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

Benzos for Recovering People?

Recently, a colleague asked my opinion on the use of anti-anxiety medications called benzodiazepines in people either struggling with or recovering from an addiction (to something else of course.) Benzodiazepines (benzos for short) include common medications such as alprazolam (Xanax,) lorazepam (Ativan) and clonazepam (Klonapin.) Here is my reply:

First, I personally think that the idea that no-one who is in recovery from an addiction should ever ever be prescribed another potential intoxicant is a remnant of the all or none thinking in 12 step groups and programs. It's not based in fact. Yes, there may be a relative increase in risk, but the risk of true addiction to benzos (as opposed to development of tolerance and physical dependence) in an anxious pt is near zero in most people so the absolute risk is pretty low in someone with alcohol or opioid addiction, for example. The same holds true for pain medication in alcohol dependent people. I try to balance risks and benefits as I do with any patient or treatment. The science tells us for most people that an addiction is specific to a drug, not to "addiction" or intoxication of any type. There is no such thing as an "addictive personality." The other thing I'm impressed with is how poor any current pharmacotherapy is for chronic anxiety. The best treatment is good CBT, but it's hard to find and many pts aren't good candidates (although they might be for skillful psychodynamic therapy.) So I don't know about you, but I often find myself and the pt between a rock and a hard place.

An example patient is someone who had childhood onset of moderate to severe anxiety, often starting with separation anxiety and school refusal. Some patients report the onset of panic attack before the age of 10. Most of these people are extremely anxious all of their lives. I see them because they have became alcohol dependent. I generally prescribe an antidepressant, an SSRI or SNRI, but these seem to have poor efficacy in these primary anxiety patients, as opposed to people with depression and anxiety together. In one recent patient I  stopped benzos and the patient got to the point where I thought she would relapse to drinking w/o relief so I prescribed lorazepam and she almost immediately got much better, more stable, and with markedly reduced desire to drink. To my knowledge she hasn't used benzos in an addictive fashion, although the other problems of tolerance and lack of long-term efficacy haven't gone away. I usually try everything else I can: beta blockers, anticonvulsants, antidepressants, rarely antipsychotics if nothing else works. I always prescribe relaxation training and breathing exercises, give patients info about mindfulness approaches and also always recommend a CBT workbook for anxiety. I may recommend seeing a therapist. But sometimes it's only benzos that seem to help.

Some years ago a colleague of mine studied vets with severe chronic PTSD who were on benzos, expecting their outcomes to be worse than others. Theirs were better than others. Now that may simply be due to this group being more stable/adherent so therefore benzos were continued. But still, where is the evidence in the published lit that shows that long-term benzo use is often damaging? I worry that we prescribe truly toxic drugs like antipsychotics and depakote or lamotrigine to avoid benzos. And where is the evidence that many of these drugs actually help anxiety or are safe to treat it?

I think also there is a bias here: with very weak evidence of risk, we withhold benzos and with no evidence of efficacy or safety we prescribe toxic risky drugs instead. Make sense?

Also, underlying the bias is the pervasive idea, spread by 12 step treatment programs that 12 step treatment or groups are 100% effective if the person just does as they're told. You and I both know that's absurd and untrue. Medicine frequently involves compromise between ideal and pragmatic goals, and balancing various risks and benefits.

Finally, there is fairly strong evidence that untreated insomnia, pain and anxiety contribute substantially to increased relapse risk. It's easy to say "they should just tough it out or go to more meetings" but that seems pretty unreasonable and unsupportable to me.

In the end, I view it as all coming down to outcomes. Is the pt better off? Are their sxs less? Are they more functional? Does a rx for benzos help them recover more fully?

Be good to discuss some time....

Mark

Comments and Responses

I want to thank the (currently) small group of readers and followers. Please spread the word! Consider a contribution!

But please remember that if you send something by comments I have no way to contact you. If you'd like me to reply, please either send an email to drwillenbring@gmail.com or include your email in your comment. All comments are moderated, and I don't publish any comments that have personally identifiable information unless it's someone who wishes to be identified as an author. If there is something about a personal situation, I don't publish that info.

MW

How Many Hospitalized Pain Patients are Addicted?

Here is a response I recently wrote to a colleague inquiring about my impression of pain management at United Hospital in St. Paul. The questions were about what proportion of inpatients were addicted to opioids and how to improve pain management in the hospital.

Hi XXXX,

The question about proportion of inpts with opioid addiction is complicated.

First, the number of clear opioid addicts is small. These addicts are people who use heroin for example, or inject or snort other opioids. This also includes people who clearly have use that is out of control. Remember, addiction is compulsive, destructive drug use. Examples of this latter group are people who use far in excess of what is prescribed, who go to multiple doctors, who use to get intoxicated, and whose use is clearly dysfunctional. Pain management for this group is difficult and these patients are usually grossly undertreated, out of both ignorance and moral condemnation. However, the approach to these patients in overall management is pretty clear in that ongoing prescription of regular opioids by a typical provider is contraindicated and these pts by and larger only respond to opioid agonist therapy (maintenance) with either buprenorphine or methadone. There is not a single study demonstrating efficacy of 12 step or other rehab in treating established opioid addiction and relapse is all but inevitable, usually shortly after leaving rehab. Unfortunately, that is usually what they are referred to. That's like referring a diabetic to a spa for a couple of weeks, and not offering any medication, but that's what's done.

Second are those with no prior significant opioid use, or relatively minimal use, in other words, typical pts requiring pain management. I don't think we do very well with this group based on my observations, in large part due to ignorance about individual variation in pain sensitivity, pain tolerance, opioid metabolism, etc. This is the easiest group to demonstrate improvement.

Third are the most problematic. These poor folks have chronic severe pain requiring ongoing management with opioids. Unfortunately, there is a wide variability in how these pts and this treatment are perceived. There is a group of vocal opponents who strongly believe pts should never be offered this treatment. Most experts are in the middle, realizing that long term opioid treatment for chronic pain has modest benefit on average (about 30% reduction in pain, range 0-50%) and which comes with a fair amount of risk and baggage. Nevertheless the vast majority of pain experts understand that although some pts are able to tolerate severe pain without opioids, many are not and with with all of its baggage, we're stuck with opioids until something else comes along. Note that opponents of opioid therapy have no evidence on their side and there arguments are based on studies of highly select patients and animal models and they usually exaggerate the harms, so I think their beliefs are mostly based on moral judgements or at least wishful thinking. All the published expert guidelines recommend appropriate use of long term opioid treatment if managed properly.

Whether a pt like this is "addicted," a "drug-seeker," a "somatizer," "manipulative," a "drug-coper," "malingering," or other pejorative terms is therefore mostly in the eye of the beholder, and projection of the clinician's values, beliefs and judgments rule the day. Basically, the observers are voicing an opinion that the patient is asking for and using these medications for inappropriate or invalid reasons, such as emotional relief (as if one could discern between pain and one's response to it.) Here's my rule about the value of such judgements: Can this opinion be disproved? If not, to me it's worthless. For example, I might interpret pain behavior in a certain individual as a manipulation "just to get high" rather than to "relieve legitimate pain." Now try to disprove that. You can't. So I might respond to the clinician, "You're just saying that because your father was an alcoholic and your mother was histrionic and constantly complaining about various vague physical symptoms." Now try to disprove that. You can't. So if you ask certain other clinicians in the hospital, you're more likely to get a "diagnosis" of "addiction" than if you ask me. None of us can prove we're right because the science isn't there and this is an almost impossible problem to conduct rigorous studies on. I choose to stay with ignorance and not assume I understand something that we cannot (because the science isn't there) and to approach the problem pragmatically: "How can I maximize function and relief from suffering?"

In my practice, the rule I use is this: is the patient better or worse off with the medication than without? If the answer is better, and the patient takes the medication as directed, then that person isn't addicted. By definition, their use is not compulsive or destructive, so therefore they are not addicted. (Although they will have symptoms if they suddenly stop, but that's true with Effexor too.) 

So I think this last group of patients experiences wide fluctuations in attitudes, behaviors, opinions and treatments from one clinician or facility to the next. My patients complain bitterly about this, about how they feel that everyone sees them as "addicts" or "Junkies," how they are treated with contempt and judgment by some clinicians, and how often their pain is inadequately treated. They may be overtreated or undertreated, but undertreatment is much more common that overtreatment. This is a group that would require a concerted focused effort to improve pain management. Scott Tongen helped with this by developing new protocols for opioid tolerant patients, and Ben has been promoting the use of ketamine to reduce need for opioids, which I think is not well researched, but appears to be very promising.

Sorry for the lengthy reply, but there's no simple way to think/talk about this, unless you're one of the people who just says,"Man up!" 

As for quality improvement, I would guess that considerable work would need to be done to actually understand who is and is not getting good pain management before developing an intervention.

And no, I do not think UTD is better/worse than other places in this regard.

All the best!

Mark

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

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MW