We Still Have a Ways to Go

Very excited to feature a post written by Paula DeSanto, Founder and President of Minnesota Alternatives and a leader in the movement to bring paradigm change to chemical dependency and mental health treatment in Minnesota. Thank you, Paula

We Still Have a Ways to Go

Four years ago I was inspired to open a clinic to help people with substance use issues because of the many, many stories I was hearing about ineffective and often times, harmful treatment.

While we are making progress with embracing more person-centered, stage matched interventions; I continue to have experiences that affirm how far we still have to go.  For example:

I was training a large group of clinicians and practitioners about person-centered care, and we were having a very spirited discussion about why drug and alcohol counselors seem compelled to report their clients use to probation officers.  I have worked as a mental health professional for over 2 decades and mental health clinicians don’t share this compulsion.   In fact, I can’t recall any MH worker ever thinking that this was their professional responsibility.

As this discussion progressed, a man raised his hand and offered a useful perspective.  He commented, “I worked as a probation officer for over 8 years, and throughout that time, we always thought of addiction providers as extensions of us.  There was a strong sense of “we – they” and the counselors job entailed trying to catch the clients using.”

Why do drug and alcohol clinicians think their job includes the role of a correctional officer?

No wonder clients “go underground” in treatment and say whatever they think others want to hear.

Another example:

I was interviewing a young woman who smoked a large quantity of cannabis daily and her parents were very concerned about her well-being.  She had been in treatment previously including some very prominent programs.   I asked this young woman why she smoked pot but before she had a chance to answer her mother jumped and stating, “She smokes because she has a brain disease, and her disease is controlling of her life”.

I again asked the young woman why she smokes, and she proceeded to explain that she smokes to relax especially at night before bed. What unfolded was a discussion about other motives for use and exploration as to whether this young woman even thought she had a problem.

A few days later her mother called me and shared this comment:

“My daughter has been in some of the best programs in the state and I have never heard anyone ever ask her why she uses.  She has always been told that she has a brain disease and they have the fix for it.”

“Kudos to you for asking.”

The Need for Something New in Addiction Treatment

It will come as no surprise to regular readers of this blog that there is a need for new approaches to treating addictions. In particular, people with substance use disorders (SUDs) and their families need access to current, scientifically based practice and greater consumer choice of treatment modalities. Today, I've been receiving a resounding validation of this fact from the response to Jane Brody's column for the New York Times three days ago. In the last two days, I've received almost 30 calls from all parts of the US from people who are interested, if not desperate, for something new, either for themselves or for a relative who is suffering from this disease. One person called me from China!

The main focus of Jane's column was a terrific new book by Anne Fletcher titled Inside Rehab. It's already #1 on the Amazon best-seller list for alcoholism recovery books, and it's been receiving widespread coverage that is overwhelmingly positive. And this is before it's actually available to the public! (Full disclosure: I was one of many experts in the field whom Anne used as resources for her book, and since she also lives in MN, we have become friends.) Jane, with whom I had previously talked with when I was at NIH, called to talk about the book and the state of the treatment field today, and this conversation figured fairly prominently in the column.

Of course, I'm grateful for the coverage of my efforts to change the treatment system and of Alltyr, but I'm saddened by the similarity of the stories I hear time and again. Mostly, it's about going through rehab over and over, almost all of them 12-step oriented, cookie-cutter programs that show films, give lectures, send clients to 12-step groups and use low-quality group  counseling. Clients of these programs are told that the program always works if they accept it, that they must not be motivated or willing, or that they are in denial, and so forth. Families often report nearly bankrupting themselves paying for expensive residential rehab programs that don't work. In too many cases, 12-step abstinence based treatment is used for opioid addiction even though all the evidence shows it doesn't work. Almost always, these are stories about repeated episodes of time-limited low quality treatment without continuity over time, attention to co-existing psychiatric and medical disorders, or meaningful family involvement. There is very little consumer choice or even information about the various options that have been shown to work. Little has changed from when I was at NIH, and frequently gave talks and interviews that were covered in the media. I would always receive calls and emails there asking how to find evidence-based treatment.

At the same time, I am heartened by this latest demonstration of how pressing the need is, how many people are desperately wanting something new. And it inspires me anew to keep pressing forward on a mission that at times feels overwhelming, where there are so many barriers and where progress is often difficult to see. The palpable pain and suffering I hear remind me why I'm doing this. And I know I am not alone, and as more people join the effort the momentum will continue to build.

MW

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!

MW

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 21^st century.

1. http://www.huffingtonpost.com/2012/09/10/romney-obamacare-repeal_n_1872667.html

2. http://www.cbo.gov/sites/default/files/cbofiles/attachments/43472-07-24-2012-CoverageEstimates.pdf

3. http://mentalhealthcarereform.org/affordable-care-act-prevention-grants-will-support-sbirt-tobacco-cessation/ , http://www.samhsa.gov/newsroom/advisories/1207254120.aspx

4. http://www.samhsa.gov/data/2k12/NSDUH103/SR103AdultsAMI2012.pdf

5. http://www.americanprogressaction.org/issues/poverty/report/2012/09/11/11945/romney-ryan-plan-slams-the-poor-showers-more-money-on-the-rich/

6. http://www.whitehouse.gov/blog/2012/03/21/ryan-republican-budget-consequences-imbalance

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 www.learn2cope.com?

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. 

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

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

Families' Health Costs Reduced After Addiction Treatment

This is a the second blog about healthcare costs and substance use disorders (SUD). The first one (6 Sept 2012) dealt with healthcare costs among patients who presented for treatment for SUD. This one is from the same great health services research group founded and anchored by Connie Weisner at UCSF, and addresses a novel topic: the healthcare costs of family members of patients with SUD, and the effect of SUD outcomes (abstinence vs. non-abstinence) in the index patient on family members’ healthcare costs (Weisner, Parthasarathy et al. 2010).

In this study, a group of patients who presented for treatment for SUD (and who were thus likely to have chronic or recurrent, and more severe, SUD, compared to people not presenting for treatment) were followed for 5 years. One year following treatment entry, they were asked questions pertaining to their current (past 30 day) use of a wide variety of intoxicants. Those who had used none in the previous 30 days were considered abstinent for study purposes, while those who had used anything were considered non-abstinent. (Note that in other studies as well as this one, 30-day abstinence at the 12 month time point is strongly related to longest continuous period of abstinence over the entire five years.) Also over this 5 year period, healthcare costs of family members were also tracked, and family members whose index patient were abstinent at 1 year were compared to those who were not. Just to avoid confusion, I’ll state that differently: healthcare costs for families over a 5 year period were compared between those whose family member was either abstinent or not for the past 30 days 1 year after treatment entry.

The results were both surprising and encouraging. First, the authors point out that in the first year following treatment entry, healthcare costs for family members may well go up, as they attend to medical, SUD and psychiatric problems they neglected due to the crisis associated with escalating use and problems in the SUD patients. Thus, it is important to long past the one-year point. Thus, a major strength of the study is that they studied costs over five years. Another strength is that they compared both groups to matched controls without SUD.

And sure enough, in the first two years, healthcare costs were higher among both groups of family members of SUD patients compared to non-SUD control families but were not different between abstinent and non-abstinent groups. However, beginning in the third year the abstinent began to diverge from the non-abstinent families. By year 5, the abstinent family members’ costs were not different from the non-SUD controls, while the non-abstinent family members’ were significantly higher. Average cost for abstinent family members at year five was $3 per member per month, while average cost for non-abstinent family members was $36 per member per month, a 12-fold difference!

In summary, 30-day abstinence one year after treatment for SUD strongly predicted the costs for their family members over the ensuing four years. Healthcare costs of family members of SUD patients abstinent at one year began to go down three years following treatment and by year five, did not differ from control families without SUD. However, costs for family members of SUD patients not abstinent at one year were 12 times higher than for either abstinent SUD families or for control families! Thus, SUD outcomes are strongly related not only to healthcare costs of the SUD patients themselves but to their families as well!

A lot of money could be saved (not to mention the misery that could be avoided) by improving rates of abstinence following SUD treatment. Other studies, by this and other groups, have found that providing ongoing continuing care over long periods is associated with improved rates of abstinence and reduced healthcare costs among SUD patients (see previous blog.)

To me, these findings have two implications:

1)    Current, evidence-based treatment needs to be more widely available to people and, to encourage them to come, they need to include a lot more consumer choice about path to recovery, as well as form and place of treatment, and

2)    We need more research on how to improve rates of abstinence, which are far too low to be acceptable. This will require more money. The only way to get more money for addiction research is advocacy by the people affected: people with SUD, recovering from SUD, and their friends and families. We need to advocate not just for more treatment, but for more money for research. More on this later.

Weisner, C., S. Parthasarathy, et al. (2010). "Individuals receiving addiction treatment: are medical costs of their family members reduced?" Addiction 105(7): 1226-1234.

Do Scientists Know Nothing About Addiction?

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

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

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


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


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


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


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


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


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


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


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