Deaths from Prescription Opioids Not Evenly Distributed

Last November, the CDC issued a report detailing the rise of prescriptions for opioid (narcotic) pain killers such as oxycodone (Percocet, Oxycontin), hydrocodone (Vicodin, Norco), methadone, morphine (MS Contin), fentanyl patches (Duragesic), and others, from 1999-2008. As expected, prescriptions for these medications have increased pretty dramatically. Here's the chart from that report, showing sales of opioid pain relievers (OPR), admission for addiction treatment related to OPR and OPR deaths per 100,000 persons. Basically, sales more than tripled, treatment admission quadrupled and deaths almost tripled. Since 2008, these trends have continued if not accelerated. In Minnesota for instance treatment admissions for opioid addiction are now greater than that for cocaine, methamphetamine, cannabis or other non-alcohol drugs. (Alcohol of course, continues to be the elephant in the room, with all indicators much higher than all other drugs combined.)

However, the rates for these indicators are not evenly distributed across the states. Here are two graphs from the same report showing rates across the US. What they show is that the rates for OPR sales and rates for overdose deaths vary widely across the country. For the most part, the rates of sales and deaths track together although there are exceptions (Oregon, Hawaii for example.) The national rate for overdose deaths is 11.9/100,000 but rates vary from 5.5 in Nebraska to a whopping 27 in New Mexico, a five-fold difference. Of note, nearly all of the deaths are in people taking them for medical purposes and the rates of non-medical use are low across the country. What these figures indicate is that there is no single solution for the entire country. Rather, the approaches need to be tailored to the particular states and regions with the highest figures. Not surprisingly, given the number of older adults living there, Florida tops the country for example in kilgrams of OPR sold.  However, the overdose death rate is 8th highest. New Mexico, however, with the highest overdose death rate, has OPR sales lower than the national average. Unfortunately, the federal government has taken a blanket approach focused on training physicians, which suggests that the appearance of doing something is more important than actually doing something that works.

Comments on Comments

I appreciate readers of my blog, especially those who comment. This kind of dialogue is important and informative. However, I have some suggestions if you wish to leave a comment.

I have received several comments with personal information in the comment itself. All comments are moderated, so I don't publish these, at least not as is. Sometimes I will go to the trouble of inserting into a post excerpts that delete any personal information, but it is much easier if you don't put it there in the first place.

If you want to contact me directly, send me an email at DrWillenbring@gmail.com. Even then, remember that email is not secure, so I discourage highly personal information in emails as well. Although the risk of the email being interrupted is small, information about substance use can be very destructive if it did fall into the wrong hands.

If you wish to make an appointment to see me, call my office number at +1-612-276-2055. My current practice is cash (or credit card) only, but I will give you a receipt to submit to your insurance company.

MW

An Ordinary Weekend

Last weekend I was on call for psychiatry at United, the hospital in St. Paul that I work for. It's been a moderately busy weekend for me, but not because there isn't any more demand for services, but because our inpatient beds are full. And guess what? So are the inpatient psychiatry beds not only throughout the Twin Cities Metro Area, but also the entire state! Halfway through the weekend we sent a patient to the last open adolescent psychiatry bed in Fargo, ND! So there are two patients this weekend who have had to stay in the emergency department, because there is no place to admit them. I continue to be amazed that I live in a country that would send its mentally ill children hundreds of miles away from their families because it's not willing to pay for the services they need locally.

And as usual, among the patients newly hospitalized whom I saw, about half were addicted to a psychoactive substance, usually alcohol. This is also typical. Now that I'm cutting back on my clinical practice, I'm unable to offer them a new form of treatment, one that is oriented around treating the disease as it is, rather than as we would like it to be. I was able to offer that for the last 2 years, but now I'm moving more into efforts to change things more broadly, to help others provide that kind of service and thus leverage my knowledge and skill. And that is going well and finally seems to be picking up speed. This stuff really takes a lot of time and effort!

But I still find it hard not to offer these patients an alternative to another run through a rehab program they've already experienced multiple times before. Any treatment that has been shown to be ineffective in a particular patient ought no longer to be pursued. I don't continue to prescribe naltrexone or Prozac to someone after it repeatedly fails to alter the course of illness, thinking that perhaps someday it will become effective! But embracing fully another approach is not without its problems too.

That's because to do so takes us right into some painful insights. Our treatments are modestly effective at best. There are many people for whom we have no effective treatment. And it's not their fault, it's because the science isn't yet at a point where we can understand what's wrong and help correct it. Our instruments are crude, primitive. Well-meaning, yes. We can always provide comfort, understanding, and a willingness to stay with someone to the end. But all too often, there is nothing we can do to change what we see as the inevitable conclusion of a process we don't understand: addiction. And I can tell you that it is difficult indeed to stay engaged with someone who is dying of an addiction neither she nor I nor you nor AA nor rehab nor medication nor the criminal justice system nor anyone else can help. We accept that grim reality with other diseases like heart disease or cancer. But we have a hard time accepting that brain diseases like addiction or bipolar disorder can be incurable and ultimately fatal. And most importantly, it's not because the person dying does not want to live or isn't trying in every way to stop the march towards death. We have to stop blaming the victims when our treatments fail and at least offer them succor along the way.

Implementing the NIAAA Guide in Primary Care Clinics

After two years, it finally feels like things are coming together. Allina Health continues to be a great place to try out new ideas for addressing alcohol and pain, across hospitals and clinics. I've been able to recruit up to three primary care clinics in the SBIRT+ project, which is focused on addressing alcohol in primary care. (SBIRT+ stands for Screening, Brief Intervention and Referral to Treatment, Plus Point of Service Care. Point of service care reflects treatment for alcohol dependence (not just at-risk drinking) in primary care. The NIAAA Clinician's Guide uses this model.) Allina is also developing a collaborative care model at a pilot clinic and I expect to be involved in that effort, which is focused on coordination of care and reduction in preventable hospitalization for patients with complex chronic illnesses. Heavy drinking is common among people with chronic diseases who demonstrate high cost and poor outcomes. To reach the goals of reducing costs and improving outcomes requires addressing drinking and other co-morbidities such as depression in addition to improving care for their other chronic medical conditions.

This is a very ripe time for new ideas. Health care clinicians are disillusioned with the time-limited rehab system, where there is only one option that doesn't change even after repeatedly showing lack of effectiveness. They want guidance on what to do next. They are intrigued by the NIAAA Guide's clear guidelines for addressing heavy drinking across the spectrum of severity (from risk drinking to functional dependence to severe recurrent dependence) and by medical treatment options, especially anti-relapse medications. Contrary to what many in the addiction treatment field believe, doctors and other primary care clinicians want very much to help but have pretty much been told to "leave it to the addiction experts," which for the most part means counselors alone, and for relatively short periods. However, the patients spend much more time in primary care than they do in any treatment programs.

In the last week, I've presented SBIRT+ at two primary care clinics, and in the next week I'll be talking to two or three more. I'll fill you in as I go.

MW

A Routine Day for an Addiction Psychiatrist

Today I had a fairly routine day in my practice. On a typical day, I encounter a wide range of people, problems, challenges and successes. I suppose it's not much different from any medical practice that way. But all of my patients are pretty complex and challenging. They all have multiple problems that are intertwined and that cannot be fully teased apart. The most common problems I encounter are addiction, pain, depression, anxiety, insomnia, brain injury, ADHD and PTSD. Relationship, marital and family problems are very common, as are various social and economic problems such as unemployment, disability, poverty, lack of health insurance and homelessness. These are all common problems, and they usually occur in some combination of two, three or more of them. Often there are significant other medical problems as well, including arthritis, heart disease, cancer, multiple sclerosis, lung disease and many others. I have to say it's enough to scare a person once you realize what fate can bestow on you. Most of my patients feel very alone and isolated. They often think they are the only ones who experience what they are experiencing and there is therefore something wrong with them. This isn't true of course. The experience of suffering from these problems is pretty similar across different people, which is not to diminish the importance or meaning of suffering for each person. But most of us don't meet others who are confronting the same or similar issues we are so we feel alone. Those around us who are well almost never understand, and all too often are judgmental. I think some of that is redirected anger at the inconveniences and losses that they experience when a loved one becomes disabled. Most of us think it isn't ok to feel angry with a loved one who becomes ill or disabled, but anger along with sadness and empathy are almost universal. But for someone who has never experienced depression or chronic pain or addiction, it can be very hard to understand why their loved one isn't responding better, isn't getter better or well, or requires ongoing medication to function. I spend quite a bit of time with friends, partners, spouses, children, parents of my patients explaining the illness(es) and treatment(s). It usually makes a difference, sometimes to the point of saving a marriage or preventing rejection from a family. Every day, however, I feel privileged that these people, my patients, let me share their lives in a pretty intimate way. A lot of whatever effectiveness I have comes from simply sharing the path and doing my best to understand what someone is going through without judging them. If nothing else, at least I can give them that.

Revolutionizing Health Care Related to Alcohol Use

My current organization, Allina Hospitals and Clinics, has embarked on an ambitious and to my knowledge unprecedented effort to rationalize our approach to alcohol throughout the system. (The Veterans Health Administration has been addressing alcohol use in primary care for several decades and is as usual way ahead of private care, yet another example where government beats private care by a wide margin. However, their system is so unlike private practice that what happens in the VHA is difficult to translate.) I am leading Allina's effort and we've developed an ambitious agenda and a very aggressive timeline. If we're successful it will be almost a revolution across a large HCO (health care organization.) Allina consists of 11 hospitals, about 60 primary care clinics and many speciality clinics. Last year, there were more than 1 million hospital admissions and almost 4 million clinic visits within the Allina system.

I'm excited about this. It is nothing short of amazing that a large HCO would choose alcohol as a major focus across the organization. So far, the response has been enthusiastic. Physicians and other clinicians are very frustrated with the lack of consistency across parts of the system. They are frustrated that there seem to be so few options for patients admitted to hospital. Even if someone has been through 12 step rehab a dozen or more times, that is still the only option available: another run through rehab. They are desperate for something new. Clinicians are realistic. Most of what we do in medicine is care for chronic incurable conditions. Although we sometimes make people completely well, more often we help mitigate the ravages of an incurable condition. And sometimes we are pretty poor at even that. In cases with really severe, progressive illness we are often pretty helpless, along with the patients and families. So health care professionals are comfortable with care that is less than curative but is at least comforting, and perhaps that slows the rate of deterioration. And they want to be involved and active in managing chronic diseases.

Allina's initiative is remarkable in that it will address alcohol across an entire HCO. This includes emergency departments, primary care, hospital and ICU care and specialty addiction treatment. The goal is to create a fully integrated system that addresses alcohol wherever a heavy drinker interacts with the system and that coordinates the flow of care across boundaries such as inpatient/outpatient care and primary/specialty care. All of this is intended to be as fully evidence based as possible, which is always a challenge but it's an important aspiration. The vision is very ambitious and I am unaware of any other quite like it. If it succeeds, it can serve as an example for other HCOs.

Translating the science to practice is a daunting challenge. Allina is to be commended for choosing alcohol as a focus for such an effort. I'll keep you updated as this progresses.

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.