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.


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.


Curbing Prescription Addiction

April 21, 2011

It should come as no surprise to anyone that prescription drug abuse is a serious problem.  As if we needed any reminder, a flurry of articles recently hit the press, showing just how serious the problem is.  Opioids (narcotic pain medications like Vicodin, Oxycontin, methadone, etc) are the most widely prescribed drugs in America, according to IMS and to a recent survey by the National Institute on Drug Abuse (NIDA), and prescriptions can lead to misuse, abuse, and dependence.

Predictably, the government plans to get involved.  As the New York Times reported earlier this week, the Obama administration wants to create legislation “requiring doctors to undergo training” before being permitted to prescribe opioid pain meds.

Hearing “government” and “training” in the same sentence doesn’t exactly inspire confidence.  What will the “training” consist of?   An online seminar?  A paper-and-pencil exam from the DEA?  A separate section on “managing pain patients” in our Board Certification exams?

[And didn’t we do this already?  As a matter of fact, yes, we did:  Back in 2000, JCAHO (the “Joint Commission” which accredits healthcare organizations) required doctors to undergo training to recognize and treat pain disorders.  Back then, we were told that we weren’t treating pain often enough.  Maybe the pendulum has swung too far in the other direction?  Maybe we’ve done our job too well?]

With respect to the prevention of opioid abuse, I agree it’s a good idea for doctors to recognize the warning signs of addiction, to implement monitoring procedures (like random urine tests and treatment contracts), to deny early refills, and to inquire about other risk factors for abuse.  Sadly, many doctors don’t take these measures and need encouragement to do so.  But something tells me that simply providing government-mandated “prescriber education” won’t fix the problem.

In my opinion, there are two other important issues to be addressed before this “training” will prove to be useful.

The first is to get rid of existing inefficiencies.  The truth is, most doctors already know the proper steps for prescribing potentially abusable opioids to pain patients.  Some clinics (particularly pain clinics) follow these steps with all patients, simply as a matter of course.  But in most treatment settings these steps are difficult to take.  Regular urine monitoring is cumbersome and intrusive (although relatively inexpensive); generating a treatment contract takes time (although it’s arguably the most important “paperwork” of the appointment); and reviewing a patient’s full medication history is a challenge.  Moreover, most of our non-patient-care resources and personnel are devoted to billing and data entry, rather than in these ancillary services that, in the long run, are far more important to cost-effective patient care.

[A side note: many states provide a “prescription drug monitoring” service to permit doctors to view prescriptions for controlled substances that any patient has filled in that state.  However—at least in California—the application process takes 3-6 months, the data are typically delayed about 2-3 months, it does not include non-controlled drugs, and not all pharmacies participate.  It still blows my mind that for the last 10-15 years it has been easier to purchase airplane tickets online or to send computer files halfway around the globe than to determine whether the patient sitting in my office has filled a prescription for OxyContin in the last 90 days.  Simply improving the existing technology would be the most immediately beneficial step.]

The second—and, in my opinion, more important—item is for doctors to understand what is the goal of treatment.  Not just “relief of pain,” but when (if at all) can the treatment be said to be complete?  I’ve written about this before (see “When Does Treatment End?”), and I’m convinced it’s an important question not just in the treatment of pain but in the management of all conditions, even those we consider “chronic.”  I believe that all prescribers need to ask themselves, “How long will the patient need this medication?” and engage the patient in this discussion, too.

I frequently see patients who have been prescribed opioid pain medications, or benzodiazepines or stimulants (not to mention SSRIs or other psychiatric meds), who have no idea how long they’ll need to take them.  They just “got a script.”  And because these medications are highly reinforcing (they relieve pain or anxiety, and sometimes have a pleasant psychoactive effect as well), they’ll continue to ask for more.  Why shouldn’t they, since they were never told they should stop?

In any treatment setting, the patient and doctor should have a mutual understanding of the goals and likely duration of treatment.  This plan can (and should) be flexible, but it should always have some realistic end point.  Moreover, we should always measure our progress relative to that goal, rather than “kicking the can down the road” and letting someone else deal with the discontinuation of care later.  I don’t think doctors should be in the business of denying care to patients, but if we’ve already had the discussion of when treatment might end, the issue of “no” has already been raised, and the patient understands this.

How would this minimize the abuse of addictive medication?  For one thing, it would limit access to the drug because we, a priori, are refusing to provide an endless supply.  In turn, this helps the patient recognize that everything is being prescribed for a particular purpose, whether for the transient relief of post-op pain or the longer-term management of cancer pain.  If and when other symptoms emerge, they need to be discussed and treated separately—or a more comprehensive treatment plan should be developed, if the evolving symptoms fit a characteristic pattern.

I know this is a tall order, and these suggestions may be hard to implement in many of the places where narcotic prescribing is common (ERs, urgent care clinics, etc).  But they are important measures to take.  We need to take the steps we know we should take (rather than wait for the government to tell us to do so—because we know how that will turn out).  And we need to think about patients as people with the power to heal, and plan for the healing process to take place, rather than give knee-jerk reactions (i.e., prescriptions) for symptoms.  If we do this, patients will be less likely to take matters into their own hands and “self-medicate,” and the outcome of treatment will be better for all.


The Power Of No

April 3, 2011

Why is it that when someone tells us we can’t have something, we just want it more?  Marketers (those masters of neuropsychology) use this to their great advantage.  “Call now!  Offer expires in ten minutes!”  “Only one more available at this price!”  “Limited edition—Act now!”  Talk about incentive salience!!!

This phenomenon is known as the Scarcity Effect—a psychological principle saying that individuals don’t want to be left alone without an item—particularly something they believe they cannot have.  We’ve all experienced this in our personal lives.  Tight budgets often invite wasteful expenditures.  Obsession over “forbidden foods” has ruined many a diet.  Saying “no” to a child is frequently a trigger for constant begs and pleas.

Given the apparent universality of this concept, it’s surprising that we fall victim to it in medicine as often as we do, particularly at times when we want to motivate behavior change.  Saying “no” to a patient usually doesn’t work—it’s human nature.  In fact, if anything, the outcome is usually the opposite.  Reciting the dangers of cigarette smoking or obesity, for example, or admonishing a patient for these behaviors, rarely eliminates them.  The patient instead experiences shame or guilt that, paradoxically, strengthens his resistance to change.

But if we understand the Scarcity Effect, we doctors can outsmart it and use it to our advantage.  This can be important when we prescribe medications which are likely to be misused or abused, like sleep medications or benzodiazepines (Valium, Xanax, and others).  These drugs are remarkably effective for management of insomnia and anxiety, but their overuse has led to great morbidity, mortality, and increased health costs.  Similarly, narcotic pain medications are also effective but may be used excessively, with unfortunate results.  We discourage excessive use of these drugs because of side effects, the development of physical dependence, and something I call “psychological dependence”: the self-defeating belief I see in many patients that taking a pill is absolutely necessary to do what the patient should be able to do by him- or herself.

If I give a patient a prescription and say something like “Here’s a script for 15 pills, but I’m not giving you a refill until next month,” I’m almost inviting failure.  Just as expected by the Scarcity Effect, the patient’s first thought is usually “but what if I need 16?”

(I’ve worked extensively in addiction medicine, and the same principle is at work here, too.  When an alcoholic in early recovery is told that he can never have a drink again, he immediately starts to crave one.  Now I know that most alcoholics in early recovery are not in the position to say “no” to a drink, but this is the ultimate goal.  Their ability and willingness to say “no” is far more effective for long-term sobriety than someone else saying “no” for them.)

So why exactly does inaccessibility lead to craving?  Because even when it’s clear that we cannot have something, our repeated efforts to get it sometimes pay off.  And here’s where another psychological principle—that of intermittent reinforcement—comes in to play.  People who play the lottery are victims of this.  They know (most of them!!) that the odds of their winning are vanishingly low.  Most people never win, and those who play regularly are almost always losers.  However, every once in a while they’ll get lucky and win a $5 scratcher (and see the news stories about the $80 million jackpot winner just like them!) and this is incredibly reinforcing.

Similarly, if a doctor tells a patient that she should use only 10 Ambien tablets in 30 days– and that no refills will be allowed– but she calls the doctor on day #12 and asks for a refill anyway, getting the refill is incredibly reinforcing.  In the drug and alcohol treatment center where I used to work, if someone’s withdrawal symptoms did not require an additional Valium according to a very clear detox protocol, he might beg to a nurse or staff member, and occasionally get one—precisely what we do not want to do to an addict trying to get clean.

The danger is not so much in the reinforcement per se, but in the fact that the patient is led to believe (for very therapeutic reasons) that there will be no reinforcement, and yet he or she receives it anyway.  This, in my view, potentially thwarts the whole therapeutic alliance.  It permits the patient’s unhealthy behaviors to prevail over the strict limits that were originally set, despite great efforts (by patient and doctor alike) to adhere to these limits.  As a result, the unhealthy behaviors override conscious, healthy decisions that the patient is often perfectly capable of making.

One solution is, paradoxically, to give more control back to the patient.  For example, prescribing 30 Ambien per month but encouraging the patient to use only 10.  If she uses 12 or 15, no big deal—but it’s fodder for discussion at the next visit.  Similarly, instead of making a statement that “no narcotic refills will be given,” we can give some rough guidelines in the beginning but let the patient know that requests will be evaluated if and when they occur.  Recovering addicts, too, need to know that relapses and craving are not only common, but expected, and instead of seeing them as failures of treatment (the big “no”), they are a natural part of recovery and worthy of discussion and understanding.

In medicine, as in all sciences dealing with human behavior, ambivalence is common.  Preserving and respecting the patient’s ability to make decisions, even those which might be unhealthy, may seem like giving in to weakness.  I disagree.  Instead, it teaches patients to make more thoughtful choices for themselves (both good and bad)—exactly what we want to encourage for optimal health.


The Dangerous Duality of “Dual Diagnosis”

March 23, 2011

When psychiatric illness coexists with a substance use disorder, we refer to this as a “dual diagnosis.” This term makes clear that we’re talking about two conditions in the same person, which could exist independently of each other (hence they’re also sometimes called “co-occurring disorders”), rather than one disorder causing the other—as seen, for example, in cases of a methamphetamine-induced psychotic reaction or an alcohol-induced depression.

Of course, no two conditions in medicine ever exist truly independently of each other, particularly in psychiatry, and the high prevalence of “dual diagnosis” patients (more than a third of alcoholics, for example, have a co-occurring mental illness, and at least 20% of persons with a mood disorder have a drug use problem) suggests that there’s something about mental illness that makes people more susceptible to addictive disorders, and vice versa.

A “dual diagnosis” label should, theoretically, draw attention to the special concerns these patients face, and to the need for specialized and integrated treatment.  Unfortunately, in practice, this rarely occurs.  Instead, this knowledge often results in compartmentalized care, which may have unfortunate consequences for the dually diagnosed.

How so?  Consider an inpatient psychiatric ward.  Patients are admitted to these units for brief “acute stabilization,” when they are actively symptomatic, often with psychosis, thoughts of suicide, or other poorly controlled symptoms.  Because these hospitalizations are very short, there’s little or no opportunity to engage in meaningful addiction treatment.  Even when the immediate precipitant of the patient’s acute episode is identified as the abuse of a drug or alcohol, we often discharge patients with little more than a written instruction to “go to AA” or “consider rehab” (or my personal favorite, shown above [click for larger version], which would be funny if it weren’t real).  Similarly, in the psychiatrist’s office—particularly when the visits are only 10 or 15 minutes long—there’s usually no time to discuss the addiction; at best, the patient might get something along the lines of, “oh, and be sure to try to cut down on your drinking, too.”

Even though this is commonplace, it sends a powerful yet dangerous message to the addict:  it says that his addiction is less important than the mental disorder, less worthy of treatment, or, perhaps, impossible to treat.  It might signal to the addict that his psychiatrist is unwilling or unable to talk about the addiction, which may be (subconsciously) interpreted as a tacit approval of the addictive behavior.  (If you think I’m exaggerating, then you’ve probably never experienced the overwhelming power of addictive thinking, and its unique ability to twist people’s judgment and common sense in extreme ways.)

It’s also just bad medicine.  As any ER psychiatrist can attest, substance-induced exacerbations of mental illness are rampant and a major cause of hospital admissions (not to mention medication noncompliance, aggression, criminal activity, and other unwanted outcomes).  Ignoring this fact and simply stabilizing the patient with the admonition to “consider” substance use treatment is unlikely to improve the long-term outcome.

In the drug or alcohol treatment setting, the situation is often quite similar.  Sometimes a therapist may not be aware of a patient’s mental health history or active symptoms, in which case he or she might have unrealistically high expectations about the patient’s progress. On the other hand, if the patient is known to carry a psychiatric diagnosis, a therapist might incorrectly attribute even the slightest resistance—and addicts show a lot of it—to that mental illness (even when the symptoms are well-controlled) and miss the opportunity to make substantial inroads in treatment.  Neither alternative “meets the addict where he is,” challenging him with demands that are appropriate for his capabilities and his level of understanding.

True “dual diagnosis” treatment, where it exists, involves close interaction among addiction therapists, rehab counselors, psychiatrists, and others involved in the mental, physical, social, and spiritual well-being of each patient.  Some psychiatrists are well-versed in the nature of addiction (those who have first-hand experience of addiction and recovery are often well positioned to understand the demands on the recovering addict), and, similarly, some addiction experts are adept at identifying and managing symptoms of mental illness.  With this combination, patients can benefit from individualized treatment and are given fewer opportunities to fly beneath the proverbial radar.

However, for most patients this is the exception rather than the rule.  “Addition psychiatrists” are sometimes little more than prescribers of a replacement therapy like Suboxone or naltrexone, and rehab programs often include mental health treatment “at a distance”—i.e., sending clients to a 15-minute visit with a psychiatrist who’s not involved in the day-to-day challenges of the recovering individual.  Addicts need more than this, and I’ll return to this topic in later posts.

Any discussion about improving real-world psychiatric treatment must address the dual-diagnosis issue.  We desperately need more psychiatrists who are knowledgeable about substance abuse disorders and the interplay between addictions and mental illness, and not just the latest “anticraving” drugs or substitution therapies.  We also need to educate other addiction treatment providers about the manifestations of mental illness and the medications and other therapies available.  Providing compartmentalized or lopsided care—even when well-intentioned—does no service to a struggling patient, and may in the long run do more harm than good.


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