Can We Still Treat Addiction if Cannabis is Legalized?

July 27th, 2014

There’s probably two issues being talked about in addiction today more than any other. The first is the epidemic of opioid overdose deaths and the second is the legalization of marijuana by some states. I haven’t heard of anyone in favor of opioid overdoses so that has little controversy. The same cannot be said for legal pot.

One of the reasons for the controversy in this issue is that it’s really the amalgamation of more than one issue. The arguments I’ve heard both for and against have all been the conflation of arguments for and against four separate proposals. They are: legalizing marijuana for medical use (medical marijuana), local and state decriminalization of marijuana (decriminalization), state legalization of personal use marijuana (personal use legalization), and full federal legalization of marijuana (repeal of prohibition). The mixing and matching of these arguments adds to confusion. It isn’t uncommon, for example, for a person arguing for repeal of prohibition to use arguments for medical marijuana and be answered by the arguments against personal use legalization. In this case neither debater is actually debating the question they think they’re talking about.

Please understand, I actually am quite neutral on this issue. All I do is treat addiction and it’s just as easy for me to treat a patient using a legal drug as an illegal drug. I really don’t care one way or the other.

This was going to be a large opus listing all the pros and cons of the various proposals above, and it has sat in draft form for over a month, but time has gotten ahead of me. Two things have prompted me to wrap this up and put it out in a smaller form: the increasing negative health affects of synthetic cannabinoids and the recent editorial in the New York Times supporting repeal of prohibition.

Anyone who’s read my book or has followed my blog knows that I see addiction as a single illness. The effect of prohibiting a drug is to increase the cost (both economic and social) of using that drug. People with and without addiction will be incentivized to not use it, however people with addiction will just switch to another drug – unless we treat the illness. And make no mistake, cessation of drug use is not treating the illness; neither is putting people in jail. So prohibiting a drug, any drug, is not helpful to addicted patients.

But then I hear the arguments from colleagues “Repealing prohibition of cannabis will make it harder to treat addiction because people will claim they should still be able to smoke it like cigarettes.” I think that’s ridiculous. If you have to threaten your patients with legal consequences you probably don’t know how to treat addiction. If you aren’t addressing smoking as part of the illness, you probably don’t know how to treat addiction. Okay, I say to patients everywhere, “Maybe it is just like smoking cigarettes, and there’s good evidence that if you continue to pop your dopamine with cigarettes you’re more likely to restart the use of the thing you just went to treatment for. We’re not asking you to stop smoking and be miserable; we’re asking you to let us help you with medication and other treatments to improve the state of your illness so that your brain no longer wants to smoke.” I really don’t care that tobacco is legal; it’s not a good idea for someone with addiction to smoke. I don’t care that sugar is legal; it’s not a good idea for someone with diabetes to eat it.

So really, purely as an addiction doctor, I can’t say that repeal of prohibition would make my job any harder. Are there going to be social consequences? Quite likely. But I think society gets to make that choice, and does so, with all sorts of things. What society is doing when it says one drug is legal and another isn’t, is choosing the social consequences. All drugs have them, and democratic society has a right to pick which ones it will tolerate and which it won’t. I’ll never live in a society free from social consequences of drug use, so I’ll get used to whatever you guys choose. The real choice society hasn’t faced yet is whether we’re going to continue on this prohibition marry-go-round regulating one drug or the other while the disease goes undressed or if we’re tired of 50 years of a drug war and want to start actually addressing the illness.

And speaking on consequences, there’s one we should ask ourselves about concerning cannabis prohibition. THC is a partial agonist at the Cannabinoid Receptor Type I (CB1), that means that it turns on the receptor part of the way. Cannabis has been grown so that it’s more potent per gram than it was 30 years ago but THC is still a partial agonist, and cannabis still has more than THC in it. There are many cannabinoids in cannabis, and some may counter the effects of THC. It’s not completely known. But one thing is certain, it’s not like pot is a pure agonist at CB1, but the synthetic cannabinoids being marketed in convenience stores are.

With the rise of an internationalized world, chemists in the eastern hemisphere were able to synthesize an increasing number of pure full agonists at CB1 that are far more powerful than even the most potent cannabis out there. The first synthetic cannabinoids were the JWH compounds and after a couple of years they were made illegal. Before they even were, the chemists had the next set ready, and the next. We will never be able to make new chemicals illegal faster than scientists in another country can make new ones we’ve never heard of. On top of that, we can’t create confirmatory tests to use for these things at anywhere near the pace of their invention so we’ll always have people in treatment who are negative for existing tests even though they are using. That’s new, and that does make treating addiction harder. Now we aren’t dealing with a readily available partial agonist with known effects and a good way to track its use, but a range of unknown full agonists that are causing an increasing number of catastrophic health effects (this will be the next epidemic after opioids calm down).

So the question society needs to ask is this, “Would there be as much use of synthetic cannabinoids with the attendant psychosis, suicides, and homicides we’ve been seeing lately if cannabis itself were legal and regulated?” I won’t pretend for a minute that if we repealed prohibition that synthetic cannabinoids would go away; that genie is out of the bottle, but would there have been as much economic incentive to create these things if cannabis had been legal? We need to take a look at the second order costs of our decisions, and so far, we only look at the first order savings. We see there are problems with pot and we make it illegal to save those problems. Now we have bigger problems that we didn’t see coming.

The real problem is how we look at costs and benefits. We keep thinking that the choices for people are between using this bad thing and not using anything. That’s never been the choice. The overwhelming amount of drugs used are used by the few people who use a lot and those people, mostly, have addiction. For them not using isn’t an option without treatment and recovery, so the choice we are really making with prohibition is this, take legal risks and keep using this or go find something else. We might even like what they find (smoking cigarettes, over work, eating too much), but the disease, without treatment, just gets worse regardless of the social acceptability of the drug used. Whether pot is legal or not, the real question before is whether we’re ready to look at this disease the way it exists in nature and deal with it, or if we want to continue our half-century of delusion and continue to complain.

The Most Important Problem in Addiction

July 24th, 2014

A tweet I read led me to watch a video of chemists giving career advice. I don’t particularly need career advice from chemists, but clicked the link anyway. The tweeter, David Collum (@DavidBCollum), said in the video that he had been in a job interview and the interviewer had asked two questions. The first was, “What is the most important problem in organic chemistry.” Being young and wanting to impress, Dr Collum replied with something about genetics and biology. The questioner’s next question was this: “Then why aren’t you working on it?”

The interview gave me pause. What is the most important problem in addiction and am I working on it? I’ll tell you want I think.

I think the most important problem in addiction today is our society’s conceptualization of it as a behavioral diagnosis rather than a medical one. Because the diagnosis is behavioral, we assume everyone is normal before they use the first drug. That allows us to blame the formation of the illness on stupid behavior. That allows us to believe that we can prevent the illness by preventing drug use. That allows us to underfund treatment, aim at the wrong place for efforts at prevention, focus on punishment as deterrence, and fight the war on drugs. That’s another war we’ve spent billions losing.

If we didn’t have this conceptualization, we’d see the biology of midbrain dopamine and understand its genetic origins. Instead of focusing on prevention of drugs or drug use, we’d be doing early identification of people at risk. We’d be intervening early with kids who had lowered dopamine tone and improve their function so that, if they took a drug, it wouldn’t do anything. We’d save billions if not trillions, not to mention the lives that would go un-ruined and un-lost.

I’m glad to say, if anyone asked me the questions they asked Dave, I’d be able to say, “I have been.” But I can’t claim to have been very successful. I’m in contact with colleagues every day and even in those I respect a great deal I hear bits of the old thinking. I’m inpatient, I guess. On the other hand I meet young people in my field who get it.

Thomas Kuhn popularized the term “paradigm shift” in his book called The Structure of Scientific Revolutions. He didn’t say that paradigms shift because new information comes out or because everybody thinks it’s a good idea. He basically said that paradigms finally shift when the old guard retires or dies and the new guard takes over. Maybe if people with addiction would stand up a bit more, advocate for themselves a bit more, some of the old guard would retire faster.

Opioid Substitution Therapy: Measuring Impairment in a Clinically Relevant Population

July 23rd, 2014

Opioid Substitution Therapy: Measuring Impairment in a Clinically Relevant Population
J. Cameron Davis and Howard Wetsman MD FASAM

Abstract
Background: The CDC has labeled opioid overdoses an epidemic while treatment is readily available to those suffering. Current research indicates that the best treatment outcomes are in opioid maintenance therapies, yet such therapies carry a significant stigma; opioid maintenance therapy is impairing to patients. Methods: Measures of cognitive ability, the Iowa Gambling task (IGT) and the continuous performance task (CPT), were used to determine cognitive impairment in opioid maintenance patients before and after prescription buprenorphine use. Data was collected from a retrospective chart review of patients enrolled in a medically managed intensive outpatient program that uses frequent neurocognitive testing. Participants were 38 sequential opioid dependent admissions from August to December 2012 who both received buprenorphine and had both before and after testing. Results: A significant difference in IGT scores between the pre and posttest conditions was found with buprenorphine medicated patients having higher average scores than in the pre medication condition, F (74) = 10.74, p=.0016. Target accuracy on the CPT did not differ significantly in any of the time blocks between pre and posttests. A significant difference in foil accuracy was found between the pre and posttests in both the two second block, F (74) = 10.81, p=.0015, and the four second block, F (74) = 5.41, p=.0228 with medicated patients showing improvement over their pre-medicated condition. Conclusion: Evidence from this study does not support the currently prevalent idea that introduction of buprenorphine opioid maintenance treatment will impair patients. This has tremendous implications for buprenorphine maintenance therapy demonstrating that reward overvaluation and impulsivity both decreased after the introduction of prescription buprenorphine in a clinically relevant population. The research also supports the subjective report of opioid dependent maintenance patients that they actually function better when prescribed buprenorphine.

Opioid substitution therapy: Impairment
Opioid dependence is a fast rising cause of death, with opioid overdoses reaching epidemic status(1). In spite of this, treatment is readily available and can help opioid dependent individuals. Risk of relapse following opioid withdrawal is common, and “detox” alone does not count as satisfactory treatment for opioid dependence(2). Best treatment outcomes are in opioid maintenance therapies(3). Unfortunately opioid substitute therapy still carries a significant stigma.
Opioid maintenance therapy in the form of methadone has been available since the 1960’s, but requires a large infrastructure under current law. Recently, maintenance has also become available in the forms of buprenorphine, which specially licensed physicians can prescribe in an office based setting. While this increase in treatment options is welcomed, buprenorphine is a largely underutilized treatment. In contrast, there has been an overall increase in full opioid agonist pain treatment. This has been accompanied by a 63 percent increase in opioid deaths from 1999 to 2004 according to a 2007 national survey on drug use and health(4). This calls for a reevaluation of the stigma surrounding opioid maintenance therapy and a need to use the best therapy available.

Methadone
In spite of its good record as treatment, there are other problems with methadone. Pud et al. (2012) reported that methadone maintenance patients experience pain, depression, and sleep disorders, which disrupts their general state of health and well-being(5). Methadone has also been found to be impairing. Mintzer et al. (2002) researched psychomotor and cognitive performance among methadone maintenance patients(6). Assessed on a broad range of performance tasks; methadone patients exhibited impairment relative to controls in five out of eight tasks. Methadone maintenance patients are also significantly more likely to make risky decisions when they had been unsuccessful on the previous trial(7). Such disruptions further hinder the success of rehabilitation.

Buprenorphine
Buprenorphine has been approved because of the need for a new maintenance treatment with fewer drawbacks. Buprenorphine is a semi-synthetic opioid approved by the Food & Drug Administration in 2002 in the forms of ‘Subutex’ and ‘Suboxone’ for treatment of opioid addiction. Buprenorphine is a partial mu opioid agonist and kappa antagonist utilized as an effective treatment of opioid dependence (8,9,10,11,12,13). There are many additional benefits such as effectiveness in treating neuropathic pain, having a ceiling effect on respiratory depression, mild withdrawal symptoms, less physical dependence, and less cognitive impairment compared to other forms of treatment(14). Buprenorphine has been increasingly replacing methadone maintenance because of its lower risk of abuse, side effects, and its ceiling effects for respiratory depression.
While numerous studies have compared the impairment of buprenorphine to methadone, with most research finding buprenorphine less impairing than methadone (15-25) there is an ongoing perception among those who treat addiction that buprenorphine is an impairing opioid. Soyka et al. (2005) compared both treatments in a randomized study of drug dependent patients and found that buprenorphine was less impairing on cognitive functions than methadone in a driving-related battery(26).
Unfortunately, a cursory perusal of the literature tends to confirm the perception of buprenorphine as impairing, because most confirming studies used strictly healthy volunteers. MacDonald et al. (1989) examined the psychomotor effects of buprenorphine in 12 healthy male volunteers and found it caused significant psychomotor impairment on seven out of eight psychomotor tests(27). Effects peaked at four hours post-dose and were still apparent eight hours later. Similarly, Zacny et al. (1997) cited buprenorphine as increasing impairment on subjective and psychomotor performance measures compared to equianalgesic morphine. The impairment was found in a study examining 16 subjects without history of opiate dependence(28). This evidence supports what is known about the opiate buprenorphine. As opioid dependent persons generally find opioids stimulating rather than sedating, these two studies are not applicable to a clinical population.
To further the understanding of buprenorphine impairment Mintzer et al. (2004) evaluated dose-related effects of repeated administration of buprenorphine/naloxone sublingual tablets in opioid dependent patients. Results revealed minimal impairment in performance as dosage increased. The only significant effect was impairment in episodic/long-term memory at the highest level of buprenorphine (32/8mg) (29).
Additionally, research indicates that long term buprenorphine maintenance does not cause impairment to those undergoing treatment. Shmygalev et al. (2011) studied the impact of long-term maintenance treatment by comparing 30 patients utilizing sublingual buprenorphine treatment with 90 matched controls. Three control subjects were used on each buprenorphine patient with subjects matched for age and sex. They were tested for driving ability using the Vienna Test System and showed no significant cognitive deterioration. Patients receiving a stable dose of sublingual buprenorphine showed no significant impairment of complex psychomotor or cognitive performance compared to healthy controls (30).
Stable doses are only present in laboratory studies, whereas in a clinical atmosphere a patients prescription will change or they may forget to medicate. Singhal et al. (2008) cited that buprenorphine maintenance patients often abuse the drug by taking additional doses over and above the maintenance dose. To examine the impact this might have on psychomotor performance, they studied 19 subjects maintained on buprenorphine and administered the maintenance dose followed by three additional doses at two-hour intervals. Subjects completed a psychomotor performance battery following each administration. Performance on Digit Symbol Substitution Test and Trail Making Test-A and B improved significantly with each assessment, while other tests remained unaffected (31). Buprenorphine dose increase has no effect on impairment. Other possibilities could explain the presumption of buprenorphine “abuse.” For example, patients could be under-dosed because of the sedating stereotype of the opiate and therefore perform better once closer to their effect dosage.

Naltrexone
Another popular treatment method for opioid dependence is naltrexone maintenance; approved by the Food and Drug Administration in 1984. Naltrexone, unlike methadone and buprenorphine, is an opioid antagonist or blocker and cannot induce any euphoric drug-like effects. Messinis et al (2009) compared the neurophyshological functioning of 18 buprenorphine maintenance patients, 32 naltrexone maintenance patients, and 34 healthy controls. The results indicate that there were no significant difference in any of the cognitive measures between the buprenorphine and naltrexone groups or between the naltrexone group and controls. Yet, the study cites buprenorphine to have performed more poorly than controls on conceptual flexibility, executive functions, encoding and delayed recall of verbal and visual information(32). This study’s conclusions are questionable because the authors find no difference in impairment between buprenorphine maintenance and naltrexone, while they also claim that naltrexone is less impairing. Moreover, Minozzi et al. (2011) reviewed 13 studies of naltrexone versus placebo or other treatments. The analysis inferred the studies conducted have not been all-encompassing enough to adequately evaluate naltrexone for treatment of opioid dependence (33). In spite of the lack of evidence there are still advocates for naltrexone maintenance therapy as a less impairing alternative to buprenorphine.

Missing from the literature is a clinically relevant comparison of buprenorphine maintenance patients versus those treated with naltrexone or with those not treated at all. Extended evaluation of this comparison may indicate which treatment leads to lesser degree of impairing effects. Choosing a treatment plan that is both effective and does not sacrifice cognitive abilities could lead to more people completing treatment and more people seeking treatment because of a higher success rate. Many clinical and laboratory observations have hypothesized that the primary neural substrates of persistent compulsive drug use are long-term associative memory processes involving multiple neural circuits that receive input from midbrain dopamine (34). In a naturalistic clinical setting, we examined the outcomes from two common cognitive testing measures associated with dopamine tone yet to be used to measure function of buprenorphine maintenance, the continuous performance task (CPT) and the Iowa Gambling task (IGT). If the common presumption of buprenorphine as impairing is correct, this should be evident in before and after measures of these tests.

Method

Participants
Data was collected from a retrospective chart review of patients enrolled in a medically managed intensive outpatient program that uses frequent neurocognitive testing. As an anonymous retrospective chart review, the research was granted exempted status by Crescent city IRB. The participants were 38 sequential opioid dependent admissions from August to December 2012 who both received buprenorphine and had both before and after testing. There were 21 males and 17 females. To evaluate the effects of buprenorphine and not other medications or other aspects of the program, only the tests directly before and after being prescribed buprenorphine were examined.

Materials
Cog Testing: Iowa Gambling Task & Continuous Performance Task
Measures of cognitive ability: the Iowa Gambling task (IGT) and the continuous performance task (CPT) were used to determine cognitive impairment. The testing occurred on a desktop computer in an undisturbed room at the treatment center using the freeware PEBL.
The IGT is a card task that measures reward overvaluation (35). The goal of the task is to win as much money as possible in 100 trials picking from four possible decks. Each participant starts with a $2000 loan. After each card selection, a reward and a penalty are given to the participant. The reward depends on the deck you choose, while the penalty is different for different cards in the deck. Graphics at the bottom of the screen display the earnings or losses acquired. The IGT is a measure of reward overvaluation, a hardwired symptom of low dopamine tone (36). Those with reward overvaluation also initially sample all of the decks, but then go on to lose money. Reward overvaluation caused by low midbrain dopamine tone occurs when rewards are overvalued and risks unrecognized.
The CPT is a go/no-go task measure of attention and impulsivity. Using the letter “X” as the non-target stimuli and all other letters as target stimuli; responses were recorded using the spacebar. Over a 14 minute period the letters cycle through three distinct intervals between letters: one, two, and four seconds. The goal of the test is for the participant to respond as quickly and accurately to target stimuli, while not responding to non-target stimuli. The major variables the CPT produces are target accuracy, foil accuracy, and reaction time means for correct & error responses. Target accuracy accounts for the rate at which the participant correctly responds to the target stimuli. Foil accuracy accounts for the rate at which the participant correctly did not respond to non-target stimuli. Mean reaction time measures the average amount of time between presentation of the stimuli and the participants’ response at that interval. These measures are calculated for each block (1, 2, & 4 seconds) of stimuli.

Procedures
The IGT and CPT were given together by an administrator. The administrator led each participant into an undisturbed room and seated them at a desk with a computer monitor. The administrator then opened the testing program PEBL, explained the gambling and impulsivity testing about to take place, and exited the room as the participant began. The testing lasted about 25 minutes on average. After each testing session the administrator recorded the results. Participants were tested at the very beginning of the treatment program, after symptom scores stabilize and/or change in medication, and upon discharge from the program.

Results
A one-way within subjects ANOVA was conducted using the software JMP to compare the effects of buprenorphine on IGT and CPT scores. A significant difference in IGT scores between the pre and posttest conditions was found with buprenorphine medicated patients having higher average scores than in the pre medication condition, F (74) = 10.74, p=.0016.

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Target accuracy on the CPT did not differ significantly in any of the time blocks between pre- and post-tests.

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A significant difference in foil accuracy was found between the pre and posttests in both the two second block, F (74) = 10.81, p=.0015, and the four second block, F (74) = 5.41, p=.0228 with medicated patients showing improvement over their pre-medicated condition. No statistically significant difference was found for the one second block.

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Discussion
Using tests close together allows examination of the impact of the drug while minimizing the benefits of the additional addiction therapy. The practice effect was not a factor because the pre drug test was not the first time all of the participants were tested.
The IGT is a measure of reward overvaluation, a hardwired symptom of low dopamine tone. Reward overvaluation occurs when rewards are overvalued and risks unrecognized. The magnitude of motivation positively correlates with the incentive salience of reward-related cues and the reward itself (37), thus allowing the behavioral mechanisms to be carried out to fruition without regard for any impediments or distractions. If reward overvaluation can be decreased even an impulsive patient will at least not be impulsive with the same dangerous behaviors as before. The data support that buprenorphine maintenance treatment does not worsen reward overvaluation. This has tremendous implications for buprenorphine maintenance therapy demonstrating that buprenorphine in a clinical population does not impair this executive function.
Similarly, low foil accuracy on the CPT is related to decision-making impairments: impulsivity and inattention (38). A normal brain, when given more time, will take more time to notice the “X” and increase accuracy. A brain with low midbrain dopamine will, instead, speed up in an attempt to speed up the computer. The data are supportive of the thesis that impulsivity and attention are not worsened with buprenorphine treatment.
Generally, target accuracy is used as a proxy for attention, but it has been noted by us that only severely impaired patient or patients who do not understand the directions score less than 90% accuracy; rendering this statistic of questionable use to the study question. Target accuracy was examined only to confirm the integrity of the testing.
In summary, reward overvaluation and impulsivity did not worsen after the introduction of prescription buprenorphine in a clinically relevant population. Evidence from the current research does not support the currently prevalent idea that introduction of buprenorphine opioid maintenance treatment will impair patients. The research may also lend support to the subjective report of opioid dependent maintenance patients that they actually function better when prescribed buprenorphine.
Limitations of the current study include the small sample size and the geographical constraints of using an outpatient facility. Both of which are factors that deserve attention in future replication of this research.
Anecdotally other addiction patients, outside of this study, at the same facility indicated feelings of frustration intolerance during the CPT and during the long (4sec.) block. They began to answer rapidly to try and “speed up the test” to no avail. Future research would benefit by looking at the implications the CPT may have on frustration intolerance in clinical populations. Also future studies could further investigate the relationship between genetics, testing, and dopamine and serotonin levels on reward overvaluation to better pinpoint at risk genotypes.

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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):

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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):

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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.