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What Adderall Can Teach Us About Medical Marijuana

June 19, 2012

An article in the New York Times last week described the increasing use of stimulant medications such as Adderall and Ritalin among high-school students.  Titled “The Risky Rise of the Good-Grade Pill,” the article discussed how 15 to 40 percent of students, competing for straight-As and spots in elite colleges, use stimulants for an extra “edge,” regardless of whether they actually have ADHD.  In this blog, I’ve written about ADHD.  It’s a real condition—and medications can help tremendously—but the diagnostic criteria are quite vague.  As with much in psychiatry, anyone “saying the right thing” can relatively easily get one of these drugs, whether they want it or not.

Sure enough, the number of prescriptions for these drugs has risen 26% since 2007.  Does this mean that ADHD is now 26% more prevalent?  No.  In the Times article, some students admitted they “lie to [their] psychiatrists” in order to “get something good.”  In fact, some students “laughed at the ease with which they got some doctors to write prescriptions for ADHD.”  In the absence of an objective test (some computerized tests exist but aren’t widely used nor validated, and brain scans are similarly circumspect) and diagnostic criteria that are readily accessible on the internet, anyone who wants a stimulant can basically get one.  And while psychiatric diagnosis is often an imperfect science, in many settings the methodology by which we assess and diagnose ADHD is particularly crude.

Many of my colleagues will disagree with (or hate) me for saying so, but in some sense, the prescription of stimulants has become just like any other type of cosmetic medicine.  Plastic surgeons and dermatologists, for instance, are trained to perform medically necessary procedures, but they often find that “cosmetic” procedures like facelifts and Botox injections are more lucrative.  Similarly, psychiatrists can have successful practices in catering to ultra-competitive teens (and their parents) and giving out stimulants.  Who cares if there’s no real disease?  Psychiatry is all about enhancing patients’ lives, isn’t it?  As another blogger wrote last week, some respectable physicians have even argued that “anyone and everyone should have access to drugs that improve performance.”

When I think about “performance enhancement” in this manner, I can’t help but think about the controversy over medical marijuana.  This is another topic I’ve written about, mainly to question the “medical” label on something that is neither routinely accepted nor endorsed by the medical profession.  Proponents of medical cannabis, I wrote, have co-opted the “medical” label in order for patients to obtain an abusable psychoactive substance legally, under the guise of receiving “treatment.”

How is this different from the prescription of psychostimulants for ADHD?  The short answer is, it’s not.  If my fellow psychiatrists and I prescribe psychostimulants (which are abusable psychoactive substances in their own right, as described in the pages of the NYT) on the basis of simple patient complaints—and continue to do so simply because a patient reports a subjective benefit—then this isn’t very different from a medical marijuana provider writing a prescription (or “recommendation”) for medical cannabis.  In both cases, the conditions being treated are ill-defined (yes, in the case of ADHD, it’s detailed in the DSM, which gives it a certain validity, but that’s not saying much).  In both cases, the conditions affect patients’ quality of life but are rarely, if ever, life-threatening.  In both cases, psychoactive drugs are prescribed which could be abused but which most patients actually use quite responsibly.  Last but not least, in both cases, patients generally do well; they report satisfaction with treatment and often come back for more.

In fact, taken one step further, this analogy may turn out to be an argument in favor of medical marijuana.  As proponents of cannabis are all too eager to point out, marijuana is a natural substance, humans have used it for thousands of years, and it’s arguably safer than other abusable (but legal) substances like nicotine and alcohol.  Psychostimulants, on the other hand, are synthetic chemicals (not without adverse effects) and have been described as “gateway drugs” to more or less the same degree as marijuana.  Why one is legal and one is not simply appears to be due to the psychiatric profession’s “seal of approval” on one but not the other.

If the psychiatric profession is gradually moving away from the assessment, diagnosis, and treatment of severe mental illness and, instead, treating “lifestyle” problems with drugs that could easily be abused, then I really don’t have a good argument for denying cannabis to patients who insist it helps their anxiety, insomnia, depression, or chronic pain.

Perhaps we should ask physicians take a more rigorous approach to ADHD diagnosis, demanding interviews with parents and teachers, extensive neuropsychiatric testing, and (perhaps) neuroimaging before offering a script.  But in a world in which doctors’ reimbursements are dwindling, and the time devoted to patient care is vanishing—not to mention a patient culture which demands a quick fix for the problems associated with the stresses of modern adolescence—it doesn’t surprise me one bit that some doctors will cut corners and prescribe without a thorough workup, in much the same way that marijuana is provided, in states where it’s legal.  If the loudest protests against such a practice don’t come from our leadership—but instead from the pages of the New York Times—we only have ourselves to blame when things really get out of hand.

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Addiction Psychiatry and The New Medicine

May 21, 2012

I have always believed that addictive disorders can teach us valuable lessons about other psychiatric conditions and about human behavior in general.  Addictions obviously involve behavior patterns, learning and memory processes, social influences, disturbed emotions, and environmental complexities.  Successful treatment of addiction requires attention to all of these facets of the disorder, and the addict often describes the recovery process not simply as being relieved of an illness, but as enduring a transformative, life-changing experience.

“Addiction psychiatry” is the area of psychiatry devoted to the treatment of these complicated disorders.  Certain trends in addiction psychiatry, however, seem to mirror larger trends in psychiatry as  whole.  Their impact on the future treatment of addictive behavior has yet to be determined, so it would be good to evaluate these trends to determine whether we’re headed in a direction we truly want to go.

Neurobiology:  Addiction psychiatry—like the rest of psychiatry—is slowly abandoning the patient and is becoming a largely neuroscientific enterprise.  While it is absolutely true that neurobiology has something to do with the addict’s repetitive, self-destructive behavior, and “brain reward pathways” are clearly involved, these do not tell the whole story.  Addicts refer to “people, places, and things” as the triggers for drug and alcohol use, not “dopamine, nucleus accumbens, and frontal cortex.”  This isn’t an argument against the need to study the biology of addiction, but to keep due focus on other factors which may affect one’s biology.  Virtually the same thing could also be said for most of what we treat in psychiatry; a multitude of factors might explain the presence of symptoms, but we’ve adopted a bias to think strictly in terms of brain pathways.

Medications:  Researchers in the addiction field (not to mention drug companies) devote much of their effort to disxover medications to treat addictions.  While they may stumble upon some useful adjunctive therapies, a “magic bullet” for addiction will probably never be found.  Moreover, I fear that the promise of medication-based treatments may foster a different sort of “dependence” among patients.  At this year’s APA Annual Meeting, for instance, I frequently heard the phrase “addictions are like other psychiatric disorders and therefore require lifelong treatment” (a statement which, by the way, is probably incorrect on TWO counts).  They weren’t talking about lifelong attendance at AA meetings or relapse prevention strategies, but rather to the need to take Suboxone or methadone (or the next “miracle drug”) indefinitely to achieve successful recovery.  Thus, as with other psychiatric disorders– many of which might only need short-term interventions but usually result in chronic pharmacological management—the long-term management of addiction may not reside in the maintenance of a strong recovery program but in the taking of a pill.

New Providers:  Once a relatively unpopular subspecialty, addiction psychiatry is now a burgeoning field, thanks to this new focus on neurobiology and medication management—areas in which psychiatrists consider themselves well versed.  For example, a psychiatrist can become an “addiction psychiatrist” by receiving “Suboxone certification” (i.e., taking an 8-hour online course to obtain a special DEA license to prescribe buprenorphine, an opioid agonist).  I have nothing against Suboxone: patients who take daily Suboxone are far less likely to use opioids, more likely to remain in treatment, and less likely to suffer the consequences of opioid abuse.  In fact, one might argue that the effectiveness of Suboxone—and methadone, for that matter—for opioid dependence is far greater than that of SSRIs in the treatment of depression.  Many Suboxone prescribers, however, have little exposure to the psychosocial aspects—and hard work—involved in fully treating (or overcoming) an addiction, and a pill is simply a substitute for opioids (which itself can be abused).  Nevertheless, prescribing a medication at monthly intervals—sometimes with little discussion about progress toward other recovery goals—resembles everything else we do in psychiatry; it’s no wonder that we’re drawn to it.

Patients:  Like many patients who seek psychiatric help, addicts might start to see “recovery” as a simple matter of making an appointment with a doctor and getting a prescription.  To be sure, many patients have used drugs like Suboxone or methadone to help them overcome deadly addictions, just as some individuals with major depression owe their lives to SSRIs or ECT.  But others have been genuinely hurt by these drugs.  Patients who have successfully discontinued Suboxone often say that it was the most difficult drug to stop—worse than any other opioid they had abused in the past.  Patients should always be reminded of the potential risks and dangers of treatment.  More importantly, we providers have an obligation to make patients aware of other ways of achieving sobriety and when to use them.  Strategies that don’t rely so heavily on the medical model might require a lot more work, but the payoffs may be much greater.

——

Addictions involve complex biological, psychological, and social dimensions that differ from person to person.  The response of the psychiatric profession has been to devote more research to the neurobiology of addictions and the development of anti-addiction drugs, potentially at the expense of exploring other aspects that may be more promising.  As expected, psychiatrists, pharmaceutical companies, third-party payers, and the general public are quickly buying into this model.

Psychiatry finds itself in a Catch-22.  On the one hand, psychiatry is often criticized for not being “medical,” and focusing on the biology of addiction is a good way to adhere to the medical model (and, perhaps, lead us to better pharmacotherapies).  On the other hand, psychiatric disorders—and especially addictions—are multifactorial in nature, and successful treatment often requires a comprehensive approach.  Fortunately, it may not yet be too late for psychiatry to retreat from a full-scale embrace of the medical model.  Putting the patient first sometimes means stepping away from the science.  And as difficult and non-intuitive as that may be, sometimes that’s where the healthiest recovery can be found.


Big Brother Is Watching You (Sort Of)

February 17, 2012

I practice in California, which, like most (but not all) states has a service by which I can review my patients’ controlled-substance prescriptions.  “Controlled” substances are those drugs with a high potential for abuse, such as narcotic pain meds (e.g., Vicodin, Norco, OxyContin) or benzodiazepines (e.g., Xanax, Valium, Klonopin).  The thinking is that if we can follow patients who use high amounts of these drugs, we can prevent substance abuse or the illicit sale of these medications on the street or black market.

Unfortunately, California’s program may be on the chopping block.  Due to budget constraints, Governor Jerry Brown is threatening to close the Bureau of Narcotic Enforcement (BNE), the agency which tracks pharmacy data.  At present, the program is being supported by grant money—which could run out at any time—and there’s only one full-time staff member managing it.  Thus, while other states (even Florida, despite the opposition of Governor Rick Scott) are scrambling to implement programs like this one, it’s a travesty that we in California might lose ours.

Physicians (and the DEA) argue that these programs are valuable for detecting “doctor shoppers”—i.e., those who go from office to office trying to obtain Rx’es for powerful opioids with street value or addictive potential.  Some have even argued that there should be a nationwide database, which could help us identify people involved in interstate drug-smuggling rings like the famous “OxyContin Express” between rural Appalachia and Florida.

But I would say that the drug-monitoring programs should be preserved for an entirely different reason: namely, that they help to improve patient care.  I frequently check the prescription histories of my patients.  I’m not “playing detective,” seeking to bust a patient who might be abusing or selling their pills.  Rather, I do it to get a more accurate picture of a patient’s recent history.  Patients may come to me, for example, with complaints of anxiety while the database shows they’re already taking large amounts of Xanax or Ativan, occasionally from multiple providers.  Similarly, I might see high doses of pain medications, which (if prescribed & taken legitimately) cues me in to the possibility that pain management may be an important aspect of treating their psychiatric concerns, or vice versa.

I see no reason whatsoever that this system couldn’t be extended to non-controlled medications.  In fact, it’s just a logical extension of what’s already possible.  Most of my patients don’t recognize that I can call every single pharmacy in town and ask for a list of all their medications.  All I need is the patient’s name and birthdate.  Of course, there’s no way in the world I would do this, because I don’t have enough time to call every pharmacy in town.  So instead, I rely largely on what the patient tells me.  But sometimes there’s a huge discrepancy between what patients say they’re taking and what the pharmacy actually dispenses, owing to confusion, forgetfulness, language barriers, or deliberate obfuscation.

So why don’t we have a centralized, comprehensive database of patient med lists?

Some would argue it’s a matter of privacy.  Patients might not want to disclose that they’re taking Viagra or Propecia or an STD treatment (or methadone—for some reasons patients frequently omit that opioid).  But that argument doesn’t hold much water, because in practice, as I wrote above, I could, in theory, call every pharmacy in one’s town (or state) and find that out.

Another argument is that it would be too complicated to gather data from multiple pharmacies and correlate medication lists with patient names.  I don’t buy this argument either.  Consider “data mining.”  This widespread practice allows pharmaceutical companies to get incredibly detailed descriptions of all medications prescribed by each licensed doctor.  The key difference here, of course, is that the data are linked to doctors, not to patients, so patient privacy is not a concern.  (The privacy of patients is sacred, that of doctors, not so much; the Supreme Court even said so.)  Nevertheless, when my Latuda representative knows exactly how much Abilify, Seroquel, and Zyprexa I’ve prescribed in the last 6 months, and knows more about my practice than I do (unless I’ve decided to opt out of this system), then a comprehensive database is clearly feasible.

Finally, some would argue that a database would be far too expensive, given the costs of collecting data, hiring people to manage it, etc.  Maybe if it’s run by government bureaucrats, yes, but I believe this argument is out of touch with the times.  Why can’t we find some out-of-work Silicon Valley engineers, give them a small grant, and ask them to build a database that would collect info from pharmacy chains across the state, along with patient names & birthdates, which could be searched through an online portal by any verified physician?  And set it up so that it’s updated in real time.  Maintenance would probably require just a few people, tops.

Not only does such a proposal sound eminently doable, it actually sounds like it might be easy (and maybe even fun) to create.  If a group of code warriors & college dropouts can set up microblogging platforms, social networking sites, and online payment sites, fueled by nothing more than enthusiasm and Mountain Dew, then a statewide prescription database could be a piece of cake.

Alas, there are just too many hurdles to overcome.  Although it may seem easy to an IT professional, and may seem like just plain good medicine to a doc like me, history has a way of showing that what makes the best sense just doesn’t happen (especially when government agencies are involved).  Until this changes, I’ll keep bothering my local pharmacists by phone to get the information that would be nice to have at my fingertips already.


Biomarker Envy V: BDNF and Cocaine Relapse

October 18, 2011

The future of psychiatric diagnosis and treatment lies in the discovery and development of “biomarkers” of pathological processes.  A biomarker, as I’ve written before, is something that can be measured or quantified, usually from a biological specimen like a blood sample, which helps to diagnose a disease or predict response to a treatment.

Biomarkers are the embodiment of the new “personalized medicine”:  instead of wasting time talking to a patient, asking questions, and possibly drawing incorrect conclusions, the holy grail of a biomarker allows the clinician to order a simple blood test (or brain scan, or genotype) and make a decision about that specific patient’s case.  But “holy grail” status is elusive, and a recent study from the Yale University Department of Psychiatry, published this month in the journal Biological Psychiatry, provides yet another example of a biomarker which is not quite there—at least not yet.

The Yale group, led by Rajita Sinha, PhD, were interested in the question, what makes newly-abstinent cocaine addicts relapse?, and set out to identify a biological marker for relapse potential.  If such a biomarker exists, they argue, then it could not only tell us more about the biology of cocaine dependence, craving, and relapse, but it might also be used clinically, as a way to identify patients who might need more aggressive treatment or other measures to maintain their abstinence.

The researchers chose BDNF, or brain-derived neurotrophic factor, as their biomarker.  In studies of cocaine-dependent animals who are forced into prolonged abstinence, those animals show elevations in BDNF when exposed to a stressor; moreover, cocaine-seeking is associated with BDNF elevations, and BDNF injections can promote cocaine-seeking behavior in these same abstinent animals.  In their recent study, Sinha’s group took 35 cocaine-dependent (human) patients and admitted them to the hospital for 4 weeks.  After three weeks of NO cocaine, they measured blood levels of BDNF and compared these numbers to the levels measured in “healthy controls.”  Then they followed all 35 cocaine users for the next 90 days to determine which of them would relapse during this three-month period.

The results showed that the abstinent cocaine users generally had higher BDNF levels than the healthy controls (see figure below, A).  However, when the researchers looked at the patients who relapsed on cocaine during the 3-month follow-up (n = 23), and compared them to those who stayed clean (n = 12), they found that the relapsers, on average, had higher BDNF levels than the non-relapsers (see figure, B).  Their conclusion is that high levels of BDNF may predict relapse.

These results are intriguing, and Dr Sinha presented her findings at the California Society of Addiction Medicine (CSAM) annual conference last week.  Audience members—all of whom treat drug and alcohol addiction—asked about how they might measure BDNF levels in their patients, and whether the same BDNF elevations might be found in dependence on other drugs.

But one question really got to what I think is the heart of the matter.  Someone asked Dr Sinha: “Looking back at the 35 patients during their four weeks in the hospital, were there any characteristics that separated the high BDNF patients from those with low BDNF?”  In other words, were there any behavioral or psychological features that might, in retrospect, be correlated with elevated BDNF?  Dr Sinha responded, “The patients in the hospital who seemed to be experiencing the most stress or who seemed to be depressed had higher BDNF levels.”

Wait—you mean that the patients at high risk for relapse could be identified by talking to them?  Dr Sinha’s answer shows why biomarkers have little place in clinical medicine, at least at this point.  Sure, her group showed correlations of BDNF with relapse, but nowhere in their paper did they describe personal features of the patients (psychological test scores, psychiatric complaints, or even responses to a checklist of symptoms).  So those who seemed “stressed or depressed” had higher BDNF levels, and—as one might predict—relapsed.  Did this (clinical) observation really require a BDNF blood test?

Dr Sinha’s results (and the results of others who study BDNF and addiction) make a strong case for the role of BDNF in relapse or in recovery from addiction.  But as a clinical tool, not only is it not ready for prime time, but it distracts us from what really matters.  Had Dr Sinha’s group spent four weeks interviewing, analyzing, or just plain talking with their 35 patients instead of simply drawing blood on day 21, they might have come up with some psychological measures which would be just as predictive of relapse—and, more importantly, which might help us develop truly “personalized” treatments that have nothing to do with BDNF or any biochemical feature.

But I wouldn’t hold my breath.  As Dr Sinha’s disclosures indicate, she is on the Scientific Advisory Board of Embera NeuroTherapeutics, a small biotech company working to develop a compound called EMB-001.  EMB-001 is a combination of oxazapam (a benzodiazepine) and metyrapone.  Metyrapone inhibits the synthesis of cortisol, the primary stress hormone in humans.  Dr Sinha, therefore, is probably more interested in the stress responses of her patients (which would include BDNF and other stress-related proteins and hormones) than in whether they say they feel like using cocaine or not.

That’s not necessarily a bad thing.  Science must proceed this way.  If EMB-001 (or a treatment based on BDNF) turns out to be an effective therapy for addiction, it may save hundreds or thousands of lives.  But until science gets to that point, we clinicians must always remember that our patients are not just lab values, blood samples, or brain scans.  They are living, thinking, and speaking beings, and sometimes the best biomarker of all is our skilled assessment and deep understanding of the patient who comes to us for help.


Addiction Medicine: A New Specialty Or More Of The Same?

July 14, 2011

In an attempt to address a significant—and unmet—need in contemporary health care, the American Board of Addiction Medicine (ABAM) has accredited ten new residency programs in “addiction medicine.”  Details can be found in this article in the July 10 New York Times.  This new initiative will permit young doctors who have completed medical school and an initial internship year to spend an additional year learning about the management of addictive disease.

To be sure, there’s a definite need for trained addiction specialists.  Nora Volkow, director of the National Institute on Drug Abuse (NIDA), says that the lack of knowledge about substance abuse among physicians is “a very serious problem,” and I have certainly found this to be true.  Addictions to drugs and alcohol are devastating (and often life-threatening) conditions that many doctors are ill-prepared to understand—much less treat—and such disorders frequently complicate the management of many medical and psychiatric conditions.

Having worked in the addiction field, however (and having had my own personal experiences in the recovery process), I’m concerned about the precedent that these programs might set for future generations of physicians treating addictive illness.

As much as I respect addiction scientists and agree that the neurochemical basis of addiction deserves greater study, I disagree (in part) with the countless experts who have pronounced for the last 10-20 years that addiction is “a brain disease.”  In my opinion, addiction is a brain disease in the same way that “love” is a rush of dopamine or “anxiety” is a limbic system abnormality.  In other words: yes, addiction clearly does involve the brain, but overcoming one’s addiction (which means different things to different people) is a process that transcends the process of simply taking a pill, correcting one’s biochemistry, or fixing a mutant gene.  In some cases it requires hard work and immense will power; in other cases, a grim recognition of one’s circumstances (“hitting bottom”) and a desire to change; and in still other cases, a “spiritual awakening.”  None of these can be prescribed by a doctor.

In fact, the best argument against the idea of addiction as a biological illness is simple experience.  Each of us has heard of the alcoholic who got sober by going to meetings; or the heroin addict who successfully quit “cold turkey”; or the hard-core cocaine user who stopped after a serious financial setback or the threat of losing his job, marriage, or both.  In fact, these stories are actually quite common.  By comparison, no one overcomes diabetes after experiencing “one too many episodes of ketoacidosis,” and no one resolves their hypertension by establishing a relationship with a Higher Power.

That’s not to say that pharmacological remedies have no place in the treatment of addiction.  Methadone and buprenorphine (Suboxone) are legal, prescription substitutes for heroin and other opioids, and they have allowed addicts to live respectable, “functional” lives.  Drugs like naltrexone or Topamax might curb craving for alcohol in at least some alcoholic patients (of course, when you’re talking about the difference between 18 beers/day and 13 beers/day, you might correctly ask, “what’s the point?”), and other pharmaceuticals might do the same for such nasty things as cocaine, nicotine, gambling, or sugar & flour.

But we in medicine tend to overemphasize the pharmacological solution.  My own specialty of psychiatry is the best example of this:  we have taken extremely rich, complicated, and variable human experiences and phenotypes and distilled them into a bland, clinical lexicon replete with “symptoms” and “disorders,” and prescribe drugs that supposedly treat those disorders—on the basis of studies that rarely resemble the real world—while at the same time frequently ignoring the very real personal struggles that each patient endures.  (Okay, time to get off my soapbox.)

A medical specialty focusing on addictions is a fantastic idea and holds tremendous promise for those who suffer from these absolutely catastrophic conditions.  But ONLY if it transcends the “medical” mindset and instead sees these conditions as complex psychological, spiritual, motivational, social, (mal)adaptive, life-defining—and, yes, biochemical—phenomena that deserve comprehensive and multifaceted care.  As with much in psychiatry, there will be some patients whose symptoms or “brain lesions” are well defined and who respond well to a simple medication approach (a la the “medical model”), but the majority of patients will have vastly more complicated reasons for using, and an equally vast number of potential solutions they can pursue.

Whether this can be taught in a one-year Addiction Medicine residency remains to be seen.  Some physicians, for example, call themselves “addiction specialists” simply by completing an 8-hour-long online training course to prescribe Suboxone to heroin and Oxycontin abusers.  (By the way, Reckitt Benckiser, the manufacturer of Suboxone, is not a drug company, but is better known by its other major products:  Lysol, Mop & Glo, Sani Flush, French’s mustard, and Durex condoms.)  Hopefully, an Addiction Medicine residency will be more than a year-long infomercial for the latest substitution and “anti-craving” agents from multi-national conglomerates.

Nevertheless, the idea that new generations of young doctors will be trained specifically in the diagnosis and management of addictive disorders is a very welcome one indeed.  The physicians who choose this specialty will probably do so for a very particular reason, perhaps—even though this is by no means essential—due to their own personal experience or the experience of a loved one.  I simply hope that their teachers remind them that addiction is incredibly complicated, no two patients become “addicted” for the same reasons, and successful treatment often relies upon ignoring the obvious and digging more deeply into one’s needs, worries, concerns, anxieties, and much, much more.  This has certainly been my experience in psychiatry, and I’d hate to think that TWO medical specialties might be corrupted by an aggressive focus on a medication-centric, “one-size-fits-all” approach to the complexity of human nature.


When A Comorbidity Isn’t “Comorbid” At All

July 7, 2011

When medical professionals speak of the burden of illness, we use the term “morbidity.”  This can refer either to the impact of an illness on a patient’s quality of life, or to the overall impact of a disease on a defined community.  We also speak of “co-morbidities,” which, as you might expect, are two concurrent conditions, both of which must be treated in order for a patient to experience optimal health.

Comorbidities can be entirely unrelated, as in the case of a tooth abscess and fecal incontinence (at least I hope those are unrelated!).  Alternatively, they can be intimately connected, like CHF and coronary artery disease.  They may also represent seemingly discrete phenomena which, upon closer inspection, might be related after all—at least in some patients—like schizophrenia and obesity, depression and HIV, or chronic fatigue syndrome and XMRV (oops, scratch that last one!).  The idea is that it’s most parsimonious to find the connections between and among these comorbidities (when they exist) and treat both disorders simultaneously in order to achieve the best outcomes for patients.

I was recently asked to write an article on the comorbidity of alcoholism and anxiety disorders, and how best to manage these conditions when they co-occur.  Being the good (and modest—ha!) researcher that I am, I scoured the literature and textbooks for clinical trials, and found several studies of treatment interventions for combined anxiety and alcoholism.  Some addressed the disorders sequentially, some in parallel, some in an integrated fashion.  I looked at drug trials and therapy trials, in a variety of settings and for various lengths of time.

I quickly found that there’s no “magic bullet” to treat anxiety and alcoholism.  No big surprise.  But when I started to think about how these conditions appear in the real world (in other words, not in a clinical trial), I began to understand why.

You see, there’s great overlap among most psychiatric diagnoses—think of “anxious depression” or “bipolar with psychotic features.”  As a result, psychiatrists in practice more often treat symptoms than diseases.  And nowhere is this more the case than in the diagnosis and treatment of addictions.

Addictions are incredibly complex phenomena.  While we like to think of addictions like alcoholism as “diseases,” I’m starting to think they really are not.  Instead, an addiction like alcoholism is a manifestation or an epiphenomenon of some underlying disorder, some underlying pain or deficiency, or some sense of helplessness or powerlessness (for a more elaborate description, see Lance Dodes’ book The Heart of Addiction).  In other words, people drink not because of a dopamine receptor mutation, or a deficiency in some “reward chemical,” or some “sensation-seeking” genotype, but because of anxiety, depression, or other painful emotional states.  They could just as easily be “addicted” to gambling, running, bike riding, cooking (and yes, sex) as ways of coping with these emotions.  Incidentally, what’s “problematic” differs from person to person and from substance to substance.  (And it is notable, for instance, that mainlining heroin = “bad” and running marathons = “good.”  Who made that rule?)

“But wait,” you might say, “there’s your comorbidity right there… you said that people drink because they’re anxious.”  Okay, so what is that “anxiety”?  Panic disorder?  Post-traumatic stress disorder?  Social phobia?  Yes, there are certainly some alcoholics with those “pre-existing conditions” who use alcohol as a way of coping with them, but they are a small minority.  (And even within that minority, I’m sure there are those whose drinking has been a remarkably helpful coping mechanism, despite the fact that it would be far more supportive of our treatment paradigm if they just took a pill that we prescribed to them.)

For the great majority of people, however, the use of alcohol (or another addictive behavior) is a way to deal with a vastly more complicated set of anxieties, deficiencies, and an inability to deal with the here and now in a more direct way.  And that’s not necessarily a bad thing.  In fact, it can be quite adaptive.

Unfortunately, when we psychiatrists hear that word “anxiety,” we immediately think of the anxiety disorders as written in the DSM-IV and think that all anxious alcoholics have a clear “dual diagnosis” which—if we diagnose correctly—can be treated according to some formula.  Instead, we ought to think about anxiety in a more diffuse and idiosyncratic way:  i.e., the cognitive, emotional, behavioral, and existential phenomena that uniquely affect each of our patients.  (I’m tempted to venture into psychodynamic territory and describe the tensions between unconscious drives and the patient’s ego, but I’m afraid that might be too quaint for the sensibilities of the 21st century mind.)

Thus, I predict that the rigorous, controlled (and expensive, and time-consuming) studies of medications and other interventions for “comorbid” anxiety disorders and alcoholism are doomed to fail.  This is because alcoholism and anxiety are not comorbid in the sense that black and white combine to form the stripes of a zebra.  Rather, they make various shades of grey.  Some greys are painful and everlasting, while others are easier to erase.  By simplifying them as black+white and treating them accordingly, we miss the point that people are what matter, and that the “grey areas” are key to understanding each patient’s anxieties, insecurities, and motivations—in other words, to figuring out how each patient is unique.


How Much Should Addiction Treatment Cost?

May 22, 2011

Drug and alcohol abuse are widespread social, behavioral, and—if we are to believe the National Institutes of Health and most addiction professionals—medical problems.  In fact, addiction medicine has evolved into its own specialty, and a large number of other allied health professionals have become engaged in the treatment of substance abuse and dependence.

If addiction is a disease, then we should be able to develop ways to treat addictions effectively, and the costs of accepted treatments can be used to determine how we provide (and reimburse for) these services.  Unfortunately, unlike virtually every other (non-psychiatric) disease process—and despite tremendous efforts to develop ways to treat addictions effectively—there are still no universally accepted approaches for management of addictive disorders.  And the costs of treating an addict can range from zero to tens (or hundreds) of thousands of dollars.

I started thinking of this issue after reading a recent article on abcnews.com, in which addiction psychiatrist Stefan Kruszewski, MD, criticized addiction treatment programs for their tendency to take people off one addictive substance and replace it with another one (e.g., from heroin to Suboxone; or from alcohol to a combination of a benzodiazepine, an antidepressant, and an antipsychotic), often at a very high cost.  When seen through the eyes of a utilization reviewer, this seems unwise, expensive, and wasteful.

I agree with Dr Kruszewski, but for a slightly different reason.  To me, current treatment approaches falsely “medicalize” addiction and avoid the more significant psychological (or even spiritual) meaning of our patients’ addictive behaviors.  [See my posts “Misplaced Priorities in Addiction Treatment” and “When Does Treatment End.”]  They also cost a lot of money:  Suboxone induction, for instance, can cost hundreds of dollars, and the medication itself can cost several hundred more per month.  Likewise, the amounts being spent to develop new pharmacotherapies for cocaine and stimulant addiction are very high indeed.

Residential treatment programs—particularly the famous ones like Cirque Lodge, Sierra Tucson, and The Meadows—are also extremely expensive.  I, myself, worked for a time as a psychiatrist for a long-term residential drug and alcohol treatment program.  Even though we tried to err on the side of avoiding medications unless absolutely necessary (and virtually never discharged patients on long-term treatments like Suboxone or methadone), our services were quite costly:  upwards of $30,000 for a four-month stay, plus $5000/month for “aftercare” services.  (NB:  Since my departure, the center has closed, due in part to financial concerns.)

There are cheaper programs, like state- and county-sponsored detox centers for those with no ability to pay, as well as free or low-cost longer-term programs like the Salvation Army.  There are also programs like Phoenix House, a nonprofit network of addiction treatment programs with a variety of services—most of which are based on the “therapeutic community” approach—which are free to participants, paid for by public and private funding.

And then, of course, are the addicts who quit “cold turkey”—sometimes with little or no support at all—and those who immerse themselves in a mutual support program like Alcoholics Anonymous (AA).  AA meetings can be found almost everywhere, and they’re free.  Even though the success rate of AA is probably quite low (probably less than 10%, although official numbers don’t exist), the fact of the matter is that some people do recover completely without paying a dime.

How to explain this discrepancy?  The treatment “industry,” when challenged on this point, will argue that the success rate of AA alone is abysmal, and without adequate long-term care (usually in a group setting), relapse is likely, if not guaranteed.  This may in fact be partially true; it has been shown, for instance, that the likelihood of long-term sobriety does correlate with duration of treatment.

But at what cost?  Why should anyone pay $20,000 to $50,000 for a month at a premiere treatment center like Cirque Lodge or Promises Malibu?  Lindsay Lohan and Britney Spears can afford it, but few else—and virtually no insurance plans—can.

And the services offered by these “premiere” treatment programs sound like a spa menu, rather than a treatment protocol:  acupuncture, biofeedback, equine therapy, massage, chiropractic, art therapy, nature hikes, helicopter rides, gourmet meals or private chef services, “light and sound neurotherapy,” EMDR, craniosacral therapy, reiki training, tai chi, and many others.

Unfortunately, the evidence that any one of these services improves a patient’s chance of long-term sobriety is essentially nil.  Moreover, if addiction is purely a medical illness, then learning how to ride a horse should do absolutely nothing to help someone kick a cocaine habit.  Furthermore, medical insurance should not pay for those services (or, for that matter, for group therapy or a therapeutic-community approach).

Nevertheless, some recovering addicts may genuinely claim that they owe their sobriety to some of these experiences:  trauma recovery treatment, experiential therapy, “male bonding” activities (hat tip to the Prescott House), and yes, even the helicopter rides.

The bottom line is, we still don’t know how to treat addiction, or even what it really is in the first place.  Experts have their own ideas, and those in recovery have their own explanations.  My opinion is that, in the end, treatment must be individualized.  For every alcoholic who gets sober by attending daily AA meetings, or through religious conversion, there’s another addict who has tried and failed AA numerous times, and who must enroll in multiple programs (costing tens of thousands of dollars) to achieve remission.

What are we as a society willing to pay for?  Or should we simply maintain the free-market status quo, in which some can pay big bucks to sober up with celebrities on the beaches of Malibu, while others must detox on the bathroom floor and stagger to the AA meetings down the street?  Until we determine how best to tailor treatment to the individual, there’s no shortage of people who are willing to try just about anything to get help—and a lot of money to be made (and spent) along the way.


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