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.


Do What You’re Taught

February 5, 2012

In my mail yesterday was an invitation to an upcoming 6-hour seminar on the topic of “Trauma, Addiction, and Grief.”  The course description included topics such as “models of addiction and trauma/information processing” and using these models to plan treatment; recognizing “masked grief reactions” and manifestations of trauma in clients; and applying several psychotherapeutic techniques to help a patient through addiction and trauma recovery.

Sound relevant?  To any psychiatrist dealing with issues of addiction, trauma, grief, anxiety, and mood—which is pretty much all of us—and interested in integrative treatments for the above, this would seem to be an entirely valid topic to learn.  And, I was pleased to learn that the program offers “continuing education” credit, too.

But upon reading the fine print, credit is not available for psychiatrists.  Instead, you can get credit if you’re one the following mental health workers:  counselor, social worker, MFT, psychologist, addiction counselor, alcoholism & drug abuse counselor, chaplain/clergy, nurse, nurse practitioner, nurse specialist, or someone seeking “certification in thanatology” (whatever that is).  But not a psychiatrist.  In other words, psychiatrists need not apply.

Well, okay, that’s not entirely correct, psychiatrists can certainly attend, and–particularly if the program is a good one—my guess is that they would clearly benefit from it.  They just won’t get credit for it.

It’s not the first time I’ve encountered this.  Why do I think this is a big deal?  Well, in all of medicine, “continuing medical education” credit, or CME, is a rough guide to what’s important in one’s specialty.  In psychiatry, the vast majority of available CME credit is in psychopharmacology.  (As it turns out, in the same batch of mail, I received two “throwaway” journals which contained offers of free CME credits for reading articles about treating metabolic syndrome in patients on antipsychotics, and managing sexual side effects of antidepressants.)  Some of the most popular upcoming CME events are the Harvard Psychopharmacology Master Class and the annual Nevada Psychopharmacology Update.  And, of course, the NEI Global Congress in October is a can’t-miss event.  Far more psychiatrists will attend these conferences than a day-long seminar on “trauma, addiction, and grief.”  But which will have the most beneficial impact on patients?

To me, a more important question is, which will have the most beneficial impact on the future of the psychiatrist?   H. Steven Moffic, MD, recently wrote an editorial in Psychiatric Times in which he complained openly that the classical “territory” of the psychiatrist—diagnosis of mental disorder, psychotherapy, and psychopharmacology—have been increasingly ceded to others.  Well, this is a perfect example.  A seminar whose content is probably entirely applicable to most psychiatric patients, being marketed primarily to non-psychiatrists.

I’ve always maintained—on this blog and in my professional life—that psychiatrists should be just as (if not more) concerned about the psychological, cultural, and social aspects of their patients and their experience as in their proper psychopharmacological management.  It’s also just good common sense, especially when viewed from the patient’s perspective.  But if psychiatrists (and our leadership) don’t advocate for the importance of this type of experience, then of course others will do this work, instead of us.  We’re making ourselves irrelevant.

I’m currently experiencing this irony in my own personal life.  I’m studying for the American Board of Psychiatry and Neurology certification exam (the “psychiatry boards”), while looking for a new job at the same time.  On the one hand, while studying for the test I’m being forced to refresh my knowledge of human development, the history of psychiatry, the theory and practice of psychotherapy, the cognitive and psychological foundations of axis I disorders, theories of personality, and many other topics.  That’s the “core” subject matter of psychiatry, which is (appropriately) what I’ll be tested on.  Simultaneously, however, the majority of the jobs I’m finding require none of that.  I feel like I’m being hired instead for my prescription pad.

Psychiatry, as the study of human experience and the treatment of a vast range of human suffering, can still be a fascinating field, and one that can offer so much more to patients.  To be a psychiatrist in this classic sense of the word, it seems more and more like one has to blaze an independent trail: obtain one’s own specialized training, recruit patients outside of the conventional means, and—unless one wishes to live on a relatively miserly income—charge cash.  And because no one seriously promotes this version of psychiatry, this individual is rapidly becoming an endangered species.

Maybe I’ll get lucky and my profession’s leadership will advocate more for psychiatrists to be better trained in (and better paid for) psychotherapy, or, at the very least, encourage educators and continuing education providers to emphasize this aspect of our training as equally relevant.  But as long as rank-and-file psychiatrists sit back and accept that our primary responsibility is to diagnose and medicate, and rabidly defend that turf at the expense of all else, then perhaps we deserve the fate that we’re creating for ourselves.


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.


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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