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:

• 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

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

How to Save $30,000 and Get Better Results

I have had numerous patients who have been pressured by their families to "go away" to some residential treatment program, usually it seems in another state (than Minnesota). Florida, Arizona and California seem to have a concentration of these, especially "Executive Programs" with gourmet food, precious handling, "equine therapy," "golf therapy," yoga, life coaching, and of course first class accommodations. They run from $20,000 to $70,000 for a month. These are people who have severe, recurrent addictions, usually to alcohol but some are addicted to opioids like heroin. Almost all have been through some sort of rehab multiple times before. Many but not all have money. Often enough, it's a family member who is coughing up the big bucks.

What do they get? One patient relapsed on the plane on the way home. Not a single one had any lasting benefit. Almost all relapsed within weeks, often days after returning home. In other circumstances, patients and families, and in Minnesota, state government, will pay for lengthy stays, 90, 120, 180 days in some "recovery environment." Again, it's plenty costly. But do they get any benefit? The vast majority do not.

It's an uphill battle to try to convince family members that sending their loved one away for some period of time to some "special place" is very unlikely to change their long-term outcomes. People just do not want to believe it. And admittedly, it's a hard pill to swallow. After all, the chemical dependency treatment industry has done a commendable job of spreading the idea that anyone can recover "if they really want to." And of convincing people that they have some unique answer to an ancient problem that defies easy resolution. The really difficult fact is this: all of our treatments (yes, that includes 12 Step treatment programs and AA) have modest effects at best. (The exception to this generalization is for opioid maintenance therapy with Suboxone or methadone for addiction to opioids such as Oxycontin or heroin. Opioid maintenance therapy is extremely effective and more cost-effective than almost any medical intervention other than vaccination.) Too many people do not respond to any available treatment. And they die of their illness. They die of a hereditary, brain-based behavioral disorder that makes them vulnerable to compulsive use of alcohol, opioids, cocaine, meth or cigarettes. It's not that they aren't motivated to change. I have to say, this is one of the cruelest things that rehabs do: people are told they could stop the process if they wanted to. But guess what? Some people can't. No matter how hard they try to "work the program." No matter what they do. Even if they go 90x90, or attend 1000 12-step meetings a year. They are mystified. "Why do I keep doing this? I'm not stupid! I know what will happen, but I do it anyway." This is the mystery of addiction.

In other chronic severe diseases, health care providers constantly experience failure of available treatments, and are able to accept it. People die of heart disease, cancer, diabetes, stroke, multiple sclerosis, dementia. But in the rehab industry, staff members are protected from experiencing treatment failure. First, treatment is time limited. So, instead of having to live with patients who come back with recurrent illness when the treatment doesn't work, staff members don't have to live with (and struggle to help) people who don't respond to treatment. Second, the entire industry (and unfortunately, too many 12-step program members) believe without doubt that "treatment doesn't fail patients, patients fail treatment." Try telling that to someone with metastatic cancer, end-stage liver failure, Parkinson's disease or chronic obstructive liver disease. But because we continue to stigmatize people with addiction, we get by with it, we are told to reject them, to use "tough love," to let them "bottom out." In my experience, in too many people "bottom" is 6 feet under ground. We condemn family members who don't abandon their loved ones as "enablers." What could be more cruel than this?

As a healer, one of the hardest things I do is to stay engaged with someone who dies of addiction. To not reject them. To not condemn them. To understand they are in the grips of something neither they nor I nor anyone else can control or stop, short of imprisoning them (and even then, prisons and mental hospitals are usually full of drugs.) To accept the limitations of our available treatments. To be compassionate even as death approaches. In the last year alone, in my part-time clinical practice, I have lost 6 patients to addiction.

It's not actually different than dying of diabetic renal failure, or of multiple sclerosis, or cancer. We can accept those illnesses as "not the person's fault." But when it's a brain-based disease, we cannot fathom that a brain can become dysregulated to the degree that someone loses control of their behavior to such an extent that they die from it. It's too frightening. We can't stand the thought that we aren't in full control of our lives. That we can't control our own behavior completely.

And yet, we all know better. We all have areas of problem, non-optimal behavior. We smoke. We drink too much. We don't exercise enough. We can't get our behavior right with our spouse or partner or children. We lose it. We shop too much. We can't handle money. We eat too much. We don't take good care of ourselves when we have a chronic illness. We lose our tempers. We work too hard, or not hard enough. We ignore important things. We procrastinate.

Yet we cling to the illusion of control. Of self-determination. We control our fates. Why can't "they"?

Just to be clear, I am not advocating that people with brain-based behavioral disorders not be held responsible for their behavior. For example, I am not advocating that people who commit crimes while intoxicated should be found innocent because of their addiction. As we move further into understanding the brain mechanisms underlying destructive and/or illegal behavior, this question looms large. But I have concluded that even though brain dysregulation might underlie much of this type of behavior, society only works if we hold people responsible for their behavior in spite of that fact. Individual responsibility for behavior is a social and political necessity that cannot be sorted out by science. In this blog, I am addressing how to provide health care for people with addiction and nothing else.

It's terrifying to think of having a behavior so out of control that it kills us. Anorexia nervosa. Depression. Bipolar disorder. Schizophrenia. Addictions. Antisocial and borderline personality disorders. All have substantial mortality rates. People with serious mental illness die 25 years early on average! Is it because people don't care if they die? I know that's not true, I've worked with too many of them. No, it's because the brain is a flesh-and-blood organ that can get sick, dysregulated, in specific ways that the individual cannot have insight into and cannot control. And it kills them. We have to come to grips with this grim reality if we have any hope of overcoming these dread diseases.

One thing I do know is this: some short-term high-end expensive rehab program is not going to change anything. The best hope is long-term care management with an experienced and qualified clinician or team of clinicians. That's what we do for diabetes, heart disease, cancer, stroke, arthritis. That's the best we can do for people with severe addictions. And it is a heck of a lot cheaper besides. Give me $30,000; I'll see you daily for a year! Geez, with 8 patients, I could make $240,000 a year!

I can obtain better results at a fraction of the price than any high-end time-limited treatment program. I guarantee it! And yet, I have to accept that despite all of my best efforts, and theirs, and their families', some of my patients will not respond. And some will die as a result. And they deserve our compassion, not condemnation.

What do you think? Please spread this around, comment on it, argue, agree or do something else. These are incredibly important questions.

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.

Continuing Care Produces Reduces Costs for Substance Use Patients

Persuasive Research for a Chronic Care Model for Some People with SUD

There are two fascinating research reports that recently came out of the group anchored and founded by Connie Weisner, a very productive and insightful scientist conducting health services research at Kaiser-Permanente in San Francisco. In addition to being a first-class scientist, Dr. Weisner is a genuinely good person and a great mentor who has built an extremely productive group. Jennifer Mertens is one of her protégés who has emerged as a first-class scientist in her own right.

The first of these two articles examined the healthcare costs of a group of people who presented for substance use disorder (SUD) treatment at a Kaiser facility. First-authored by Sujaya Parthasarathy, another up-and-coming health services researcher, this study followed SUD patients and compared their health care costs over the ensuing 9 years, compared to a matched group of non-SUD patients (Parthasarathy, Chi et al. 2012). The aim of the study was to examine the association between elements of continuing care over that period and health care costs. Continuing care was defined as ideally having three components: an annual primary care visit plus the availability and use of either SUD or psychiatric services as needed. They hypothesized that people with more components of continuing care would have lower healthcare costs. They had previously shown that having more elements of continuing care was associated with greater rates of abstinence.

What did they find? Having all three elements of continuing care available and used was associated with lower health care costs over a 9 year period, compared with those receiving fewer components. The SUD patients who did not receive continuing care had inpatients costs of $66 per member per month (that’s a lot), while those receiving continuing care did not differ from non-SUD controls.

This study is observational. That is, it followed people over time and then examined correlations, or associations among different variables. There is a principle in research, which is, “Correlation does not imply causation.” That is, one cannot determine what causes what, merely that two variables, such as receiving continuing care and abstinence, tend to occur together more than would be expected by chance. So, it cannot be concluded, for example, that providing continuing care caused improved outcomes and reduced healthcare costs. Or whether patients who were already doing well (for whatever reason) caused more continuing care by making better use of appropriate healthcare services.

Nevertheless, I believe that, combined with other studies, there is a powerful argument to be made that SUD services should include all three components when appropriate: primary care, SUD treatment services and mental health treatment, and that these services should be available on a continuing basis for as long as needed. This is, after all, how we treat virtually every other disease, from asthma to depression to arthritis. It also makes sense to make every effort to make them available in as seamless and integrated a fashion as possible.

Parthasarathy, S., F. W. Chi, et al. (2012). "The role of continuing care in 9-year cost trajectories of patients with intakes into an outpatient alcohol and drug treatment program."  6. Retrieved 0230027, lsm, 50, from http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=22584889.

Update on operating in the trenches of health care

This is from an email I recently sent to a colleague. It also relates to the comment on my last blog by Dr. Dawson, and the new assembly line psychiatry. I can't begin to count the number of patients of mine who complain that they've been to other psychiatrists who never talked to them, spent 10 mins and prescribed drugs. This, in my view, results in gross overtreatment with medications, poor decision-making regarding medication management, poor patient outcomes, lack of patient participation in treatment decision-making, as well as patient and family dissatisfaction. I don't think it's possible to properly evaluate a patient in that amount of time. If the patient is so stable they don't really need an evaluation, just a prescription, then they don't need a psychiatrist, their primary care doctor can do that.

There is now a terrible shortage of psychiatrists, and it will reach truly crisis proportions in the next 10 years as the aging workforce retires or dies. This could be changed by reforming practice to make it more gratifying (and effective), increasing compensation (psychiatry is the third-lowest paid specialty, after pediatrics and primary care (family practice and general internal medicine), and involving patients and families more in decision-making. Unfortunately, the mistakes made in the past, such as separating psychotherapy (now provided by therapists and counselors from a wide variety of backgrounds and competencies)  from medication management (by psychiatrists), with another: replacing psychiatrists with "mid-level" providers, such as nurse practitioners and physicians assistants. The result is simply an ongoing degradation of psychiatric practice and care and outcomes, and an increasing shortage of competent and well-trained staff.

But I digress. Here's the email, responding to a question about how things were going in my post-NIH world.

All is good here, working my butt off in practice and still working to establish a new model of scientifically based treatment in the next year. As with most things, it turned out to be more complex and difficult than initially imagined, but there is tremendous enthusiasm among health care professionals and even more so among patients and their families, who are very very frustrated with the current state of affairs. So the time is still ripe, if not riper than ever. Toughest parts are going to be staffing, especially with docs, and financing and the business model, especially with the continuing near-depression we are still in. 

I have to say, working where I do, in downtown St. Paul, I treat a lot of people who have lost everything, when they had everything in 2007. Their jobs, homes, families, self-esteem, health. Everything. Experiencing the human face of this terrible economic crime gives a whole different perspective. And Minnesota is in better shape than most places, and has arguably the best safety net in the country. So I can't imagine what it's like in Arizona, Texas or Florida. At any rate, I'm fortunate to work (part-time) for a company that essentially subsidizes psychiatric care for the poor. Again, that is not the norm around the country. Minnesota has a law requiring health care organizations to be non-profit, which makes all the difference in the world. 

The other part of the health care world I've had the pleasure of experiencing is the horrible nature of the health insurance industry, and the games they play to deny payment for care they are obligated to, by putting up lots of bureaucratic barriers, knowing that many patients or doctors will give up. Yesterday, for example, I was trying to induct Suboxone treatment for a patient in the clinic (who was in withdrawal) and the insurance company wouldn't pay for the Suboxone without a prior authorization (one of the most common and frustrating barriers.) So the patient had to go to the pharmacy, get the coverage denied before we could initiate the PA request, then the nurse went through the hoops, spending 30 mins, but the company wouldn't even give an answer for 24 hours. So the pt had to leave without the Suboxone, use more illicit opioids until we got the approval, then return to the clinic again in withdrawal, or start at home. And you can't get a PA in advance, it has to be denied first. So the patient spent an entire afternoon waiting around for the PA, the nurse spent 30 mins on the phone, and I spent about 30 mins of my time trying to make this work (none of which we got paid for). And people wonder why our system costs so much. And this didn't make any sense at all anyway, all they needed to know was that the indication was opioid dependence. 

MW

The (unbridgeable?) gap between academia/NIH and the real world

One major lesson I have learned is that the gap between academia/NIH and the real world of practice in large private health care organizations is so vast that it's almost hard to believe. Even though I have always had a significant clinical involvement, I was shocked at how little I understood about how the real world works. It's taken more than two years to figure out how it works, and very humbling. (Example: Hospitalist: Hi, haven't met you before, nice to meet you. I need some help with this patient with opioid addiction and pain. Me: Hi Dr. Jones, happy to help. Hospitalist: Have you been in this area for a long time? Me: I worked at the VA and the University for many years, then was at NIH for 5 years, then recently moved back here. Hospitalist: NIH? That's very nice. Now, can you help me get this patient out of the hospital?)

MW