Addiction and Economic Decision Making

July 14th, 2014

I just had the opportunity to listen to a podcast with Dr Colin Camerer that I thought was very interesting. If you click the link there are two interviews. The first is with James Rickards and worth the listen (it’s the reason I listened to the podcast in the first place), but it’s the last one, with Dr Camerer, that I want to write about today. It has implications for people with addiction who want to invest in financial markets to fulfill their responsibilities to others to maintain the wealth they create.

What he said was so interesting to me that I started to look up his other work. I didn’t realize anyone had done these studies or confirmed conjectures I’d been using to treat addiction. To find someone outside of the addiction field doing it is amazing.

So the upshot is that using fMRI to study people who are trading an imaginary stock for real money in a situation where the actual value of the stock is known, bubbles still happen. The group still runs the price up above where they all know it belongs and they do it knowingly. They know that, for instance, the fair market price is 14 and when the project ends the price will be 14 and yet they still run the price up to 15,16,17 and higher.

He noted there were three groups of people. The first group, see the bubble and don’t participate. They weren’t very interesting to him, but I bet they were pretty good value investors. The second group he noted were those that rode the price up and sold too slow to get out in time, and the third group were those that bought on the way up and dumped quickly. The last group were the most successful. Something to note though is that everyone went through this only one time, so you really can’t tell if people were “smart” or lucky. It may very well be that people switch groups after they learned from mistakes, but he’ll have to look at that in future studies.

With that background, let me tell you what he found on fMRI. The first group, the ones that stayed out. Their Insula lit up while watching the price feed. The group that lost money, their Nucleus Accumbens lit up while trading. So why is that important?

The Inusla is a sort of internal perception engine. It tells you if you have a fever, if you’re eating something disgusting, if someone is making a bad face at you, if your dopamine level is too low, or any other “bad” internal signal. The Inusla is the part of your brain that says, “Look, something is wrong here. I don’t know what it is, but figure it out, because it could be a saber tooth tiger.” There’s another part called the Cingulate that is designed to tell you how urgently you need to fix this and get you motivated, sort of like “Wow, that is a tiger. Run!!!!” or “No, you just have a fever. Lay down.” So that group that stayed out of the bubble, took a look at the prices rising and knew there was something wrong. They didn’t feel the need to ride it up. They could take a look at the prices, see they were irrational, and sit there doing nothing. Wow, how many people can do that? But that’s what a normal brain does.

Now the people who lost the most had the Nucleus Accumbens light up when they traded. That tells me they were getting reward. There’s a funny thing about people with normal reward levels, that is, normal levels of dopamine at the Nucleus Accumbens. They don’t get reward from stuff like trading and their Insula works fine. But if you are low in dopamine, your insula isn’t fine and stuff like being right on a stock gives you a big lift. That doesn’t sound like a problem, but the other part of that dopamine hit in an otherwise low dopamine Nucleus Accumbens is that it sets up an association to the reward. If you get reward from trading stocks, you’ll want to trade stocks. If you get reward from watching porn, you’ll want to watch porn. If you get reward from shooting heroin, you’ll want to shoot heroin. Or maybe you’ll want to shoot heroin while watching porn while trading on your Schwab account. Good luck with that.
If you trade for reward, you aren’t trading for profit, and you’ll lose money. Investing should be boring, not exciting. If you have addiction and someone gives you a reward, you’ll form an attachment and do that thing more than is good for you. See the connection?

So what about the other people, the ones Camerer calls the smart money. They bought even though they knew it was a bubble, but they got out in time. How do I explain those people? Well, until Camerer does this again, I’m going with “they were just lucky.” I know investors who can look at a rising market and say, “Wow, that’s a bubble. There are some really stupid people that are going to run this thing up past it’s fair value. I can get on board and be ready to get off early before they all figure out they’re stupid,” but I don’t know many of them. Most people I know who participate in bubbles have an almost religious devotion to the belief in whatever is bubbly and instead of seeing an impending top they just see a new buying opportunity. The normal people among them learn after a few times and just avoid bubbles. I believe it is those people with addiction, low dopamine at the Nucleus Accumbens, that are getting a perceptible dopamine spike and reward from trading who can’t get out in time. They get attached because of the dopamine spike and can’t relate rationally to the rewarding event. They don’t get the signal from their Insula that something is wrong for two big reasons: the Insula is already saying something is wrong because of the low dopamine state, and the event precipitates brief normalization of dopamine and a relief of anything that’s wrong. So where a person without addiction is seeing more risk, a person with addiction sees, not risk, but something wonderful that there should be more of.

So if you have addiction, should you not invest? No, that’s not what I’m saying. I will say you shouldn’t day trade or even trade much at all, but investment is great. In fact, value investing is a wonderful long term way for addicted people to gain wealth, and like all functions in recovery, it’s best done in groups. You can’t go very far wrong with a group conscious. I may like IBM and think it’s undervalued but if 4 other sane sober minds who have read they same thing I have think it isn’t, it probably isn’t, especially when I’m sure it is. In fact the more sure I am that everyone else is wrong, the greater the probability that I’m not thinking right.

Another important recovery tool in successful sober investing is inventory. “We bought IBM at 115 because we thought it was undervalued and we said we’d be wrong if it fell to 100. It did; we were wrong.” If you can’t say you’re wrong when you’re wrong, don’t invest.

So until we all have fMRI headsets at home, we’ll have to use recovery principles in this field of endeavor, just like any other field of endeavor, in order to stay on track.

Does it Take Recovery to be an Addiction Doctor?

July 6th, 2014

I’m in regular email contact with a large number of colleagues in Addiction Medicine and most endorse psychosocial treatment, especially 12-step involvement in addiction treatment. That is, medication alone isn’t an effective long term treatment for addiction. For the most part I agree when it comes to addiction, but there are undertones that have some disturbing implications in the way we think of addiction as a society. Most of my colleagues are in the middle of the road, neither putting medication or recovery first, but using whatever works to treat the patient in front of them. However some who espouse psychosocial treatment, specifically 12-step program involvement, seem to negate the use of medication in treating addiction.

Recently a question was raised, “How long does a doctor have to be in recovery after treatment before he can switch specialties and work in addiction medicine?” There are a couple of implications here that could be examined a bit more deeply.

First, the question implies that there is some time after the addicted physician is safe to return to medical practice in which he is not safe to practice addiction medicine. That is, that addiction patients need something more than safe medical care from their doctor. Second, the question implies that time in recovery will remedy this deficit. One wonders, if this is true, if doctors who don’t have addiction and aren’t in recovery have this thing and don’t need recovery to practice addiction medicine, or that such unaffected doctors shouldn’t be practicing addiction medicine because they can’t get from recovery what addicted doctors get. The idea that there is some requirement for recovery in addiction medicine is surprising widespread, though not as widespread as it once was, and that may be a hint about how we got it in the first place.

The origins of our field, in the deep dark past before AA, were physicians who saw addiction as a biological illness, but had little to offer affected individuals. After AA came into being, there was a smattering of doctors from the earliest days that got sober with the 12 steps and, at some point, some of these sought to merge their professional responsibilities with what they learned in recovery. The treatment centers were born. The role of the doctor in this model is quite limited. Treat withdrawal, treat sequelae of drug use, and provide medical teaching to reinforce the spiritual message that the counselors give: that addiction is a spiritual malady for which no medication will work. In fact, in my early learning about addiction medicine, one of the definitions I was given of an addiction doctor is someone who filled the doctor niche in the addict’s life so some other doctor wouldn’t give him a medication. It’s sort of like being a receptor antagonist.

So, going to the 12 step source, there is a passage on page 18 of Alcoholics Anonymous (the Big Book) that many take as a requirement for addiction recovery if one is to do this work. “But the ex-problem drinker who has found this solution, who is properly armed with facts about himself, can generally win the entire confidence of another alcoholic in a few hours. Until such an understanding is reached, little or nothing can be accomplished.” This follows a bit about how hard a time doctors had getting an alcoholic to open up, so one can be forgiven for jumping to the conclusion that only an addicted doctor can help an addict. Before I go to the next paragraph, let me tell you about the email responses from some of my colleagues.

This particular email string got very active on this question and the answers fell into a few categories. There were people like me that wondered why it mattered. There were people who felt that there was some period of time that varied between 2 and five years of recovery before the doctor was ready. Finally there were people who said that it was the quality not the time of recovery that mattered. But both of these two last groups generally said that recovery was important because addiction was primarily a spiritual malady. That’s the part that sticks in my craw. Well, it would if I had a craw.

So what does the Big Book say about this issue? Nothing, but let’s read the sentence after the last quote. “That the man who is making the approach has had the same difficulty, that he obviously knows what he is talking about, that his whole deportment shouts at the new prospect that he is a man with a real answer, that he has no attitude of Holier Than Thou, nothing whatever except the sincere desire to be helpful…”
So again we see this reference to “same difficulty” and some take it to mean that only a doctor with experience in recovery can help a person with addiction. I have many fine colleagues who don’t have addiction, and some that work no recovery program what so ever. Yet they are still very good Addiction Medicine physicians, and this last quote tells us why.

They don’t approach the patient as if he had a special problem. They understand that he has the same problem they do. He’s a human being to whom something has happened beyond his control and over which he has no power. That is a ubiquitous human experience and one doesn’t need to have addiction to relate. It is obvious that they know what they are talking about because they are learned, not only from books and science, but from past patients that they have respected as people listened to diligently. Because they know the hope inherent in their past patients’ experiences in getting sober, their entire deportment screams that they have an answer – they’ve seen it work. Because they see the patient as human as they are, they have no holier than though attitude and approach the patient in a horizontal manner rather than with a hierarchical authority. And finally they are heard most because it is clear to anyone listening that they are only there to help.

So is it whether or not a physician is in recovery, or is it whether or not a physician treats the patient with the dignity and respect that the best of recovery teaches us to use with every person. Is there a timeline for learning this? Is this set of attitudes something specific to Addiction Medicine?

I see addiction as a biopsychsociospiritual illness, but I see all chronic illness that way. Spiritually, I don’t see any difference between surrendering to the fact of having diabetes or surrendering to the fact of having addiction. I don’t see any difference between surrendering to a lifestyle change for diabetes in treatment or surrendering to a lifestyle change for addiction in treatment. But how many people in diabetes care are treated with those same 5 criteria noted above in working with an alcoholic? How often does anyone with a chronic illness experience being listened to with respect, being seen horizontally, being given the hope of a physician’s past successes and having a physician who has no other cause but to be of help? Perhaps what we’re looking for in the newly recovering physician is something that we’ve lost in most physicians. That would be sad indeed. One can see how some of my colleagues can come to the conclusion that recovery from addiction gives one something that a normal person can’t have, because they perhaps don’t see it often in their normal colleagues.

But even science aside, let’s take a step back for a minute and look at what an illness is. The dictionary definition is the non-functioning or malfunctioning of a biological system. Well that certainly is true of addiction; the midbrain reward system and related systems don’t function correctly. Now some illnesses are acute, like strep throat, and others are chronic, like addiction and diabetes. And even with chronic illness, medicine and doctors are focused on a cure. Take a look a the website of the American Diabetes Society or the Cystic Fibrosis Foundation or the foundation associated with any other chronic illness and you’ll see one goal, wipe it out. Not true of addiction. Addiction, if seen as a spiritual malady, and because one is seen as better in addiction recovery than “before he had addiction”, it is something some wouldn’t even want to cure.

I’ve had colleagues with addiction say they are grateful for the illness, I’ve had patients say that as well. The logic is that if we didn’t have addiction, we wouldn’t have needed recovery, and we wouldn’t have been forced to accept a spiritual view of life that has made life more worthwhile. I’ve heard many speakers in AA say they feel sorry for “earth people” who just can’t get to where they are. Well, there are moments I can feel that, but any time I fail with a patient isn’t one of them.

As a doctor, my goal is to wipe out addiction, put myself out of business. Any other goal, to me, seems self serving. If I really believe in God, I’m sure he can find another way to bring someone to a spiritual life other than afflicting them with this scourge. This disease isn’t the only tool, I’m not the only tool, and their suffering isn’t the only tool.

I get confused when I hear doctors talk like priests and rabbis. Even if the goal of addiction treatment is to bring someone to a spiritual plain, non-addicted people can be brought to a state of belief; I don’t see why our role isn’t to help with medication to make the person as normal as possible so that the method that works for the other 80% works for them. There is a group of doctors however that sees the suffering of the untreated illness necessary for true movement. I’ve heard this called the necessity for “authentic suffering.”

So how long does a doctor need to be in recovery before he can start in the specialty of addiction medicine? As long as it takes to understand he’s a doctor, not a spiritual savior. As long as it takes to accept his role while being able to explain his truth to the patient and still accepting that it’s the patient’s life and the patient’s treatment plan. As long as it takes to gain the humility to know that I don’t know the only right way. For some, in and out of recovery, that seems to take decades.

How to Save $500 Billion and 500,000 Lives a Year

July 2nd, 2014

Well, that title was provocative, wasn’t it? Of course the short answer is, to treat addiction. $500 billion and 500K lives is what addiction takes out of this country every year. And those are conservative numbers, because things like gambling, over eating, etc don’t even figure into the way the government does these stats.

Ok, I have to be honest. It’s a little overblown, because to save this much you’d have to do great treatment on every one of the people in the country with addiction, but studies have shown that only 16% of them ever get a shot at treatment. So really, it looks like our max savings will be only $80 Billion and 80,000 lives. Ah, well. I could live with that.

But more than 80% of people with addiction can’t live with that, so isn’t there a better way? You know I’m going to say yes, don’t you?
Ok, yes, there is.

If we had better treatment for addiction, treatment that worked for illness, treatment that didn’t call the person names if it failed, treatment that was based in continuous improvement, and personalized for every individual, then if we had that treatment, we’d probably have more than 16% of people with addiction willing to come and get it. Those same studies that find that only 16% of people ever have a shot at treatment also say that the number one reason is stigma. Stigma, both perceived and real, is the number one thing that keeps people from treatment, and that means it’s the number one thing that kills people with addiction. And since one of the causes of stigma is the perception that addiction has such poor treatment outcomes, what we have is a positive feedback loop leading to a death spiral. The more people think that treatment doesn’t work, the fewer people will avail themselves of treatment and the more people will think addiction is a hopeless case,the less treatment there is, and on and on and on.

So is there a better way? I think so. Actually, I thought so over a decade ago; now I know so. I know because I’ve seen it. I know because it works.

This better way is so simple, so obvious, so easy to do, that everyone just avoids doing it. Well, actually, there’s another reason as well. It’s also a good bit more expensive than regular addiction treatment. To understand why, let me first tell you about regular addiction treatment as an outpatient.

The general method is the Intensive Outpatient Program (IOP) which is a regulatory term for group treatment with at least 9 contact hours a week usually split up into three meetings a week, three hours each meeting. There’s usually about 12 people in each group with one counselor who is making around $50 an hour. Most insurers pay (in our neck of the woods) around $175 a day for treatment. There’s usually a one-on-one session for an hour as well some time during the week, and because the patient is in IOP, that counts as a contact day and gets another $175. So the income to the provider is generally about $700/week per patient, times 12 patients, $8400 per IOP program. There’s also urine screening by point of care cup which, if the treatment provider has qualified for CLIA waived status, can be billed at about $40 a test so we can add two of those per patient a week, or another $960 for a total weekly income of $9360.

With that income the provider must pay the counselor ($30/hour) $1200 per week and buy the cups ($5/each) for $120 per week for a total clinical expense of $1320 per week. Add to that, that there must be someone at the desk during business hours (a receptionist, case manager, etc) ($20/hour) for $800 per week as well as rent, utilities, consumables, etc ($1000/week) and you get total expenses of $3120 a week. Remember there’s a $9360 income in that week so you get a profit of $6240 a week or $324K a year. A nice business. Not many people get well with this model, but a nice business.

Now you have a treatment center treating addiction but there aren’t any doctors, even though addiction is a primary biological brain illness. So let’s add a doctor for $250K a year ($4800/week). And we’ve noticed that the doctor can’t just be a doctor, but has to be available more than a doctor can be so there’s a nurse to answer calls when the doctor is working ($80K a year, $1500/wk). The doctor needs better data than a point of care cup that is sometimes as bad as 40% inaccurate so the urine samples go to a lab for a sophisticated analysis and they have to come back quickly so the answer can be used with in the next day for treatment planning (add $250 a sample or $500 a week). The doctor also needs to know the genetic background of the patient so add genetic testing ($500 per patient) and computerized neurocognitive testing to follow the effects of medication on midbrain dopamine tone ($300 a patient).

Now that first program we talked about, the one with the single counselor, it doesn’t have much individualization. Everyone gets the same 90 min lecture at group and the same 90 min group after lecture. There is the single individual session a week, but even those are largely the same (go to meetings, get a sponsor, don’t drink, etc). So let’s add a sophisticated tracking system that actually knows where each patient is cognitively and what, exactly, the staff needs to do to take him to the next cognitive plateau. You can’t get that done just at night during group so you add a day time counselor who knows more about personal change than just group ($1200 per week) to work with people and their assignments. And the group counselor can’t be the person to collect urine specimens because group has to start on time so there’s a case manager as well ($30K a year, $575/wk).

If your an insurance company, you’re probably thinking, “That’s a lot of expense just to talk substance users into stopping.” You’d be right if that’s all addiction treatment was. But, it’s time we stop treating the disease we’d like this to be and instead treat the illness that exists in nature. Addiction isn’t substance use; it isn’t even substance abuse. It is a chronic primary biological illness of the brain. Perhaps “substance abuse treatment” is what the usual addiction treatment has been and why it hasn’t worked very well; in fact I’ll bet that’s about all you’ll ever get for $175 a day. But we have a better way.

Instead of giving everyone the same talk and watching 83% of graduates relapse and come through again, we personalize each treatment. We get better outcomes.

Instead of not using medication for this brain illness, we have a sophisticated medical algorithm for primary addiction medicine treatment. We get better outcomes.

Instead of using point of care testing we use a lab that returns a confirmed answer evaluated by a physician in light of the patient’s past three tests and hydration status before group the next day. We get better outcomes (and order fewer tests).

Instead of having group three times a week, we have group five times a week. We get better outcomes.

Instead of our doctor just seeing the patient one time to approve admission, our doctor sees the patient at least weekly and has genetic and neurocognitive test results to make better decisions. And, you guessed it, we get better outcomes.

Now let me add one more thing. We have a computerized portal in which all of our clinical work and data goes. We use this data to look at the quality of our care on a regular basis and continually make improvements in our program. If you think we get better outcomes now, just wait.

So who wants to save $500 Billion and 500,000 lives a year? Give us a call.

Does Townsend’s Disease Acceptance Score Work?

June 29th, 2014

When we started Townsend, we knew that addiction was a chronic biological illness. So, what. Doesn’t everyone know that? Everyone calls addiction an illness, right? They understand that it’s chronic right? Everyone realizes that it’s an illness of brain biology, not choice, right? Well, I might have lost you on that last one. But even if I did, you probably don’t disagree with most of the people who treat addiction, so stick with me. I’ll explain.

The current dominant model for treating addiction in America stems from the Minnesota model of the 1940′s. In that model, and its variations, people with addiction are segregated into a residential or inpatient setting and given time and education in order to learn how to be sober. The teaching is good teaching, based on the 12 steps of Alcoholics Anonymous. The support they get from their struggling peers creates a bond and a strength that individually they could not access. The 24/7 nature of the supervision and staff availability creates the intensity necessary to overcome the strong bond between addict and drug. It makes perfect sense, doesn’t it. And if we took a crowd of 100 addiction treatment people and asked them to rank the different treatments, this is what they’d put at the top of the list. It’s the gold standard.

And are there people who get this treatment and go on to manage their illness in such a way that they need no further professional treatment? Yep. It turns out that it’s about the same percentage of people who get acute hospital care for diabetes and go on to manage their illness without relapse. And if we only look at the successes, we’d get the idea that this acute treatment works great. If addiction wasn’t a chronic condition the successes would be much greater.

Okay, maybe I convinced you that addiction is chronic. But what if it’s just chronic stupidity? or chronic selfishness? The fact that addiction is a chronic problem doesn’t make it a biological illness right? Again, you’d probably agree with most people who treat addiction. When treatment doesn’t work for someone, the treaters usually say, “He wasn’t ready.” You understand that perfectly, because the last time you had a sinus infection and the medication didn’t work, that’s what the doctor told you, right? “You just weren’t ready for the treatment to work.” You never heard that from your doctor? Well, that’s probably because your doctor knows she’s not treating choice, but illness. The evidence that addiction is a biological illness is too great to put in this article, but is ready available elsewhere. It spans the decades from DiChiari’s first findings in 1988, through the “Decade of the Brain” to ASAM’s new definition of addiction in 2012. If you need to take a break to go convince yourself that addiction is a biological illness, go ahead. I’ll wait.

Okay, I’m glad we have that settled.

So now that we’re convinced, we still have a problem. Even though I believe that addiction is a biological chronic illness, the evidence that there’s some psychological factor, some occasional barrier to treatment’s effectiveness, seems overwhelming. It’s just too many people’s experience, when dealing with someone with addiction, that “he just wasn’t ready.” That got us thinking. The idea of Townsend was to create a better way to treat addiction, but if there is some undefined psychological barrier to treatment working, how could we overcome that? Well, being convinced that addiction was a chronic biological illness, we looked at the literature about chronic disease relapse. It turns out that regardless of the chronic illness that the patient has, the relapse rate of 50 to 70% is common to all. Diabetes, asthma, COPD, addiction, and anyone else you can think of, all have post treatment relapse in this same general amounts. That means that addiction treatment doesn’t have a unique problem, so it won’t necessarily have a unique solution.

What was the problem with chronic illness? People don’t want to have it. They like taking vacations from care. They like to make believe they are normal, just for a day. But why? There are specific cognitions, or ideas, that go along with this thinking.

We were able to find 5 cognitions that have to change, in order, for someone to go from active addiction to sustained voluntary recovery. And these are the same cognitions that someone with any chronic illness will need to change to go from active illness to sustained recovery. We also saw that people change their ideas in a specific way. They go from “No way am I wrong,” to “Maybe I’m wrong,” to “Damn, I’m wrong.” And sometimes they get stuck at an external barrier to change. So that gives us four stages to each of the 5 cognitive changes. We were able to construct a grid of twenty squares and assign a Disease Acceptance Score to each patient.

We then developed specific interventions to use for each score with the goal, not of making the patient a 20, but of moving him to the next highest score. The idea here is you can’t talk to a 5 about being a 20; only a 19 is ready to become a 20. You have to talk to a 5 about becoming a 6. This gave us a way to personalize treatment that had not existed before. Instead of the group lecture being the treatment; it was just the method of getting education about the illness to the patient. The real treatment was his cognitive movement, and that was personalized.

We thought we’d found a way to revolutionize addiction treatment. And once we got good at it and proved it worked, we could show others how to use it to treat patients with any chronic illness. The idea behind the DAS and cognitive moment isn’t that the illness isn’t biological; it is. The idea is that relapse is largely due to stopping recovery behavior, and stopping recovery behavior is largely cognitive. With chronic illness, repetition is the only way to create permeant recovery, and we can’t be there every day. So we need to move the patient in a reliable way to do the things on a daily basis that they need to recover. To keep this sustained they need to do these things, not for us, but because they are the logical thing to do given their own thoughts about the illness. That means that their cognitive change is the most reliable way to have them enter a voluntary day to day recovery.

So does it work? Yes, we think it does. We called sequential admissions to Townsend starting from a day 2 years prior to the phone calls with the goal of getting about 100 responses. We got 106. We asked them two questions. “How many times have you been to the emergency room since your discharge from treatment” and “How many days have you been admitted to the hospital since discharge from treatment?” We didn’t just call graduates of our program, we called all admissions. So we got people who didn’t stay long in treatment as well as those who successfully completed treatment. We divided their answers by the number of days since they’d been DC’d to give us the rates of “ED Visits per 100 days after DC” and “Hospital Days per 100 days after DC.” We then compared these rates to the DAS score at discharge (DCDAS).

Here’s the regression line for ED visits (p=.01):

Screen Shot 2014-04-04 at 5.34.04 AM

Here’s the regression line for Hospital days (p=.01):

Screen Shot 2014-04-04 at 5.35.41 AM

The DCDAS explains about 6% of the variance of the number of ED visits since discharge and 48% of the the hospital days since discharge. What’s important though is that it predicts anything two years out from treatment at all. If we can keep a person in treatment and get them to a high DAS score, we can significantly lower their medical utilization going forward. This is a pretty good proxy for treatment success given that hospitalizations and ED visits are higher in people with active addiction.

So what’s next? Well, because addiction is a chronic illness, just like other chronic illnesses, we think that these interventions for these cognitive stages will work just as well in diabetics as addicts. We’d like to find someone who has a group of such patients and wants to see also. An insurance company, maybe? I’m sure someone would like a way to decrease medical spend in those illnesses too.

Affect on Cognitive Progress of More Frequent Group Participation in an IOP

June 21st, 2014

Intensive Outpatient Programs (IOP) traditionally meet three times a week. We noticed that many patients would make cognitive progress in our program and then slip back between meetings. As our goal was to create an effective alternative to inpatient care, and the frequency of visits was a major tool used by inpatient care, we first increased to 4 times a week and then 5. Not all patients agree to this greater intensity, so we wanted to compare the outcomes of treatment against frequency of attendance to see if we should maintain this structure or return to traditional three time a week.

We examined the data from 202 consecutive admissions to 6 IOPs over approximately 6 months. In order to prevent confusion between longevity and intensity of participation we devised a density function for sessions/LOS as our predictor. Our outcome measure was our Disease Acceptance Scale score at discharge. We have elsewhere shown that it is a good predictor of future healthcare costs. We used a Density Day Step function such that densities were converted into days per week attended (1/7=0.14285, 2/7=.28571, etc). Those who attended only once per week were not indistinguishable from those who did not receive treatment before DC. Those who attended twice or three times per week were better than no treatment but three times a week was not distinguishable from twice. At four times a week there was a statistically significant difference in discharge DAS score. Five sessions a week were better than four, but not significantly so. Here’s the picture (r=0.56; p<.0001):

Screen Shot 2014-04-16 at 3.18.07 PM

To simplify matters, if a patient came less than 4 times a week they were discharged with an average DAS of 9.8 opposed to an average of 13.9 if they came 4 times a week. (r=.46; p<.0001):

Screen Shot 2014-04-16 at 3.21.03 PM

If all that is being “treated” is substance abuse, and no difference is made between substance abusers and people with the biological illness of addiction, perhaps three contacts a week are sufficient. However, addicted patients require more, which is why expensive inpatient treatment has been the gold standard for many years. Society has long confused substance abuse and addiction, and if a true alternative to inpatient treatment for addiction is desired by those paying for treatment, it needs to be designed from the ground up. Given that the discharge DAS is predictive of healthcare costs going forward, which is a good proxy for continued recovery, and that density of treatment should be at least 4 times per week, it seems clear that increasing density of sessions of IOP to 4 a week or greater is helpful in improving outcomes in outpatient treatment of addiction.

Addiction or Not

June 15th, 2014

I’ve written here before about how most of the world, with its DSM based view of addiction, is struggling to understand what the illness of addiction really is. A good example of this is a recent article by Kollins et al called “ADHD, altered dopamine neurotransmission, and disrupted reinforcement processes: implications for smoking and nicotine dependence.” That’s a long title; it must be important.

The upshot is, as you’ll see when you read the abstract, “ADHD patients smoke cigarettes at rates significantly higher than their non-diagnosed peers and the disorder also confers risk for a number or related adverse smoking outcomes including earlier age of initiation, faster progression to regular use, heavier smoking/greater dependence, and more difficulty quitting.” The study, by comparing smoking in people with and without the diagnosis of ADHD, sounds like it comes to the conclusion that ADHD is a serious risk factor for nicotine dependence, which is, of course, another way to say addiction to nicotine.

Anyone familiar with the DSM who reads Kollins’ article will come away with the impression that it is well reasoned and a good advance of the field. Unfortunately DSM is a pretty poor paradigm on which to build a way to treat addiction. I’d just like to offer a different view.

What if ADHD, a disorder of low midbrain dopamine tone, wasn’t ADHD? What if it was a disorder in which a person with lowered dopamine tone and the accompanying symptoms (poor attention, poor motivation, poor attachment except to sources of dopamine, difficulty shifting sets, lowered hedonic tone, etc.) was able to actually raise midbrain dopamine through hyperactive behavior? What if there were some people with low midbrain dopamine that didn’t need an external drug at first to raise dopamine but could raise it by jumping up and down or spinning around in circles? Wouldn’t those people attach to their behavior in the same way a low dopamine person attaches to taking a drug that raises dopamine? Does the brain really care if the dopamine comes from a shot of heroin, a cigarette, a chocolate cake, or spinning in circles? The science of the midbrain suggests it not only doesn’t care, but that there’s no way it can tell the difference.

So what if such a person had a cigarette? The rise in dopamine from the cigarette would be very attaching. They would have as hard a time of stopping smoking without dopamine replacement as they would in stopping ADHD behaviors without dopamine replacement.

So let’s look at the quote a couple of paragraphs up. Instead of thinking of ADHD as something that isn’t addiction, and nicotine dependence as something that is addiction to something specific, let’s look at them both as addiction – attachment to something that raises midbrain dopamine tone in someone with symptoms of lowered midbrain dopamine tone. Then the findings of the study don’t become a startling addition to the field, but rather a sort of “yeah, so what, we knew that already.” Let’s rewrite the quote and see how it sounds: “Addiction patients use more rewarding drugs and behaviors than their non-diagnosed peers and start using earlier (because it’s a genetic illness and they’ve had symptoms all their lives), progress faster to regular use (because no one likes to feel bad once they have a way to feel better), heavier use (because they are using it to feel normal), dependence (happens with regular use in anyone with certain drugs), and more difficulty quitting (because after they quit they are left with the untreated symptoms that made them pick it up in the first place).”

The study basically says that ADHD is a risk factor for smoking. It’s an A causes B argument. I think it’s not A causes B, but rather C causes A and B. It’s not that ADHD is a risk for addiction, but rather we’ve chosen ADHD to be the label we put on the disease of addiction before it finds a drug that we call a drug. Once we start looking at the illness as a biological entity rather than a set of arbitrarily defined behaviors we’ll have better treatment that is just about as obvious. The ASAM definition of addiction is a good start. There is a better way.

What’s it Cost?

June 8th, 2014

People ask me this all the time. I get this question from patients, family, employers, and insurance companies. I get this question from friends, politicians, lawmakers, and police. Almost everyone I talk to about addiction treatment asks this question, “What’s it cost?”

I’ve been a psychiatrist for a good while now, and a doctor even longer. For almost two decades I’ve had the primary interest of treating people with addiction. I get this question so much since I started treating addiction that I forgot, until the other day, that no one asked me that question before. That is, it’s the question our society asks people who treat addiction, and we don’t ask the same question of people who treat heart disease or diabetes.

Sure people are interested in the cost effectiveness of other branches of medicine and people who run insurance systems want to know what it costs to treat heart disease and diabetes, but even when we do ask these questions, we don’t ask them in the same way. Here’s an example.

A 2005 study, Cost Effectiveness of Statins in Coronary Heart Disease, by Franco, et al used cost per life year saved as the outcome. You might ask, what’s a life year? Is it like a light year? No, it’s one year of life added. So if a treatment adds a year that’s one life year. If a treatment adds two years of life that’s two life years. If you take the total amount spent and divide by how many years of life you added to the person by giving the therapy you’ll get the cost per life year. This is important and we’ll come back to it.

Because the cost per life year varies according to the initial risk of death, Franco et al had to take a sophisticated statistical approach which took into account the risk of heart disease. You can imagine if you are treating 100 people, all with a 90% risk of heart attack in the next three years, that decreasing the risk by 10% would produce more life years saved than the same decrease of 10% risk in 100 people with a 20% risk of heart attack in the next three years. In any case, stratifying by risk gave them a range of the cost, not of treating heart disease, but of using just this one class of medication to treat heart disease. You probably want to sit down for this next bit.

It cost $21,545 per year of life saved at the highest risk group, those with more than a 4% chance of having a heart attack in the next year. Is that a lot? Is that acceptable? Only you can decide what you think a life year is worth, but that’s not really my point. My point so far is that the question we ask about heart disease is how much does it cost to save a year of life.

But what question do we ask when we want to look at the cost effectiveness of addiction treatment? Here’s a link to NIDA’s website showing that treating addiction costs less than jailing the patient. Here’s a link to SAMHSA’s website showing that for every $1 spent on addiction treatment, society saves about $7. When we talk about treating heart disease, no one minds telling you what it will cost to save a year of life, but when we talk about addiction, we have to prove we’ll save you money. That’s because our society doesn’t value a year of an addict’s life.

We don’t really think about addiction as an illness, not an illness like heart disease that someone didn’t bring on themselves. Oh wait, heart disease is brought on by poor diet and sedentary life. Well we don’t think about addiction as a real illness like heart disease that runs in families. Oh wait, addiction is largely genetic. Well we don’t think about addiction as a real illness that has a real physical pathology like heart disease. Oh wait, addiction is a biological illness of the midbrain with a well defined pathology. All right, all right, we just don’t like addiction.

Now that’s not to say that some people haven’t done real cost effectiveness studies on addiction treatment. Let’s take a look at the most hated of addiction treatment medications, methadone. Let’s compare the cost effectiveness of keeping someone alive by putting them on a statin every day for the rest of their life or methadone every day. Here’s an abstract (costs money to link to a whole study) of a study by Barnett and Hui showing that methadone costs about $11,000 per life year, about half of what statins cost in the group in which they’re cheapest. And Barnett and Hui actually used quality adjusted life years while the statin study did not, an approach that actually makes the cost per life year look higher.

It really doesn’t matter whether we quality adjust the years or not. It doesn’t matter if we show you it’s cheaper to treat addiction than it is to treat other illnesses. It doesn’t really matter if we even show you we can save you money you’re spending elsewhere by treating addiction. What matters is whether you think addicts are people. If you do you probably won’t even ask us for proof. If you don’t, there isn’t enough proof in the world.

What Do Addiction and Economics Have in Common?

June 1st, 2014

People who follow me on Twitter get confused, I’ll bet. Half the tweets are about addiction and half are about the state of the economy or something related. “What do addiction and economics have in common,” you might ask. “Not much,” you might answer, at least not on the surface. I see a lot in common, but even if you don’t, they still have one thing in common: they aren’t the same as they were in our grandparents’ time.

In the case of addiction, there were no legal connotations at all until the Harrison Tax Act of 1905. Doctors saw it as an illness evidenced by lack of control rather than loss of control. People who had addiction weren’t considered normal people who chose wrongly, but rather ill people who had a problem. The general upswing in moral issues in America in the early 1900′s that lead us to Prohibition had earlier effects on medical care for addiction. The Harrison Tax Act forbade doctors from treating patients with addiction unless they had special licenses and registrations, and those were cut back year after year until they were pulled all together. Between 1905 and 1920 over 20,000 American physicians were fined or jailed for treating people with addiction.

In the case of economics, what’s changed is the loss of an actual standard. When my grandfather saved a dollar he was saving 1/20th of an ounce of gold, and if he needed it in five years, that $1 was still worth 1/20th an ounce of gold. He could actually save his purchasing power. Because saved money, money held back from consumption, is the basis of all investment, there was much economic growth in America from the end of the greenback regime to 1933. This was the period when the US dollar was freely convertible with gold. Since 1933 the dollar has, to a lesser and lesser degree, been backed by anything until in the last 40 years or so, it has been backed by nothing. This has led to a constant inflation that decreases the purchasing power of any saver’s money. So people save less. This means less money for actual investment, the normal fuel for an economy, so to keep the economy going more money has to be printed and given to banks to lend. This “free money” leads to more speculation and greater instability.

We can see both addiction and economics only within the social construct of our own culture. That gives us a very distorted view of what these things actually are. To see the reality in their natures we need another perspective. We could look back in time, to see how our grandparents saw things in the social construct of their culture or we could look at other cultures in the world currently to see how the problem or event is different in that culture.

For example, people are fond of pointing out the differences in drug use between cultures, but that has little to do with addiction. History and accessibility have a lot to do with what drugs people with addiction use in different countries, but it doesn’t mean that the illness is different in different countries. So khat addiction in Africa and cocaine addiction in the US are different because there is a different drug and a different culture, but if we look at the underlying neurobiology of why people are using khat and cocaine, there’s no difference. We could do the same thing with economics. We could look at inflation here and in other places. In those places where inflation has destroyed people’s lives, people tend to live closer to the actual means of production and have less faith in the system. Growth is slower but steadier and they survive catastrophes better. Because they have lower rates of growth doesn’t mean that inflation is different there than here, just that they have a different context.

One final way that addiction and economics are alike is the phenomenon of expectation. Addiction has a unique neurobiology where the Nucleus Accumbens codes for positive disconfirmation of expected reward. That means the higher the expectation, the higher the reward required for a reward signal. The lower the expectation, the less the reward that gives the same signal.

Expectation plays a role in economics as well. As economics has become unglued from physical reality and based on models of behavior, it has become paramount that people restrict their actions to those models. The models expect it. When people don’t, the unexpected happens and everyone says, “Who could have seen that coming?”

This expectation in economics actually interacts in a very specific way with the part of the brain where addiction lives. Because our current unbacked currency needs more and more currency printing to keep things growing in the absence of real savings, there is no way to save purchasing power. Because any saved money will actually result in a decrease of purchasing power, we have, for the last few generations, been getting used to faster and faster spending in an attempt to maximize the value of what we spend. Many people have said that addiction as an illness is worse than it was 40 years ago. I’m not sure that’s true. But if it is, the cause is not a particular drug or behavior, it’s the economic reality of our current currency system; that is, we see instant gratification as a rational choice that is reinforced as the societal norm.

The Effect of Medically Managed Intensive Outpatient Program Participation on Future Healthcare Costs

May 26th, 2014

In order to provide a particular insurance payor with information regarding the effect of our treatment on future costs to them we surveyed sequential patients covered by them who were admitted two years ago to our Medically Managed Intensive Outpatient Program (MMIOP) and sequential inquiring members of theirs who chose not to admit to our program. 106 former patients and 40 insurance members were contacted and data gathered on emergency department (ED) visits and hospital days since discharge from treatment (or inquiry, in the case of those insurance members that did not admit to our program and did not enter treatment elsewhere). Ninety-three (88%) of the patients completed the program, 60% having successfully reached a 17 on Townsend’s Disease Acceptance Score and 28% having reached a lower score by completion of at least 28 sessions. Five of the non-admitting members (12%) attended another outpatient program and 8 (20%) went to inpatient treatment. The average ED visits per 100 days since DC for our patients was 0.05 and for those treated elsewhere was 0.56 (r=.34; p<.0001). The average hospital days per 100 days since DC for our patients was 0.03 and for those treated elsewhere was 0.4 (r=.37; p<.0001). Cost savings were calculated.

Here are the pictures:
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Intensive Outpatient Program (IOP) is not generally considered a medical level of care. In the ASAM criteria, it is a non-medical outpatient level that may or may not have medical care associated with it. In general for the field of addiction treatment, an IOP has a medical director who is responsible for ensuring that the admitting patient is healthy enough to engage in treatment and will not pose a danger to others in the group. In some IOP’s there is a consulting psychiatrist who can help with co-occurring disorders.

In the Townsend model, the Addiction Medicine doctor is integral as addiction is treated as a biological illness. The incidence of co-occurring diagnoses is lower because the biology of addiction, once treated, is normalized and symptoms of addiction that are generally seen as symptoms of other illnesses are suppressed. This level of medical intensity and medical integration with traditional treatment produces better outcomes but is more labor intensive and more expensive to maintain.

The current study suggests that at $1200 per ED visit and $2000 per hospital day, those patients who received treatment at Townsend were less expensive to their insurer for the next two years even when the cost of the original treatment was taken into account. As increased healthcare costs have been a marker for active addiction, this suggests that the more medically and cognitively intensive Townsend Model could be a superior treatment for addiction.

Lab Utilization and Abstinence Rates When Switching Monitoring Paradigms

May 11th, 2014

Traditionally, urine toxicology, or “tox screens” have been used in treatment of substance abuse patients. Also traditionally, there’s been no difference between the treatment of substance abusers and those suffering from the biological illness called addiction. If all you’re doing is “catching” substance abusers, the screens, usually provided by a point of care cup or dip, are sufficient. This is so, not because they are a sufficient technology, but because the inaccuracy of the tests don’t matter – it’s believed that the mere fact that you are testing is a deterrent to the patient’s resuming drug use. However, if you’re treating an illness, you need more than a “drug screen;” you need actual monitoring of the illness.

When we started our Intensive Outpatient Program (IOP), we contracted with a national lab for confirmatory testing of our point of care cups. They couldn’t get us the results fast enough or with enough specificity to make clinical decisions, so we tried a second lab. That lab had a lot of problems with customer service, patient billing and speed so we tried a third. When the third was no better we decided we needed to start a new company that could open the lab we wanted to use. So in 2011 we planned to open a lab that would be dedicated to everything an addiction treater wanted from a lab. We compared data on 602 patients in 2011, that were tested using point of care (POC) tests and confirmed by a national lab, with 1682 patients from 2012 that were tested completely at the new lab.

One of the outcomes we looked at was whether the last urine done in the program was consistent with adherence or not. If it is not, it is an indication that the patient had returned to using and left the program. We also wanted to look at our utilization of labs so we added up the tests done on each patient and divided by the length of stay in the program to give us the number of urines per day in IOP.

Comparing the old established national lab to our new lab we saw an increase in the percentage of patients who’s last urine was consistent with adherence with the new lab (p=.004) indicative of people getting abstinent and completing rather than continuing to use and leaving early:

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We also noticed that we ordered fewer tests per day of IOP, because we were getting back better actionable data and didn’t need to repeat tests while some were pending (p=.03):

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We think our outcomes are better with the new lab because turn around times were faster with the new lab enabling us to more quickly intervene with patients who had fallen out of adherence to the care plan. Because we got back answers more quickly, we were able to intervene faster, get people back to abstinence faster and have fewer extra tests.

It was a hard decision to open a new company. But it’s helped our care of patients. While our doctors have always had a choice of which lab to use, some insurance companies have recently made it mandatory that we use a national lab that is on contract with them. We’re gathering data on those cases as we go forward, but the average turn around time has been over 4 days from the national lab, instead of one day for Sagenex. When we get the results from the national lab our physicians have to creatinine adjust the values if positive and manually compare them to the last three tests the patient has had to see what the result is in the context of the patient’s past tests. That’s done for us by Sagenex. Then our physician has to use that information to determine if the result be it negative or positive is consistent with adherence to the care plan, in the context of the patient’s medication, or not. That’s done for us by Sagenex if we tell them the patient’s medication.

Since we designed Sagenex to be the best lab for professionals wishing to treat the biological illness of addiction, it has more customers now than just us and has grown quite well. Unfortunately, some insurance companies can’t see the value of having Sagenex on their panel even though it provides a better product. Hopefully that will change.