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.