Everything I encounter in practice tells me the direction I'm headed is the right one. Saw yet another person today with alcoholic pancreatitis who I had not previously met someone who understood both how difficult it is to cope with the really awful chronic pain of pancreatitis, as well as her alcohol dependence and recent relapse and her bipolar disorder. I like being back in a hospital, getting to know the nursing staff, the hospitalists, and of course, the patients I see. I'm surprised at how many people I'm seeing in private practice who have very serious problems with substance use. There is such a stereotype that people who have substance problems are low-lifes who can't cope. Of course, I've always known better, but this experience is reinforcing it. To my mind, it's astonishing how few people have had access to truly competent addiction psychiatry. For these folks, another run through rehab is not the answer. I've seen several patients recently who are actually quite good at managing their various chronic medical and psychiatric conditions but who have had a slip or relapse of their substance use disorder in response to severe environmental stress. As I explained to a nursing student today, relapse in any chronic disease can be understood as the place where each of us has a breaking point. Under severe stress, some of us will lose control of our heart rhythm, our mood, our glucose control or our chronic pain. Where each of us loses control differs primarily by genetics and our particular situation. There is no point in condemning those with some chronic illnesses (depression or bipolar disorder, addiction or schizophrenia) and not others (asthma, heart failure, cancer, or arthritis.) 


Over and over, everything I'm encountering in general psychiatry practice is affirming the need to offer updated, scientifically based treatment for people who overuse or become dependent upon intoxicants.

Medical/Psychiatric Treatment of Addiction

The past two 6 weeks I've been in the process of practicing in a new environment, learning all the rules (official and unofficial), the technology (not simple or quick), and of course, the nurses, administrative staff and patients I work with on a daily basis. I've been having a lot of fun. Practicing general and addiction psychiatry is very gratifying, in part because I'm offering other medical staff and patients services they've never experienced before. People are baffled, befuddled. They are so used to the idea that treatment for addiction is education, group counseling and 12-step programs that the idea of the medical and psychiatric treatment of addiction is completely foreign to them. They are intrigued; I'm concerned about the deluge as word gets out. They've been truly desperate for it; they've had to do what they could on their own. Obtaining a "chemical dependency" consultation essentially consisted of two options: yes and no. That is, yes or no to rehab. Or, there had been so many runs through rehab that they weren't eligible for another "run." At any rate, treatment for addiction was not medical or psychiatric; it was social and spiritual. I don't denigrate peoples' spiritual experiences, they seem to be profound and uplifting experiences for many people. At the same time, when a medical condition is treated by spirituality, it suggests that there is no actual medical treatment for it. This is the history of medicine: when all else fails, pray. The problem is this: medical/psychiatric treatment of addiction is possible, feasible, cost-effective and has an excellent empirical base for it. The evidence base for treatment of addiction is better than for most medical specialties. In some cases, patients are lucky enough to find me in time, in others, tragically, they are not. They only obtain access to scientifically based treatment after suffering devastating consequences of their substance use. This is nowhere more apparent than in the treatment of chronic pain. The treatment of chronic pain in the US is extremely limited and ineffective. Patients are routinely labeled as "drug-seeking," a term that is not actually descriptive, but a value judgment.  I'll have a lot more to say about that in the future. In the meantime, I'm interested in hearing about either living with chronic pain or professionals who are treating chronic pain.

DSM-V: How Does It Stack Up?

The American Psychiatric Association has come out with the proposed fifth revision of its Diagnostic and Statistical Manual (DSM-V). The biggest news is the elimination of the two-category diagnoses of abuse and dependence. They are proposed to be folded into one diagnosis, substance use disorder, with accompanying dimensional criteria estimating severity, lethality and so forth. Is this an advance? In my view, yes. Unequivocally yes. Here's why: the abuse and dependence category have never worked the way they were intended and the have added to a lot of confusion about diagnosis. Newer research has demonstrated that substance use and its consequences exist along a single continuum. What were criteria for abuse in DSM-IV are mostly found in late-stage severe addicts. Things like role failure (inability to perform as a parent, student, employee, professional) and legal problems. DSM-IV Dependence criteria, on the other hand are among the first symptoms experience, and the most common symptoms among those with milder forms of the disorder. Things like going over self-imposed limits, a persistent desire to quit or cut down, and continuing to use in spite of physical or psychological symptoms caused by substance use, like insomnia, dyspepsia or hangover. The most common form of alcohol dependence is characterized by mostly the "internal" symptoms experienced as impaired control, in the absence of serious life disruption. Unfortunately, we keep focusing on the most severe chronic or recurrent forms of the disorder, rather than the much large group of people with milder disorders that usually remit without recurrence.

So I think the overall direction is positive, that is, a single substance use disorder diagnosis that can range from mild to moderate to severe. What do you think?

The future of addiction treatment

I'm just back from ICTAB, the International Conference on Treatment of Addictive Behaviors, held each year in Santa Fe, NM. Established by Bill Miller, this is the 12th annual conference. As you might expect, the participants are devotees or at admirers of Motivational Interviewing, the set of techniques that Dr. Miller and colleagues developed at the University of New Mexico. Dr. Miller has retired (although he was at the meeting and very present) and now Barbara McCrady, PhD, is the Director of the Center for Alcoholism, Substance Abuse and Addiction (CASAA) at UNM. Terri Moyers, PhD, was the organizer for the conference, held at the ElDorado Hotel. 

I found many kindred spirits there, professionals who had been working for years to provide scientifically based treatment for addictions. Treatment that provided highly professional, individualized treatment in an environment of respect, confidentiality and consumer choice. But so far, there's been nothing to bring them together to advocate for a comprehensive, accessible and affordable alternative to existing rehab programs. There were many senior scientists there as well. People who had been working for decades to improve the outcome of addiction treatment, to understand the basis of it, and to justify the expense of treatment. And they were excited too. They have seen their hard-won research findings sit on the shelf, not being implemented by treatment programs, not available to consumers. 

More than ever, this meeting energized me and strengthened my commitment to change the way we do business in the treatment of substance use conditions. I really think the time is ripe for change. And I am beginning to understand the power of people coming together in a common goal. There is a groundswell building that includes scientists, treatment professionals, payers, health care organizations, county, state and federal health care organizations, employers, family members, and most of all, people suffering from addiction, who desperately want access to new therapies and approaches, flexibility, professionalism, and better outcomes. I don't know a single person who believes the current system of care serves anyone very well. The time for change is now.

A caveat: sometimes, in my enthusiasm for change, I may be perceived as putting down addiction counselors and others who are currently providing treatment, or as saying that current treatments are ineffective. I know how dedicated treatment providers are, and how much they want their clients to respond and have better lives. But most are working within a framework that is 50 years old and that does not incorporate current scientific understanding of addiction and its treatment. Change may be disruptive for some providers, especially those who have been working in the field the longest. There must be sensitivity to those concerns. But we also cannot let those concerns override the need to provide the best treatment, grounded in science, to people who need it. I think there are ways to make the transition work.

I also agree that there are several approaches to behavioral treatment that are approximately equally effective if delivered skillfully. I use them myself and have experienced how helpful they are to me (helping to provide care) and to my patients and families. My concern is that those treatments, delivered individually by skillful, well-trained therapists (as is the case in the studies) are not available to most people. And, most current rehab programs don't offer that quality of therapy. The studies published by Tom McLellan, currently Deputy Director for Demand Reduction at the White House Office of Drug Control Policy (ONDCP) found that more than 90% of rehab programs in the US offer group counseling and AA, and nothing else. Together the research budgets for the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) amount to almost $2B per year. It's time the American taxpayer had access to the fruits of this investment.

More on Private Practice

Yesterday, I worked from 8:30 AM to 8:30 PM and basically crammed everything I could into the hours. I ate lunch in 10 minutes at my desk. And I still didn't get caught up. It's true that I'm learning a new electronic medical record that is quite complex and takes a lot of time to customize to my particular documentation. But I'm also having to learn an even more complex and arcane set of rules for documenting my activities for the purposes of billing. The currency of the medical realm is called a Weighted Relative Value Unit or RVU. Each procedure or visit is worth a certain number of RVUs. RVUs supposedly take into account the length of training and expertise, risk and so forth and were originally developed as a way to rationalize a payment system that had simply developed naturally over time. One of the key criticisms of the RVU system is that it rewards procedural specialties like surgical subspecialties, radiology or interventional cardiology. So-called cognitive specialties such as general internal medicine, pediatrics or psychiatry are reimbursed at a much lower rate. As a colleague of my once said, "The closer you are to the patient the less you get paid," and unfortunately it's true. This is why medical students are choosing procedural specialties over primary care and psychiatry.

At any rate, although I don't even know yet how much cash an RVU is worth, I have a two-page printout with the RVU value for each of about 40 different procedures that I might use. That is, I know the relative value of one thing over another. This is already driving my behavior, since I want to maximize my income. So now I carry around my RVU chart and am trying to memorize it. Note that a specific activity might be billed in one of several ways, so I'm going to choose the procedure code that nets the highest price. Each procedure has a complex formula involving a point system for various aspects of taking a history, examining the patient, interpreting labs and xrays, and the complexity of medical decision-making. So I'm learning to include certain things in my notes that have little import because the bureaucracy requires it. The hospital has many different coders who pore over notes and make sure that the documentation has the requisite elements to justify the procedure code. Each insurance company including government agencies have huge staffs who do nothing but make sure that documentation supports the procedure. Keep in mind that there is no reason to believe that any of this adds to patient care or improves outcome. In fact, it is not only a distraction and decreases actual patient care time, but it adds enormously to the cost of health care, all the while creating no added value.

When I was working directly for the patient, that is, through self-pay, I charged an hourly rate no matter what kind of activity I was engaged in, and as long as the patient was satisfied with the service. When patients called me, they called my cell phone, not a nurse or receptionist. I could treat more patients because I could do telephone care and secure messaging and texting and get paid for it. Now, I have to schedule a visit because nothing else gets paid for. This decreases my true productivity and inconveniences the patient unnecessarily, and also costs more because the patients often have to take off work to see me.

This system is one that rivals Alice in Wonderland. What it will take to change it is unclear to me. But I have to say I prefer both the salaried approach used by the VA and the self-pay system to this wierd, complex, arcane and burdensome system. No wonder the US spends 30 cents of every health care dollar on administration and meanwhile gets care that often falls short of even minimal expectations.

Private Practice is no Picnic

Since my return to Minnesota, I've been working  in a private practice health care organization in a highly managed care environment. I've worked previously in the Veteran's Health Organization (VA) and in a self-pay environment in Washington, DC, but not in this type of organization. It's been fun, invigorating, and challenging. And, it's giving me insight into some of the challenges facing American health care today.

One of the biggest concerns is that reinforcers of behavior are misdirected, guaranteed to induce behavior on the part of clinicians that result in net harm to patients. Here's an example: I tend to spend more time with patients and families, and I am penalized for that. There are other psychiatrists in the community that see patients for 5 mins or less for a medication check. I'm sorry, but I don't understand what can be really assessed in 5 mins. However, if I continue this way, she makes more money than I do. What message does this send? Do we expect doctors to be saints? I can tell you that idealism and professionalism go only so far. A new furnace, private school for the kids, and an occasional vacation for my wife and I are powerful competitors with idealism. 

What do we really want to reward in health care? How much would it take to meet everyone's needs, and if we can't do that how do we decide who gets what?

How do I resolve between my ideals (I've served poor people most of my career) and my personal needs (I have various debts to pay off, the house needs maintenance and we need a new car)?

At the same time, I feel that I am providing a service that people have not experienced before: true professional addiction medicine/psychiatry. Someone who can manage the complex patients, rather than just evaluating them for rehab. I've been surprised by the range and complexity of the patients I've encountered so far. My experience only increases my motivation to change the way we do business. We need to be providing truly professional science-based recommendations and treatment. And by and large, consumers do not have access to that. Rehab services are extremely imporant for those who cannot stabilize at home. In Minnesota, there are more programs than usual who are focused on providing evidence-based treatments such as Suboxone therapy for opioid dependence and pharmacotherapy for alcohol dependence. But what's difficult to access is professional treatment by physicians, the way diabetes, asthma, cancer, hypertension, and depression are treated. My goal is to create a system that will do just that.

Back in Minnesota: Opportunities and Barriers to Change

Blog entry 1-20-10

Well, it’s been over a month since I entered something in my blog. (I’m sure the millions of faithful readers have been wondering what happened.) Well, two things. The holidays. And re-entry. I’ve been negotiating re-entry into my family, my home in Minnesota, into the professional community of St. Paul-Minneapolis, and into a local health care organization (HCO) called Allina. Paul Goering, a psychiatrist and director of mental health services for Allina (a collection of hospitals and clinics in the metro area) was kind enough to not only give me a job on my return to the Twin Cities, but he also has recognized an opportunity to change the way we treat addiction. He has said repeatedly that “the way we treat addiction is not satisfactory” but that up to now there haven’t been any alternatives. Paul, besides being a really nice human being, is a skillful administrator who has made my return here much easier than it otherwise might have been. In addition, someone else I met this fall, Bobbi Cordano, is a human dynamo who serendipitously became the interim director for something called the Center for Clinical Innovation at Allina. The Center is still finding its way, but it’s devoted to supporting innovation in the delivery of services, particularly as they affect the broader community. She and I have also been talking about ALATYR, my initiative to change the way we treat addiction in America, and how we might work together to make it happen.

I have encountered other opportunities as well. The state of Minnesota Department of Human Services is interested in looking at ways to improve addiction treatment and I am in discussions with them about how to make it happen. Upon returning to Minnesota, I have been very impressed with how progressive the medical community is here, and how much the various health care organizations seem to be focused on improving care more than on making money (although they of course have to do that.) The fact that HCO’s in Minnesota have to be non-profit by state law may have something to do with this, but Minnesota also has a tradition of progressive politics and a communitarian focus. All in all, it appears there are many potential opportunities here to try out my ideas about a public health approach to substance use.

It’s also been interesting to practice in a private HCO in a highly managed care environment. Minnesota, Massachusetts, California and Seattle have led the nation in early penetration of managed care and at least in Minnesota virtually all health care is managed. (In contrast, in Washington, DC, it seems that very little of it is.) I had a small self-pay private practice in Washington before moving back here, but this is very different. And it’s giving me insight into some of the problems with our current system.

For one thing, the incentives are all wrong. I can only get paid for face-to-face time with patients, even though it would be more efficient and effective to work with a team of professionals such as nurses and therapists who provided various parts of care. Reimbursement for psychiatrists is greater for medication management alone rather than combined treatment with psychotherapy and medication management, which in my experience is more effective and is strongly preferred by many patients. A great deal of time (and money) is spent by multiple people to meet bureaucratic requirements of insurance companies and Medicare, while providing no benefit to patients whatsoever. There is no incentive to provide better outcomes, and in fact no measurement of outcomes. There is no incentive to provide better care or care based upon current evidence. Patients and families are left to their own devices to figure out where to get care, and who might be better at particular types of care, other than the annual “Best Doctors” issues of local magazines. In short, the current system with all its many interlocking components makes it extremely difficult to do the right thing. In my experience, it’s the system that determines the quality of care, not the individual provider. If we can’t line up the incentives more rationally, we are doomed. I must add, parenthetically, that the individual professionals at all levels seem to be devoted, careful clinicians and support staff who truly believe in what they do and want to provide the best care they can. The problem isn’t the people in the system- the problem is the system.

In the next few postings, I’ll share further experiences and insights as I care for patients and interact with the HCOs and government.