potential cause of action.
So, if someone is seeking treatment for addiction, and meets a professional like Mr. Hewitt, she will be be getting a distorted and factually incorrect account of what the evidence shows, and what the relative risks and benefits of different treatments are. She will typically be told that whatever the treatment the facility provides is the most effective treatment available, and often will be instructed to discontinue more effective treatments, especially medication. That is not the basis for an informed decision, and in my view, this lack of informed consent is unethical, negligent and inexcusable.
State agencies and the federal government are complicit in keeping the truth from the public. Out of misplaced fear of offending programs, staff and many recovering people who "do not believe in" certain evidence-based treatments, state licensing agencies allow addiction programs to offer virtually anything without regard for its basis. Some programs provide "nutritional therapy," others treat addiction with religion (not spirituality as is the case in 12-Step treatment programs, but actual specific religious practices,) while others use "equine therapy," "golf therapy," hypnosis and acupuncture. I would bet that fewer than 10% of programs or addiction therapists provide true informed consent. The Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Institute on Drug Abuse (NIDA) soft-pedal their recommendations, which are supposed to be evidence-based, for the same reason. For example, their publications often say things like "Medications may also become an essential component of an ongoing treatment plan, enabling opioid-addicted persons to regain control of their health and their lives." (NIDA Topics in Brief: Medication-Assisted Treatment for Opioid Addiction, 2012; emphasis mine.) Even the term "Medication-Assisted Treatment" is designed so as not to offend the ideologues who hate the idea that "working the program" might not be enough. The term suggests that the primary treatment is counseling, but in the treatment of opioid addiction, counseling is adjunctive to the primary treatment. We don't call using insulin for diabetes medication-assisted treatment, even though counseling and behavior change are as essential to proper diabetes management as they are in addiction treatment. A correct statement is this: "The only treatment proven effective for treating established opioid addiction is maintenance on a medication such as Suboxone or methadone, often with adjunctive counseling. Studies show that maintenance treatment reduces illness, mortality and crime, and is highly cost-effective. Therefore, it is the first-line treatment and the treatment of choice. There is no evidence of effectiveness for abstinence-based treatment."
Adults who are fully informed can make whatever decision they wish. If they want to go to a shaman, homeopath, naturopath, chiropractor, herbalist, spiritual healer or Reiki master for treatment of a medical condition, that's their business. But people who are deprived of access to unbiased information concerning the effectiveness, risk, benefits, and alternatives to treatments provided by a licensed professional or treatment program cannot make an informed decision. I'm waiting for the wrongful death lawsuit by a family whose loved-one died because he was not informed of the effectiveness of maintenance treatment of opioid addiction. The program will lose in court. Unfortunately, that may be what it takes to change the behavior of the addiction treatment industry.
It was an interesting interchange. I got pretty incensed when one of the "experts," Justin Hewitt, who runs a sober living facility in Los Angeles, said that the evidence about the effectiveness of maintenance treatment for opioid addiction was mixed, that there was evidence on both sides. I don't think I handled it especially well from a communications standpoint, since the moderator then ignored me and went on to ask about his personal "story" about recovery from addiction. I also re-learned that talking about studies seems to put people to sleep, but anecdotes carry real power (see: election, Presidential.) I think I redeemed myself at the end, adopting a more measured tone, and I was able to get the point across that most people with addiction eventually get well, a positive note that the moderater ended the program with.
But I no longer have any patience with treatment professionals who ignore the overwhelming evidence that abstinence based approaches simply do not work for most people with opioid addiction, or worse, distort the evidence. People are dying because of this every day. We lament the fact that deaths from opioid overdoses are up, and then we fail to provide easy and cheap access to live-saving treatment with Suboxone or methadone. Patients and families (and insurance companies, that is, us) spend hundreds of thousands of dollars repeatedly going through 12-step rehab, only to relapse within weeks or months after program completion. And people are dying because of this. In one study in the UK, the death rate among people discharged from methadone programs shot up as high as 8 fold in the following months.
The program also reinforced an evolving belief of mine, that the best way to advance evidence-based treatment of addiction is to focus on the professional duty to provide full informed consent, something lacking in most treatment facilities. Addiction treatment providers are not held to the same ethical standards of other health care professionals. Justice Cordozo, in a frequently cited landmark court case, Schloendorff v. Society of New York Hospital (1914), stated that "Every human being of adult years and sound mind has the right to determine what shall be done with his own body..." Using that principle as a basis, the current obligation for providing informed consent was established by the D.C. Court of Appeals in another landmark case, Canterbury v Spence (1972). Prior to Canterbury v Spence, the standard had been physician-oriented, based on what the local standard of practice was for informing patients. This led to the common practice of failing to disclose a diagnosis of cancer to a patient, while often informing a spouse, because the physician decided it was in the patient's best interests not to know. In Canterbury v Spence, the court established the principle that a physician's obligation was to give the patient information about a proposed medical treatment, based on what a reasonable person would want to know, in order to make a fully informed decision. They also found that the "the patient's right of self-decision shapes the boundaries of the duty to reveal." Subsequent rulings in other jurisdictions have refined this to find that failure to inform the patient about risks, benefits and alternative treatments violated ethics and law even if the treatment provided was not done negligently. That is, providing competent treatment that the patient may have rejected had they been fully informed was also wrong and potential cause of action.
So, if someone is seeking treatment for addiction, and meets a professional like Mr. Hewitt, she will be be getting a distorted and factually incorrect account of what the evidence shows, and what the relative risks and benefits of different treatments are. She will typically be told that whatever the treatment the facility provides is the most effective treatment available, and often will be instructed to discontinue more effective treatments, especially medication. That is not the basis for an informed decision, and in my view, this lack of informed consent is unethical, negligent and inexcusable.
State agencies and the federal government are complicit in keeping the truth from the public. Out of misplaced fear of offending programs, staff and many recovering people who "do not believe in" certain evidence-based treatments, state licensing agencies allow addiction programs to offer virtually anything without regard for its basis. Some programs provide "nutritional therapy," others treat addiction with religion (not spirituality as is the case in 12-Step treatment programs, but actual specific religious practices,) while others use "equine therapy," "golf therapy," hypnosis and acupuncture. I would bet that fewer than 10% of programs or addiction therapists provide true informed consent. The Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Institute on Drug Abuse (NIDA) soft-pedal their recommendations, which are supposed to be evidence-based, for the same reason. For example, their publications often say things like "Medications may also become an essential component of an ongoing treatment plan, enabling opioid-addicted persons to regain control of their health and their lives." (NIDA Topics in Brief: Medication-Assisted Treatment for Opioid Addiction, 2012; emphasis mine.) Even the term "Medication-Assisted Treatment" is designed so as not to offend the ideologues who hate the idea that "working the program" might not be enough. The term suggests that the primary treatment is counseling, but in the treatment of opioid addiction, counseling is adjunctive to the primary treatment. We don't call using insulin for diabetes medication-assisted treatment, even though counseling and behavior change are as essential to proper diabetes management as they are in addiction treatment. A correct statement is this: "The only treatment proven effective for treating established opioid addiction is maintenance on a medication such as Suboxone or methadone, often with adjunctive counseling. Studies show that maintenance treatment reduces illness, mortality and crime, and is highly cost-effective. Therefore, it is the first-line treatment and the treatment of choice. There is no evidence of effectiveness for abstinence-based treatment."
Adults who are fully informed can make whatever decision they wish. If they want to go to a shaman, homeopath, naturopath, chiropractor, herbalist, spiritual healer or Reiki master for treatment of a medical condition, that's their business. But people who are deprived of access to unbiased information concerning the effectiveness, risk, benefits, and alternatives to treatments provided by a licensed professional or treatment program cannot make an informed decision. I'm waiting for the wrongful death lawsuit by a family whose loved-one died because he was not informed of the effectiveness of maintenance treatment of opioid addiction. The program will lose in court. Unfortunately, that may be what it takes to change the behavior of the addiction treatment industry.
Thursday, October 18, 2012
Dr. W on HuffPost Live Tonight!
I'll be one of three guests on a Huffington Post Live segment on anti-relapse medications in the treatment of addiction. Tune in at 8:20 PM Eastern/5:20 PM Pacific!
MW
Tuesday, October 9, 2012
Transformation in Action
Most people realize that the current system of care, developed in 1950 and based on the Big Book of Alcoholics Anonymous (AA), is not meeting the needs of patients, families, employers, the criminal justice system, or society at large. There is tremendous waste in providing the same series of lectures, group sessions, films and AA to people over and over again, thinking that someday it will "take." As a physician, that seems similar to treating one of the new "superbugs" with penicillin over and over, thinking that perhaps "this time" it will work. Even worse, in addiction treatment we blame the patient for not responding. At least the poor patient with treatment-resistant infection doesn't have to endure that: being blamed for not responding to available treatments.
The good news is this: people who suffer from addictions, their families and friends, employers, payers, and health care systems are not only ready for change, they are desperate for a new approach. The bad new is this: in order to fully implement modern, scientifically based treatment for addiction, we have to confront a very difficult reality. With the exception of maintenance therapy for opioid (painkiller or heroin) addiction, most other treatments we currently have only have modest effectiveness. To state that is not to belittle it, or to imply that addiction treatment is less effective than treatment for other conditions. When was the last time you knew someone who was cured of their diabetes or high blood pressure? Most chronic ailments respond modestly to available treatments. That's not ideal of course, but it's OK. After all, chronic diseases in humans are extremely complicated and difficult to treat.
We have an easier time accepting that for diseases below the neck. That's my term for diseases we consider "physical" or "medical," as opposed to "psychological." But this is old-fashioned thinking. Consider "psychological" illnesses, such as depression, anorexia, addiction or schizophrenia. If these disorders aren't "physical" what are they? Do they occur without a body, a physical structure which in this case happens to be the brain? No, they don't. The brain is a flesh-and-blood organ that regulates things, just like other organs. And, just like other organs it can get "sick," dysregulated, where it cannot perform it's intended function as well as it should.
MW
The good news is this: people who suffer from addictions, their families and friends, employers, payers, and health care systems are not only ready for change, they are desperate for a new approach. The bad new is this: in order to fully implement modern, scientifically based treatment for addiction, we have to confront a very difficult reality. With the exception of maintenance therapy for opioid (painkiller or heroin) addiction, most other treatments we currently have only have modest effectiveness. To state that is not to belittle it, or to imply that addiction treatment is less effective than treatment for other conditions. When was the last time you knew someone who was cured of their diabetes or high blood pressure? Most chronic ailments respond modestly to available treatments. That's not ideal of course, but it's OK. After all, chronic diseases in humans are extremely complicated and difficult to treat.
We have an easier time accepting that for diseases below the neck. That's my term for diseases we consider "physical" or "medical," as opposed to "psychological." But this is old-fashioned thinking. Consider "psychological" illnesses, such as depression, anorexia, addiction or schizophrenia. If these disorders aren't "physical" what are they? Do they occur without a body, a physical structure which in this case happens to be the brain? No, they don't. The brain is a flesh-and-blood organ that regulates things, just like other organs. And, just like other organs it can get "sick," dysregulated, where it cannot perform it's intended function as well as it should.
MW
Saturday, October 6, 2012
Grateful for the Support
Today, I've been working on the business plan for Alltyr. I've also had to complete some documentation of patient visits this past week. It's been a good week for science-based treatment of addictions! Sacha Scoblick wrote a great interview with me on The Fix, which was picked up by Salon.com. Her posting generated a significant increase to this blog, as well as emails from suffering addicts who need help. I appreciate the interest. It is interesting that basing addiction treatment on scientific evidence is controversial. This occurs in other areas of medicine, for example: is it good to take statins for primary prevention of heart attacks? or should I get a mammogram? or should I get a PSA test for prostate cancer? Science is constantly evolving. The most disconcerting aspect to science is that it doesn't care about tradition, values, opinions, or perspectives. It says what it says. I admit that too often, scientists, the media, industry and/or advocacy groups exaggerate the impact of particular scientific findings. All of us have vested interests. But the health care consumer has to sort through the various claims and descriptions of effectiveness, treatment and comparative effectiveness. One of the missions of Alltyr is to provide unbiased information to the consumer, families, providers, payers and policy makers about what the science shows, what it negates, and what is unknown. It's not going to be easy to transform from a system based on a somewhat magical idea of transformative change to one based on the realities and limits of scientific understanding of addiction, to providing the best available care to everyone, everywhere, and to accepting the limitations of current treatment approaches. When was the last time you saw a walk/run for addiction RESEARCH? Too many people think we already have the answer to addiction, "if the addict will accept it," but the outcome studies tell us something else. We have to do better. The only to way to do better, to better serve addicts, their families, their employers, and society at large is to support more research in to the nature and treatment of addictions.
I want to thank all of you who have submitted comments and emails. We need to build a movement.
MW
I want to thank all of you who have submitted comments and emails. We need to build a movement.
MW
Friday, October 5, 2012
Recovering from Recurrent Episodes
Several of my patients had recurrences of their addictions this week. Each one of them struggled mightily with feelings of shame and guilt. "Why do I keep doing this? I'm a smart person, I know what's going to happen. And I was doing so well!" My response in each case was different of course, and depended upon that particular person's situation, disorders, severity, past history, and so on. But here are some common things I do pretty much every time:
1. Stopping suddenly and permanently is a rare outcome, with or without treatment or rehab or AA. In one study that followed people with alcohol dependence for 10 years following an episode of treatment the proportion of people remaining continuously abstinent for the entire period was 8%. So the norm is to struggle with recurrences.
2. Most people take several years of persistent effort to finally establish long-term remission, on average 5-10 years. The most important thing is to keep working at it.
3. I've begun thinking in terms of "quit attempts," much as with smoking. How many times do most of us have to "stop" before it sticks? And even then, recurrence is common even years later.
4. Think of other types of behavior change. How often do any of us make a decision to eat better/less, get more exercise, work less, work more, keep going at my meditation practice, try to be a better person, etc? And how often does that go smoothly, without slips and slides backwards? Almost never. So why would it be any different for changing substance use behavior?
5. The notion of counting sober days/months/years, sober dates, etc., is usually not helpful and may be harmful. So is the notion of "starting from scratch" after a recurrence. Every sober day is a sober day. Think more in terms of drinking or using days per month or 6 months or a year. Often I'll ask my patients to estimate the number of drinking or using days in the 6 or 12 months prior to starting treatment with me, and usually the answer is 90-100% of the days, or something like 180 days out of 180 days. Then, if they have had a period of remission, I'll ask how many drinking/using days they've had in the last 6 months, and often the answer is 3, or 5. So, 180 compared to 3. Is that an improvement? And nothing can take away those days of remission.
6. If we used the same outcome criterion for other disease as we do for addiction, here's how it would look:
1. Stopping suddenly and permanently is a rare outcome, with or without treatment or rehab or AA. In one study that followed people with alcohol dependence for 10 years following an episode of treatment the proportion of people remaining continuously abstinent for the entire period was 8%. So the norm is to struggle with recurrences.
2. Most people take several years of persistent effort to finally establish long-term remission, on average 5-10 years. The most important thing is to keep working at it.
3. I've begun thinking in terms of "quit attempts," much as with smoking. How many times do most of us have to "stop" before it sticks? And even then, recurrence is common even years later.
4. Think of other types of behavior change. How often do any of us make a decision to eat better/less, get more exercise, work less, work more, keep going at my meditation practice, try to be a better person, etc? And how often does that go smoothly, without slips and slides backwards? Almost never. So why would it be any different for changing substance use behavior?
5. The notion of counting sober days/months/years, sober dates, etc., is usually not helpful and may be harmful. So is the notion of "starting from scratch" after a recurrence. Every sober day is a sober day. Think more in terms of drinking or using days per month or 6 months or a year. Often I'll ask my patients to estimate the number of drinking or using days in the 6 or 12 months prior to starting treatment with me, and usually the answer is 90-100% of the days, or something like 180 days out of 180 days. Then, if they have had a period of remission, I'll ask how many drinking/using days they've had in the last 6 months, and often the answer is 3, or 5. So, 180 compared to 3. Is that an improvement? And nothing can take away those days of remission.
6. If we used the same outcome criterion for other disease as we do for addiction, here's how it would look:
- Someone with asthma should never have another asthma attack the rest of their lives
- Someone with high blood pressure should never have another reading above 140/90 the rest of their lives
- Someone with depression should never have another episode.
- Someone with cancer who is in remission for 3 years and then has a recurrence demonstrates a complete failure of treatment, and that period of remission is worthless.
- If permanent and complete remission is not obtained in any of these disorders, treatment is a complete failure. That is improvement but not complete and permanent remission is meaningless.
These example demonstrated the absurdity of the way we think about outcomes in substance use disorders. How about this alternative approach: the goal of treatment is to minimize the frequency, severity, length and consequences of recurrences.
7. The worst thing one can do after a recurrence is to not learn from it. I ask my patients to reframe this experience thus: we have to examine how the relapse occurred, in order to understand how this disease works in you. It's different in everyone. But by examining recurrences, we can develop better approaches to prevent the next one.
8. Finally, it's not helpful to get distracted by shame and guilt. Recurrences happen. Stop it quickly, learn from it, pick yourself up, and move on. Look to the future, look to preventing the next one.
MW
Wednesday, October 3, 2012
Program Thinking: The Bane of Addiction Treatment
I appreciate the two comments on my last blog, and they prompt a couple of responses from me. (If you didn't read them, click on the "Comments" link at the bottom of the blog.)
First, I'd like to clarify something in response to Dr. Dawson's comments. I was not arguing that people who are living in a sober structured environment do not need programming, or do not benefit from it. What I am saying is that there is no such thing as "residential or inpatient treatment." That is, studies have shown that staying overnight in the same place while receiving treatment has no outcome advantages over going home or to some other place, like a sober residence. So, there is treatment, and there is housing structure. Just like addiction psychotherapy, addiction pharmacotherapy, vocational counseling, psychiatric treatment, treatment for conditions below the neck (CBTN) (often but erroneously called "physical or medical" as opposed to "psychiatric," as if psychiatric conditions were somehow not organ-based or medical), transportation, family or marital therapy, and so on, addiction psychotherapy and housing structure are two very important, but essentially independent components of an interdisciplinary approach to comprehensive modern addiction treatment.
Marrying addiction psychotherapy to a residential treatment bed leads to "program thinking." Program thinking promotes a number of undesirable behaviors or characteristics. First, there is constant pressure to "keep the beds full." Thus, inclusion/exclusion criteria become flexible depending on bed occupancy, and people who could be treated quite well as outpatients are instead admitted to a residential program. This constant push leads to excessive costs without adding to outcome. Second, program thinking leads to cookie-cutter programming, because it's like running a factory, churning out patients and it is too difficult to have completely individualized lengths of stay or treatment plans. For example, the old joke in rehab is that we conduct a comprehensive individualized assessment and then send the client to group. It works much better to have the same groups for everyone, the same treatment for everyone, every time. Third, it leads to inappropriate levels of housing and of treatment services. Some people who need longer-term housing are pushed out at the end of the "program," while others who don't need sober housing are forced into it (and to pay for it.) Some patients need more intensive and comprehensive treatment services for a long time, but their treatment is interrupted arbitrarily, often with devastating consequences such as recurrent addiction along the way to connecting with some (different) outpatient follow up (inappropriately called "aftercare" rather than "care"). When treatment services are provided independently, then there is no disruption of services when a patient moves from one level of housing structure to another. Lack of continuity is compounded when the residential facility is geographically distant from the patient's home, which is often the case. It is always tempting to "send the patient away" to a distant facility so we don't have to worry about whether they are safe, but if we did that with every condition, we'd be sending out of control diabetics, not to mention almost all adolescents, to residential treatment too. We used to hospital people for long periods for psychiatric disorders such as depression and anxiety too, but when it became clear that that was actually harmful and expensive, it was stopped. It is long past time to stop it for addiction treatment too.
I'll respond to the other comment later.
Keep the comments and dialogue coming!
MW
First, I'd like to clarify something in response to Dr. Dawson's comments. I was not arguing that people who are living in a sober structured environment do not need programming, or do not benefit from it. What I am saying is that there is no such thing as "residential or inpatient treatment." That is, studies have shown that staying overnight in the same place while receiving treatment has no outcome advantages over going home or to some other place, like a sober residence. So, there is treatment, and there is housing structure. Just like addiction psychotherapy, addiction pharmacotherapy, vocational counseling, psychiatric treatment, treatment for conditions below the neck (CBTN) (often but erroneously called "physical or medical" as opposed to "psychiatric," as if psychiatric conditions were somehow not organ-based or medical), transportation, family or marital therapy, and so on, addiction psychotherapy and housing structure are two very important, but essentially independent components of an interdisciplinary approach to comprehensive modern addiction treatment.
Marrying addiction psychotherapy to a residential treatment bed leads to "program thinking." Program thinking promotes a number of undesirable behaviors or characteristics. First, there is constant pressure to "keep the beds full." Thus, inclusion/exclusion criteria become flexible depending on bed occupancy, and people who could be treated quite well as outpatients are instead admitted to a residential program. This constant push leads to excessive costs without adding to outcome. Second, program thinking leads to cookie-cutter programming, because it's like running a factory, churning out patients and it is too difficult to have completely individualized lengths of stay or treatment plans. For example, the old joke in rehab is that we conduct a comprehensive individualized assessment and then send the client to group. It works much better to have the same groups for everyone, the same treatment for everyone, every time. Third, it leads to inappropriate levels of housing and of treatment services. Some people who need longer-term housing are pushed out at the end of the "program," while others who don't need sober housing are forced into it (and to pay for it.) Some patients need more intensive and comprehensive treatment services for a long time, but their treatment is interrupted arbitrarily, often with devastating consequences such as recurrent addiction along the way to connecting with some (different) outpatient follow up (inappropriately called "aftercare" rather than "care"). When treatment services are provided independently, then there is no disruption of services when a patient moves from one level of housing structure to another. Lack of continuity is compounded when the residential facility is geographically distant from the patient's home, which is often the case. It is always tempting to "send the patient away" to a distant facility so we don't have to worry about whether they are safe, but if we did that with every condition, we'd be sending out of control diabetics, not to mention almost all adolescents, to residential treatment too. We used to hospital people for long periods for psychiatric disorders such as depression and anxiety too, but when it became clear that that was actually harmful and expensive, it was stopped. It is long past time to stop it for addiction treatment too.
I'll respond to the other comment later.
Keep the comments and dialogue coming!
MW
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