Actions and Intentions

April 18th, 2014

Most recovering people learn early on that “We judge ourselves by our intentions, but the world judges us by our actions.” It can be a harsh lesson whether we have addiction or not, and the phenomenon isn’t limited to addicted people. In fact, it isn’t even limited to people.
Groups have intentions too, and need to learn the same lesson.

The specific group I’m referring to here is the addiction treatment community, and I want to give you an example to start this discussion. I’m on an email list serve for a group of addiction medicine specialists who believe in psychosocial treatment, especially the application of 12-step philosophy, in addiction treatment. The other day, one of the members asked this question of the group, “I have a patient who is a few months sober. Does anyone have any recommendations for medications for cocaine craving?” There were quite a few answers, most mentioning baclofen or Anti Epilepsy Drugs (AEDs), and one mentioned modafinil. This would be expected from any group that was reading the addiction treatment literature as all these things are being studied now. There was also quite a few “nope, nothing” answers that would also be expected from doctors reading the current literature, because all the medicines are listed as experimental maybes for cocaine dependence.

The idea behind this, that there is no medication helpful to the addicted person using cocaine, is an old one. It doesn’t stem from any bad intention of our field towards addicted people; it stems from the sense of hopelessness that came from treating addicts when cocaine first gained popularity back in the 80′s. At the time, no one knew how cocaine worked. We didn’t know of any other medications that could either counter or replace it. We weren’t even sure if cocaine users were addicts. It’s hard to remember those times, but like the woman who is still cutting the end off her brisket because that’s how she learned to do it (grandma has a short pan), our field is still dominated by this sense of hopelessness when it comes to cocaine. And how are we doing? Not real well.

This is odd to me, because long before Suboxone became the first addiction super med, I’d been using what I thought of as the first addiction super med. It worked, and still does, on people with addiction who use cocaine. It’s Wellbutrin XL or any long acting form of bupropion. Why don’t we use it more? Several reasons of economics, politics, and academic bias, but in short, because it’s labeled as an anti-depressant. This is not an add for Wellbutrin, the medication is just an example. What I’d like to highlight is the pattern of the answers to my colleague’s question, and what that shows about our intentions and our outcomes.

No one asked him anything about the patient. Addict, cocaine cravings, that’s all anyone needed to hear. In our DSM world, that’s all we need, because cocaine dependence is different from dependence on other drugs. In the non-DSM world I live in, the neurobiology and mapping symptoms to drug use is critical. A pre-drug history of primary addiction symptoms is often quite helpful in determining if the patient is Type I or Type II, or a Type I who has become Type II, and therefore how to treat. We find that genetic testing is also helpful in refining our medical treatment algorithms. But I can’t find any fault with my colleagues’ intentions; they all want to end this scourge and do the best they can for our patients. The academics and government types they learn from all want the same thing as well, no doubt. It’s not the intentions I can find fault with, but how are the outcomes?

When we compare our experience with our neurobiologically based algorithmic approach compared to those patients in our treatment center who get medical advice from outside, we see a big difference in ability to stay in treatment and in cognitive change towards recovery. For cognitive change measures we use our proprietary Disease Acceptance Score which measures a person’s progress in treatment and directs the specific cognitive intervention they need to move to the next stage. In 279 consecutive admissions, 39 patients chose to get their medical advice from outside our treatment program. Here’s the difference at admission between the groups (p=NS):
Screen Shot 2014-04-18 at 8.47.37 AM

You can see that the group that didn’t see the doctor in the program actually started a bit higher on the Disease Acceptance Scale, mostly because many of them came to us for IOP as step-down from a residential or inpatient treatment. Here’s how the two groups differed at discharge (p<.0001):
Screen Shot 2014-04-18 at 8.49.15 AM

Yeah, but does our DAS mean anything? Yes, we have data that shows the DAS predicts the number of hospital days per 100 days after treatment out to two years after discharge. That’s a pretty good proxy for sobriety and health. I’ve written about the methodology elsewhere. Here’s the picture:
Screen Shot 2014-03-30 at 12.16.21 PM

We need to be looking at outcomes. The world has changed in the last few years. ASAM has a new definition, parity has occurred, and the ACA has made addiction treatment an essential health benefit, and we’re about 15 years out from the Decade of the Brain. We can’t hide behind our intentions anymore; this is an illness and intentions don’t matter. Ours don’t matter and the patient’s don’t matter. It’s a real illness that responds to real treatment, and the only thing we’ll be judged on is our actions – and, of course, the outcomes that derive from our actions.

Motivation and Addiction Treatment

April 15th, 2014

It’s long been held that motivation is important in addiction treatment. In fact, a recent article in JAM underscored this well. “Motivation as a Predictor of Drinking Outcomes After Residential Treatment Programs for Alcohol Dependence” by Bauer et. al. controlled for several other factors and found a moderate, statistically significant, predictor effect for pre-treatment motivation in the 1 year outcomes concerning alcohol. This could be seen as further confirmation of what we already know, but I wonder if it really is.

Let’s think for a minute about what it means that motivation for an outcome effects the outcome of that treatment. Remember, we aren’t talking about whether or not the person did the treatment; they controlled for that. We aren’t talking about how well the person did in treatment; they controlled for that. What we’re talking about is a cognitive attitude a person has before treatment affecting the outcome a year later. That’s just odd if you’re talking about a disease. Do people with strep throat have relapse after penicillin treatment if they weren’t motivated when they took it?

I can understand that someone’s motivation for doing the treatment would have an effect, because it would effect their doing the treatment. If I’m not motivated to take my penicillin, I might not take it, and because I don’t, I won’t have as good an effect. But in this study, all the patients were in inpatient treatment, and they controlled for self-efficacy at discharge. These people all got the “gold standard” inpatient non-medical treatment of choice for addiction. And still their motivation for the outcome affected the outcome. While this result is being touted by some inpatient treatment providers, it’s actually fodder for those that what to say addiction isn’t an illness and treatment is nothing medical and not worth paying for. That would be unfortunate.

The problem is larger than this one study though. We have motivational interviewing and motivational enhancement therapy and stages of change. Our whole field is viewing motivation to be the in thing. And when you look underneath, what are we talking about? It’s never motivation to change who we are, only motivation to change what we do. We focus so much on a behavior we forget we’re dealing with a person.

The point of the Bauer study for me is, if I go to a treatment focused on my stopping drinking and not my biological brain illness, I won’t be changed when I leave as significantly as if it were the other way around. I might very well stop drinking, but will I start overeating? or smoking more? or taking bigger risks in business? or over working? Does my addiction get better, or just my drinking?

Townsend developed the Disease Acceptance Scale (DAS) because traditional addiction treatment can’t tell you how far you are into treatment or what you need at any given point. It’s mostly just everyone gets the same thing, and some do well, and some don’t. That doesn’t work well when you’re treating illness. So where does motivation come in? Well historically, the field has loved motivated people, people who have lost enough and been through enough to already want what we have. And if you’re in AA helping newcomers for free, that’s great. But people who get money for treating an illness should do more.

It’s easy to motivate people. Think about a kid who doesn’t want to do homework. We can bribe him to do homework and get it done. Afterwards we’ll have the homework done and the same kid we had before. What’s the likelihood he’ll do his homework on his own next time? Instead of motivating someone towards a behavior, treatment should be transformative. We need to change the person to become someone who is intrinsically motivated to do the right thing, rather than motivate someone to do the right thing without changing. That’s what the Townsend Way (based on the DAS) does; it helps people change to become intrinsically motivated.

If Bauer et al ever study our system, I’d be appalled to find out that someone’s belief at day one was still operational a year later. I’d see that as a failure on our part to help the person change, not a reason to trumpet our method of treatment.

Effect of a Proprietary Method of Scoring Disease Acceptance in Addicted Patients on Predicting Future Healthcare Costs

April 11th, 2014

Abstract: 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 as long as 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 were contacted and data gathered on emergency department (ED) visits and hospital days since discharge from treatment. The mean number of days since discharge was 533 and the maximum was 730, minimum was 126. 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. The remainder did not complete the program. All patients were included in this analysis. Clinical records of each responding patient where polled for their Disease Acceptance Score at discharge (DCDAS). DCDAS predicted the number of ED visits per 100 days since discharge (r=.25; p=.01) and the number of hospital days per 100 days since discharge (r=.7; p=.01). DCDAS was predicted by the number of sessions the patient attended (r=.35; p=.0003). Cost savings per additional session were calculated.

Introduction: There have been several studies showing that addiction treatment saves social costs and medical costs. These studies have been done by government agencies and insurance companies, but there has been no identification of exactly what it is about treatment that works to save costs. Most treatment for addiction in America today is either 12 step oriented or manualized therapy (CBT, DBT, etc). Even with manualized therapies, it is hard to objectively grade where someone is in a treatment process. The Disease Acceptance Score was developed to create an objective measurement to drive treatment from day to day and to determine when someone no longer needs professional intensive treatment. It has been useful in determining treatment plans and this study is an attempt to see if DAS at discharge can predict post discharge healthcare costs as a proxy for recovery and healthy living.

Disease Acceptance Score: The DAS is a proprietary measure of Townsend that we use to follow people from the beginning (active addiction) to the end (voluntary recovery) of treatment. The score is graded from 5 to 20, with 17 being a minimum for voluntary recovery and the end of the professional treatment phase. Rather than have the psychosocial aspects of treatment be one size fits all, we use the DAS to determine who needs which intervention at which time. Each score has unique interventions that have been developed and tested to bring about progress to the next score. In this way we aim at small serial improvements rather than a single large move to recovery.

Methods: Phone calls were made by a bank of treatment center employees whose job it is to follow up on patients who have been treated. They were instructed to call former patients insured by the payor starting with those admitted two years prior until they received answers from approximately 100 patients. 205 attempted calls were made. The total number of patients in this study exceeds 100 because six called back to give data after the single attempt at contact was made (52% response rate). Each patient was asked to recall the number of ED visits and the total of hospital days in as many stays as they have had since discharge. Clinical staff with access to patient records were asked to retrieve discharge date, discharge status, and discharge DAS from each patient’s treatment record. As this analysis was done in order to examine a measure of quality for our quality improvement program, no IRB approval was attempted.
Data was collected manually and placed into an excel spreadsheet by a supervising member of staff and quality checked by another. The Excel spreadsheet calculated the rate of ED visits and hospital days per 100 days since discharge from the available data. The author did the statistical analysis using JMP software.

Results: Days since discharge did not correlate with either the number of ED visits or the number of hospital days since discharge. Measures of ED visits and hospital days per 100 days were derived and were analyzed against DCDAS. Figure 1 shows the correlation between ED visits and DCDAS (EDVisits=.29-.02*DCDAS):
Screen Shot 2014-04-11 at 5.26.34 AM

and figure 2 shows the correlation between hospital days and DCDAS(Hospital Days=4.9-.26*DCDAS):

Screen Shot 2014-04-11 at 5.28.13 AM

Figure 3 shows the correlation between sessions attended and DCDAS (DCDAS = 10.61+.18*Sessions):
Screen Shot 2014-04-11 at 5.30.26 AM

Substituting sessions for DCDAS gives us:
ED Visits per 100 days since DC = .29- .02*(10.61+.18*sessions) or =.08-.004*Sessions. Using $1200 per ED visit and $250 per IOP day we can see that for every $250 of investment in the patient’s care, $3.10 of ED care is saved per 100 days after discharge. Similarly, Hospital visits per 100 days since DC = 4.9-.26*DCDAS or =2.14-.05*sessions. Using a cost of $1500 per hospital day and $250 per IOP day we can see that for every $250 of investment in the patient’s care, $69.40 of hospital cost is saved per 100 days after discharge. This total savings from these two sources is $72.5 per 100 days or $265 per year per each $250 invested in the patient’s care.

Discussion: This represents a first validation of the DAS. As it has remained proprietary we have not put it out for the usual standardized validation testing that any new scoring system would receive. However this study shows that a number, decided on by the treatment team, predicts measures of healthcare utilization up to two years into the future. This may also provide some validation for the larger Townsend Model of combining intensive medical interventions with recovery oriented psyhosocial treatment.

Weaknesses: One weakness of this study is the sampling. We did not make second efforts to contact patients. We made one call and left a message if we could not talk to the patient on the first call. Another weakness is that this has not been peer reviewed, but that is the purpose of posting it here. Anyone wanting to review and comment is welcome and I will make changes and respond to comments as they come in.

Back in the day…

March 30th, 2014

Back in the day, when I was in medical school, I learned to do bedside lab testing. We’d get the patient’s urine and use a dipstick to read the pH, the specific gravity, and a bunch of other things. The dipsticks were a really cool technology, so many tests on a single stick. There was a bit of a problem with interpretation though. We’d show each other the sticks and try to match the colors up to the reference blocks on the bottle. We’d disagree about which color it was and try to figure out if the specific gravity was 1.01 or 1.015.

The dipsticks weren’t the only thing we did with bedside diagnostics. We did our own “heme-occult” testing using a card and some reagents that came in a dropper bottle. We’d get the patient’s sedimentation rate by taping a capillary tube of their blood to the wall. We even took blood smears and did our own blood counts. Ah, the old days.

But all those things are gone now in modern medicine, and that’s a good thing. Rather than having a lab test depend on my ability to read colors or whether or not the bottle sat in the sun and got bleached, the same urine is sent to the lab for an objective machine to test. Doctors don’t read their own “heme-occult” tests or measure see rates with a ruler either. I guess we figured that with real disease, real diagnostics were better than bedside guesses. I’m glad I know how to do those things if we ever have to face the zombie apocalypse and the break down of civilization, but until then, it’s definitely better that our doctors are sending our samples to the lab. And that’s the way it is in modern medicine, except in one place, the one place that care for the accuracy of testing doesn’t seem to have reached, the one place where real disease doesn’t need real diagnostics. I’m referring, of course, to addiction, or as it’s misnamed, “substance abuse.”

That name probably explains exactly why no one seems to be worried about accuracy. They are, after all, just substance abusers, not real patients with a real illness. The point of the test is to catch them doing something bad, not get a result a doctor can use. Boy, talk about the old days.

It’s been a decade since the “decade of the brain,” and we’ve learned a lot about addiction. We’ve learned that substance abuse and addiction are not the same thing. We’ve learned that addiction is a real illness with real treatment. We’ve learned that if we want to treat addiction in an outpatient setting we need frequent monitoring for adherence to the care plan. We’ve learned that using inaccurate monitoring leads to loss of credibility and decreased adherence. We’ve learned about that inter-rater reliability reading urine cups is abysmal. We’ve learned a lot as a field, but unfortunately, not all we’ve learned has been absorbed by all who are in the field.

I used to use cups in my practice and staff would read them. We’d send all the positive off to be confirmed. The cups were set up in such a way that if the test was positive the color would disappear from a line on the front of the cup. I remember hearing from counselors, “That lines very faint. It’s almost positive. I bet he used,” or “I can almost see the line. I bet it’s negative.” Needless to say, that wasn’t very accurate. We asked the lab to whom we were sending the positive to do a study comparing our reading with what they got from the urine. We were missing 40% of the benzodiazepines, 35% of the barbiturates, 17% of the cannabis, and a whopping 48% of the cocaine. Well, you might say, “innocent until proven guilty” so no problem, but I’m not judging people, I’m treating an illness. Not knowing that the patient used in an important piece of information that can lead me to change the care plan. If he’s using cocaine and I don’t know, I might keep trying something that isn’t working or might actually hurt him.

In addition to that, missing some positives isn’t the only problem with the cups. We had a high false positive rate on amphetamines (57%), oxycodone (23%) and MDMA (92%). So we were spending more insurance money confirming tests that weren’t actually positive. and. even worse, the treatment team was sitting with “knowledge” of a positive for days waiting for the confirmation to come back. You can tell counselors nothing is positive until it’s confirmed all you want, but it’s kind of like telling the jury to disregard the witnesses statement. People are human; it can’t be done. And that “knowledge” affects treatment negatively. It erodes the trust bond, it erodes confidence in the treatment, and we found it eroded retention in treatment.

So what we do now is send the urine to a lab where they use a more accurate screening technology and confirm the positives the way they did before. So we do less confirmations, the treatment team doesn’t see erroneous results, and the patient doesn’t have his faith in the team eroded by false positives.

But, you might say, “Those cups only cost a few dollars and the lab tests cost a lot.” Yeah, the lab does cost more, but only in addiction treatment would we look at cost instead of value. When it comes to treating addiction people never seem to see the value in the treatment. After all, it’s just talking to a bunch of substance abusers, so each treatment is the same as any other. Sounds like the only way to improve things is to make them cheaper. Well, if you don’t know anything about addiction, you might think that way.

In our addiction treatment program everyone has exposure to the same core curriculum, but everyone’s treatment is customized to where they are in the recovery process. We have a proprietary measure called the Disease Acceptance Scale that shows where the person is in their cognitive change and what, exactly, they need to make the next stage. We have a sophisticated medical algorithm that helps the doctors choose medications specifically for each patient as opposed to “alcoholics get Campral” or some other substance based method. The algorithm is based on the known neurobiology of addiction, and we use computerized neurocognitive testing to evaluate whether a medication is helping or not. We also understand the biological power of a recovery program so our goal is not to “cure” the patient but to get him to the point where he will maintain recovery voluntarily. This is key with a chronic relapsing illness such as addiction.

Do we do this perfectly? No, not yet; maybe never. But our goal is not perfection, just progress. If we continue to look at our outcomes and change our system to create better outcomes, we’ll be on the right track. One of those changes has been to stop using the urine test cups for screening. Our doctors can order their patient’s samples sent anywhere they want, but the lab that most of them use now provides a better screen with fewer confirmations, faster turn around time, and a sophisticated medical interpretation with the result. Not that positive-negative as an answer isn’t somewhat helpful, but what a treating physician really wants to know is, “Did he use since the last test?” This requires not only the daily work in the lab to ensure that the testing is accurate, but also requires correction for hydration states and having a knowledgeable physician review the past as well as present test and interpret it in the context of the history and the patient’s medication. It’s a real time saver for the treating physician.

Something’s Wrong

March 24th, 2014

There’s something desperately wrong in how we treat addiction in America, and I’m sad to say that I think it’s gotten worse in spite of having more information now than ever before. The traditional method has been to see addiction as substance abuse, and substance abuse as stemming from some conflict or misunderstanding on the abuser’s part requiring only a good talking to or at best an protracted stay away from like thinking individuals. In this old model, the abuser must be ready to change, and there’s very little we can do to make that happen.

Now to be honest there have been some improvements in this model. There’s been motivational interviewing and the stages of change, person centered treatment, and others. These person centered approaches have even lead to acceptance of methods of harm reduction while recognizing that not all substance abusers are at a stage at which they want to stop, precluding abstinence as a treatment goal. I find it odd that the same fallacy underlies the thinking of those who advocate for a non-medical abstinence based approach and harm reduction models. They’re like two baseball players arguing with each other about who gets to play first base without realizing they’re standing on a football field. They aren’t even in the right game.

Here’s the fallacy: substance abuse and addiction are the same thing and the only biological problems are those caused by drug use or co-morbid disorders. We haven’t hit many home runs with this idea, and, in fact, we’ll never even make it to first base.

I hoped this was going to get better when we started Townsend, because I thought people would see our outcomes and want to be as successful. I thought this was going to get better when they said DSM 5 would use the word addiction. I really thought it was going to get better when ASAM published its definition of addiction pointing out that it is a primary illness that one can be born with and encompasses more than drugs and alcohol.

I started to worry when it became clear that DSM5 wasn’t really going to change much at all. I really worried when ASAM’s new edition of the ASAM criteria ignored it’s own definition in favor of DSM5′s fantasy. Now I’m really worried when I see the response of insurance companies to the Affordable Care Act.

Before the ACA, having coverage for addiction treatment wasn’t normal. If you had it, you paid extra. Since this was a profit center for the insurance companies, they seem to have wanted to provide the best treatment possible to attract those that could pay for the extra care. The ACA mandates “Substance Abuse Treatment,” so there doesn’t seem to be any point in charging extra for care thats any better than traditional psychoeducation treatment. So, that may be all anyone will ever get. The idea that this is a medical illness requiring a doctor’s care for primary symptomatic treatment is probably gone. The idea that the medical care and the cognitive change in primary treatment be brought together for a better outcome may be something reserved for those well off enough to pay without insurance benefits.

I hope this isn’t true. I hope these few months have just been insurance companies worried about what’s happening and not knowing what to do. I hope the world will calm down and the people in charge will look at the numbers. If they do, they’ll see there’s a better way to treat this primary biological illness, a way that will save them money in the long run. Speaking of numbers, here’s some, or rather a picture of numbers. Since Townsend started we have offered over 1700 patients genetic testing and covered the cost ourselves, because we thought is was that important. I recently had a look at a small consecutive sample of recent patients who were tested. You’re probably thinking, “What’s a small sample going to show? Genetic studies have huge samples in the 10s of thousands.” Yeah, that’s true for tests where they don’t know what they’re looking for, but we’re using a sophisticated model of the neurobiology of addiction and have specific targets. That allows us to look at them one at a time. If they really have a large effect we should see it in a small sample. Other, more subtle targets may need bigger samples, but this one didn’t.

So back to the numbers. The sample size was 37, 35 of which had genetic testing data for the polymorphisms that we use to model this target. The missing two had no information for some of the polymorphisms so they couldn’t be modeled. The model takes the polymorphism inputs and determines function of a certain protein that is necessary for normal function. If the person has normal function at this protein they don’t need treatment at this target. If they have abnormal function, they do. The percentage of people in our population who have abnormal function at this target is much higher than in the general population, so it’s logical that it affects addiction.

Because of personal choice, some patients who were offered treatment for this abnormality didn’t take it. Here’s what the difference was.
100% of the 3 people who were normal in this function finished the program. 80% of those who needed treatment at this target and accepted it finished the program. 12% of those who needed treatment and didn’t accept it finished the program. Here’s the picture:

Polymorphism Treatment

What’s going to happen when people who need this genetic function improved go to traditional substance abuse treatment? There’s no genetic testing. Reimbursement for this kind of treatment isn’t high enough for the provider to pay for genetic testing. There’s not much integrated medical care and even less aimed at addiction symptoms as primary. What happens is that fewer people will make it through treatment, leaving the old revolving door phenomenon. It will actually cost the insurance companies and society more than they would pay if we had medically integrated treatment (a level that doesn’t even exist in ASAM’s criteria by the way).

I’m not losing hope; we’ll still be here giving the best we have. But with recent changes, it concerns me that our original mission of democratizing the best treatment possible may have just hit a speed bump. With everyone seeing “substance abuse treatment” as enough, the mandate may give cover to those who don’t want improvement to hide behind. Rather than use the last 2 decades of neurobiological advances, we’ll be stuck with medicines prescribed by the drug of abuse rather than the underlying problem that the patient has. This hasn’t worked well. The war on drugs hasn’t worked well. There’s a better way. Look for #betterway on twitter to see more.

Response to NYT Articles on Buprenorphine

November 19th, 2013

I thought about writing my own response to Deborah Sontag’s well written articles on Buprenorphine:

But I’m starting to see that others have beat me to it so I’ll just list a couple of responses here. But of general note are a couple of points:
1. Ms Sontag wrote well thought out pieces, but the editors wrote the headlines which are much more negative about buprenorphine than the pieces themselves
2. MS Sontag points out that a lot of the problems of diversion are the self-inflicted injury of a bureaucracy trying to limit access to the medication
3. There is no right answer with regard to how doctors should manage their practices with regard to this treatment. The second article juxtaposes two practices on opposite poles of the “relaxation” spectrum and shows that each has pros and cons.

Any way, here are some links to responses for further reading:
New Republic:
Central Recovery Press Blog:

I’m sure there will be more. It’s key to remember that there is an epidemic of opioid overdose deaths in this country largely fueled by the unrestricted access to long active high potency full opioid agonists in “pain clinics” around the country. It’s strikingly ironic that in the midst of this, there is controversy about a long acting partial agonist that is much safer and has been used in hundreds of thousands of people to stop the compulsive use of more dangerous full opioid agonists. What is even more ironic is that the use of Suboxone is limited while any physician can prescribe nearly limitless quantities of the more deadly full opioid agonists.

Toxicology Protocol

October 26th, 2013

ASAM is about to publish a new White Paper on Drug Testing. The paper supports determining frequency of testing according to acuity, setting, and other factors but gives no definitive details. I get this question all the time from addiction treaters so I’ve created a Toxicology Protocol Worksheet. You’ll find it on the “blogroll” to the right of this blog.

DSM V and Addiction

October 21st, 2013

A few years ago, I first heard about the changes envisioned in DSM V, specifically, that they would bring back the word, “addiction” and get rid of “Substance Dependence.” I thought, “Wow, they’re finally going to get it right.” Well, something happened between then and when they published it six months ago, because it certainly isn’t right.

One reason why “dependence” was just wrong as a diagnosis is that it already had a definition. For over a hundred years medicine had used dependence to mean that you got withdrawal if you suddenly stopped a medicine or drug. That phenomenon was only one criteria for DSM Substance Dependence, so what DSM was doing was confusing everyone by calling a larger diagnosis the same name as one of the criteria for that diagnosis. Worse than that, it was clear since the nineties that addiction had nothing to do with physical dependence (I explain why in Physical dependence was a follower of addiction, but not core to the illness.

The biggest problem with DSM was that it envisioned an order for its two substance related illnesses; abuse came before dependence. As DSM IV criteria were purely behavioral, no one was ill until they met the behavioral criteria. If you met one criteria for abuse you had it, while you needed three criteria for dependence. It was envisioned that if you got dependence you couldn’t have abuse because the diagnoses were progressive; that is, you could have abuse but not dependence, but if you progressed to dependence, you could no longer have abuse. That basically told everyone that addiction (what the rest of the world called dependence) was created by choices the person made: you were normal, used the drug, chose to abuse the drug, and then became dependent on the drug. This has only led to an increase in stigma and the promotion of a system of care that has not made a significant dent in treating addiction, largely because it leads to treatment of something that doesn’t exist instead of the illness that exists in nature. Addiction does exist in nature, and if you’ve read other blog entries you’ll know I believe it can exist before the first use of a drug. (The validity of ASAM’s new definition of addiction and Questions and Answers on Addiction)

I wrote in 2011 why addiction wasn’t a spectrum (, but this idea of a spectrum took over the DSM V process and that is exactly what they came up with. There are now not two different illnesses based on substance use, but one: Substance Use Disorder. There are now not two separate sets of criteria, but one, and you are staged on this spectrum by the number of criteria you meet. What a step backwards. The study that got this started was Saha et al’s The Role of Alcohol Consumption in Future Classifications of Alcohol Use Disorders published in Drug and Alcohol Dependence in 2007. What they showed was that the criteria for Substance Abuse didn’t come before the criteria for Substance Dependence in the natural history of heavy drinkers. Rather than say, “Gee, I wonder if that means we have it completely wrong,” they did what most academics do. They suggested that they had it a little bit wrong.

So now, with DSM V, rather than moving to a system that understood that addiction was a biological illness that did not require drug use, we have a single diagnosis, Substance Use Disorder, that doesn’t exist in nature, but is graded by the number of criteria one has met. It’s a big step backwards and not supported by the underlying neurobiological literature.

If the illness of addiction exists in nature, and is not just a made up human construct, then the DSM V staging does a great disservice to those with the illness. It lumps those who are not ill with those who are. It will lead to a furtherance of the confusion between substance abuse and addiction. It will cause society greater confusion, just at a time when society was beginning to read about the underlying neurobiology of the illness. Now, a group of “experts” are pointing out that the biology just isn’t important. There will be those in the insurance world that see the DSM V as confirmation that addiction is not an illness, but rather a consequence of a series of choices. There will be patients who have addiction that believe they don’t and patients that don’t that will believe they will. There will be doctors who won’t have a clue how to treat the illness because the staging does’t reflect nature.

These are some of the reasons why DSM is becoming irrelevant in the treatment and diagnosis of addiction. Hopefully ASAM can create a diagnostic criteria set based on its new definition of addiction that will take the place of DSM soon. Without that, insurance companies, lawyers, and law makers will be relying on the DSM which gives a badly distorted view of the illness.

12 Steps and Addiction Medicine

August 23rd, 2013

Here’s part of an email I recently received from a colleague referring to using medication to treat addiction. Remember, this is a physician who is a specialist in Addiction Medicine and who actively works in the field. Here’s the quote:

“One of the difficulties I see is that addicts and alcoholics will not submit to recovery until the pain of using is greater than the pain of living. If we continue to rescue people from their own consequences there is no incentive for them to seek recovery. Addressing addiction medically may provide temporary solace and give patients a daily reprieve however long term abstinence and recovery will not likely occur.”

It’s been bothering me since I saw it. It would be hard to find a synthesis of the ideas that are current, yet not consistent with reality, that are harbored in our field. Here’s the list of included ideas in the order they occur in the quote: addicts and alcoholics are separate and different, addiction treatment should be focused not on the illness of addiciton but the use of substances, people only come to recovery for relief of a negative state never to seek the enhancing of a positive state, making patients feel better will keep them out of recovery, relieving symptoms of addiction with medication to treat people with addiction will not work.

Addicts and alcoholics are separate: This one is so pervasive that people don’t even realize they are doing it. Why wouldn’t we just say “people with addiction?” Why would we exclude people who drink for relief of symptoms when talking about addiction? Are they really a different breed? Not at all. But there is an old idea in our field, I think derived from Cloninger’s work, that those who exclusively use alcohol are more Type I, come to the illness later and bring a more developed character structure to treatment than those who use drugs. It’s a subtle prejudice. I think the fact that alcohol is legal and other drugs aren’t, or mostly weren’t, when the prejudice was developed, has something to do with it, but there may be more. It may also be a founder effect. AA was the first recovery fellowship and the first physicians in organized Addiction Medicine, at least those who were in recovery themselves, were in AA. The truth is that the biology of addiction, for most with the illness, starts very early in childhood, if not at birth. It is a rare person with addiction that I meet that can’t relate to lifelong symptoms of the illness. What drug works to make one feel better is an accident of the genetics of reward and an accident of social and economic availability, nothing more. It’s my experience that treating people who use one drug or another is essentially no different once you understand the underlying neurobiology. In fact, I find that allowing a recovering person to maintain the distinction will limit their growth in recovery by limiting their field of attention to a single reward. This leads me to the second idea.

Addiction treatment is focused not on the illness of addiciton but the use of substances: When we forget that the illness started before the first external reward we are left with a patient treated to the point of abstinence who is essentially no less ill than when they came for treatment. He’s not drinking, let’s say, but he’s not at all aware of what he did to ameliorate his symptoms before he got the first drink. We haven’t addressed the gambling, compulsive overeating, or even the more subtle internal sources of dopamine release such as righteous indignation, lying, fantasy and having power over others. In 12 steps these things are mostly referred to as “defects of character” and “shortcomings,” but after one comes to understand the neurobiology of addiction, they just become earlier drugs. Limiting addiction treatment of “the drugs” that the person uses leaves all these other rewards unaddressed, and probably still used. We know that in the case of nicotine, those who continue to use after treatment for addiction using alcohol are more likely to go back to alcohol use than those who stop smoking in treatment. What reason do we have to believe that any of these other rewards would give us any different outcomes? We don’t have any. Like the man who lost his keys at home but is out on the street looking for them under a streetlamp, we say, “But this is where the light is better.” Focusing on the drugs only, the light is better; they are easier to see, but it’s not where the keys are. This leads to the next idea.

People only come to recovery for relief of a negative state, never to seek the enhancing of a positive state: We get this idea because we are focused only on drugs including alcohol. Mostly people who give up a drug, do so by accepting back the pain of the symptoms they used the drug to get rid of. Even those for whom the drug has stopped working but are stuck using it because of the power of the illness, don’t get immense relief from “just stopping.” But having an understanding of the neurobiology of addiction gives one several insights that go along with the spiritually based 12 step recovery outlined in the book “A New Pair of Glasses” by Chuck C. The neurobiologist would see that increasing D2 receptor density would make the person with addiction feel better, and studies have shown that in addicted animals who are given a higher D2 receptor density, use of external reward just stops by itself. We know from science that isolation and feeling less than will decrease our D2 receptor density, so the fellowship and horizontal social structure of AA should only help. But there’s more. As Chuck C wrote, “When I perform to the best of my ability, there seems to be a nod of approval from the universe that is called peace of mind.” It’s also called not having your D2 receptor density drop because you started calling yourself less than because you behaved in a way that was not true to yourself. There is not only no evidence to suggest that people can only grow out of this self-condemnation through pain, but there is a long history of Buddhist psychology that shows equal growth through the application of love. Millennia of history shows many examples of people and groups coming to change not from the pain of where they’ve been but for the love of where they could be. This brings us to the next idea.

Making patients feel better will keep them out of recovery: The best definition I can find of 12 step recovery is “living in God,” and the best definition of God I can find is “not me.” So recovery can best be described as “living in not me,” or living without self-centeredness. The idea that making patients feel better will make them more, not less, self-centered derives from an ignorance of the neurobiology of addiction. Once one sees the biological underpinnings of the illness it becomes obvious that the “self-centeredness” of the individual comes from the symptoms of the illness, not from the person’s core make up. Low dopamine is one of natures starvation signals. We are designed to get self-centered with lowered dopamine tone. We cannot be otherwise. Relieving the symptoms by raising dopamine tone makes the self-centeredness better, not worse. Addiction is a self-centering illness; treating addiction relieves self-centeredness. This leads me to the next idea.

Relieving symptoms of addiction with medication to treat people with addiction will not work: Correct addiction medication, in my experience, leads to a quicker acceptance of the 12 steps rather than a decreased acceptance of that life. When medication is effective, the message is, “It’s just an illness like any other. You aren’t defective in some terrible way, you’re just ill.” People can more quickly see that they can be of value to others. Even if you don’t believe me, evidence shows that if you increase dopamine tone, animals that use drugs stop using. Other evidence shows that normal primates with normal dopamine tone don’t like drugs and won’t use them. Even if we were only going to focus on the drugs and ignore the positive spiritual path we’d still want to increase dopamine tone in patients with low dopamine tone. But especially if we want people to accept a path in life where they are accepting themselves as ill yet valuable to others, if we want them to see the rewards they used before external substances and the full affect of the disease on their lives and include abstinence from those behaviors in their recovery program, if we want to quickly get them working the 12 steps, we would use medications to decrease symptoms.

I have some evidence for that beside my own opinion. When we started Townsend, we added some things that others treating addiction didn’t have. One thing we added was a focus on the biological symptoms and a treatment algorithm that addressed the primary symptoms of the illness. We utilized a self reported symptom score that ranged between 10 and 100 as well as computerized neurocognitive testing to track patient improvement. We also developed a Disease Acceptance Score (DAS) which measured the cognitive change from active addiction to acceptance of a recovery lifestyle. This latter score ranges from 5 to 20 where 17 is judged as having entered recovery. Also when we started I was everyone’s doctor. Every patient in all 5 clinics was seen by me if they wanted to see a doctor. Some did not and most of those had decided they didn’t want to see a doctor because they wanted to be in recovery “without medication;” many of them had already been to a medication free residential rehab and were stepping down to IOP. Of the first 271 patients, 233 (88%) saw me and 39 didn’t. The groups differed in symptom score from the start. The group that didn’t see me had a symptom score average of 33 and the ones who did started with an average score of 45 (p<.0001), an expected finding as many of those who didn’t see me had been in treatment for about a month somewhere else. In spite of some of the patients who received no medical care having already been to rehab, the two groups started about the same in terms of DAS (8.4 vs 8.1; p=N.S.). At discharge the two groups did not differ in symptom score (19.3 vs 17.7; p=N.S.), but did differ in DAS. The group that received medication finished with an average DAS of 14.7 while the other group finished with an average of 11.8 (p<.0001). On our scale that translates to the non-medication group believing they have addiction but not yet believing that it is chronic and progressive while the medication group has accepted the chronicity and progressive nature of the illness. Other work we have done has shown that a higher DAS score predicts a longer retention in the continuum of treatment and recovery. Not only did the medication group not fail to accept twelve step recovery, they actually made it farther in acceptance of the need for the 12 step program than did the non-medication group.

Does Abstinence Matter?

July 7th, 2013

I belong to a group of colleagues who are currently arguing about abstinence in recovery from addiction. To understand why any argument is needed, we need to have some historical context.

Back in the day before we had a good biological understanding of addiction, people who treated those with addiction divided up the sufferers by “drug of choice.” That is, those who primarily used alcohol were called alcoholics and those who primarily used drugs were called drug addicts, or more specifically heroin addicts, cocaine addicts, and the like. It was pretty clear back then that anyone who was an alcoholic should remain abstinent from alcohol for the rest of their lives. It was pretty clear that anyone who was a cocaine addict should remain abstinent from cocaine for the rest of their lives. To not do so was to court the disaster of a reactivated pathological state leading to a downhill course, and, often, death.
What was somewhat more controversial were two other issues.

Should someone who was, say, heroin dependent, but had never had a problem with alcohol remain abstinent from alcohol for life? And second, should someone who was, say, alcohol dependent, abstain from any prescribed medications that affected the same receptor systems such as benzodiazepines. These two problems can be referred to as the “cross addiction problem” and the “iatrogenic re-ignition problem.”

The cross addiction problem is rather easier to solve in hindsight using what we’ve learned about the illness. Even if you have never gotten a dopamine hit and crash leading to compulsive use with a drug that may do that, there’s no guarantee that you won’t in the future. We lose dopamine producing cells as we age; this is a progressive illness. There aren’t many addiction specialists who are knowledgable about the neurobiology of the disease that will tell a heroin addict it’s okay to have a beer. At least I don’t know any. In addition, in light of what we’ve learned that led to ASAM’s new definition, the cross addiction problem seems quaint in retrospect. It’s clear now that addiction is addiction regardless of drug or non-drug reward used. For someone to stop one dopamine spiking reward and start another, isn’t “cross addiction” but rather untreated addiction with a switch in rewards.

The iatrogenic problem is a little tougher because not all medications act as medications, and not all objections to medications are the same. There is the camp that claims that any medication for people with addiction will make them feel better and keep them from having the authentic suffering that will lead to a spiritual awakening in a recovery process. These physicians, mostly in recovery themselves, seem to have a bit of a different goal of treatment than most in medicine today. There are also those who have had bad experiences with their addicted patients taking medications prescribed by someone else who then went on to relapse, seemingly because of that medication. So this iatrogenic re-ignition problem has several facets we’ll have to take one at a time.

First, the authentic suffering argument. The most singled out heroes of spiritual growth in the history of AA were smokers, and this group of physicians don’t seem to fault the AA founders with continuing to use nicotine to keep their dopamine up. These founders aren’t derided as having been in “only chemical assisted recovery” as opposed to the real thing; in fact, they are held up as paragons of spiritual growth. I have to say that I am very impressed, no, astounded, that the book Alcoholics Anonymous was primarily written by a man only three years from his last drink that continued to use nicotine. If we ever need evidence that spiritual growth can occur and flourish while dopamine tone is being raised pharmacologically, Bill Wilson is that evidence. So I just can’t subscribe to the school of thought that believes that all people with addiction can only be in full or real recovery when they are completely medication free. In fact, as you’ll see below, I’d far rather have someone taking medication that doesn’t spike and crash dopamine and causes no change in immediate feeling than continue to reach for a cigarette whenever he needs one.

The iatrogenic argument has a few components that seem to come from a few varied places. There are those people with addiction who seek out doctors who will give them legal versions of the drugs that are their most effective reward. This is only a subset of continued active addiction, and the doctor here is merely the supply point. Don’t get me wrong, this isn’t a good situation, and I long for the day when no doctor is so ignorant of addiction that he or she would continue to give someone a medication that they don’t use as a medication rather than get the person to addiction treatment. However in the scheme of things these aren’t patients in treatment; these are untreated active addiction patient who just happen to get their drugs from someone with a license.

Another class of iatrogenic patients are those who are “sober” from one drug or another yet are seen as having another illness that requires medication that can be used as a drug. Alcoholics with ADHD who get on a stimulant or those with anxiety disorders who get on benzodiazepines are such patients. These patients may be seeing a non-addiction specialist for this other care, and, most often, are. Their addiction doctor looks on wondering what the other doctor is thinking giving Xanax to an alcoholic, while the other doctor is wondering what the addiction doctor is thinking not treating an anxiety disorder with the most effective rescue medicine available. What we have here is a failure to communicate. Now that ASAM has published its definition of addiction, we can see that the illness rarely starts with drug use, that there are usually symptoms of the illness and attachments to other dopamine spiking behaviors before the first identified drug. Once this information becomes widely known and accepted in the greater field of medicine, this problem will fall in significance. Currently, the only thing a psychiatrist can call a patient who is sober but having symptoms is a different diagnosis, often one that requires a sedative or a stimulant. This wouldn’t be much of a problem if these medications were designed to be given to people with addiction, but they aren’t. They are too powerful and too fast acting, which leads us to the third class.

There are those patients who are being treated with a dopamine raising (but not spiking) medication in order to treat the primary symptoms of addiction. If they are properly dosed and taking medicine as directed there are no ups and downs; that is, they don’t feel the medication taking effect. There are a few such medications, for instance bupropion, which affects the dopamine reuptake pump, and buprenrophine that affects the mu opioid receptor. If not under dosed and taken properly there should be no change in steady state levels of midbrain dopamine tone. That is, no spikes, no crashes, and therefore, no compulsive use. Just a remission of the symptoms that had required the patient to use before treatment. The group most concerned about these patients is that group wanting “abstinent” recovery, and they are concerned that as these medications work at the same site at which the patient’s most effective reward works, that they aren’t really abstinent. This group sees these medications as harm reduction rather than actual treatment, and this brings us full circle back to where we started.

When addiction was just pathological drug use, the point of treatment was stopping drug use. As no one understood the neurobiology and no one had developed proper medications affecting that biology, the only successful recoveries were those where people didn’t take medication, the medications of the day being short acting powerful agonists that spiked and led to crashes. There just weren’t that many successful treatments of alcoholic using benzodiazepines or stimulants. There were dose escalations and tolerance. As expected, once you know the neurobiology involved, patients eventually started getting spikes from those as well, and compulsive use ensued. Physicians in recovery themselves, who became leaders of addiction medicine in its early days, just never saw anything good come from giving medications to patients with addiction. And those that stayed sober and rose in power and prestige were those that were able to stay sober without medication. They became the proof of their own theory. “I got sober without medication, so you can too.” This is an illogical leap that assumes every one with addiction has the same biology and the same response to recovery activities. Later studies have shown an amazing variety of genetic abnormalities in people with addiction, and this position is just no longer tenable. But not to worry, because addiction is no longer just pathological drug use.

ASAM’s definition of addiction states that it is a primary illness with symptoms, and it is these symptoms that lead the patient to seek reward or relief in the first use. It outlines the biology which leads that first use to compulsive use, a biology that, from the beginnings of addiction medicine was thought to be different from non-addicted people (see Silkworth in Alcoholics Anonymous). It is not possible to see the point of treatment to be merely the cessation of a single drug or class of drugs. It is not even possible any longer to see the point of treatment to be the cessation of all drugs while the person continues to spike dopamine from other non-drug taking behaviors (overeating, gambling, compulsive sex, etc). What is happening now is a wholesale reoganization of thought about addiction. Is it still good treatment to get the person to stop drinking while they gain 100 pounds and die of a heart attack? Is it still good public policy to ignore the causative illness and focus on the drug de jour and then decry the “new epidemic” of the next one? The findings of the neurobiology of addiction, and their incorporation in ASAM’s new definition are watershed events. Nothing can be or will be the same again with regard to thinking about addiction.

So what is abstinence and does it matter anymore? Two really good questions. I’ll give you my answers, but they are only mine. The rest of addiction medicine is going to have to hash this out over months and years. The next answers we hear from organized medicine may be just stepping stones to the final answer, and that final answer may itself be overthrown by future evidence.

Abstinence is the act of refraining from seeking a dopamine spike in order to feel better right now. Does it matter? Yes, and no.

If I take a medication that doesn’t change how I feel now but keeps me stable over the course of the day, I’m abstinent. If I get bored when not drinking and need to shop on the internet to feel alive, I’m not. The chemical has nothing to do with it. Notice I said abstinence is an act, not a state or a process. It is the act of the moment. We are abstinent in this moment only.

Because abstinence is a momentary event it can be integrated over longer periods of time such as, “I have three weeks of sustained abstinence.” However, in practice this is rarely to the point. I have met no one in recovery who has maintained complete abstinence from any dopamine spiking behavior for 24 hours. At least that’s how it looks from the outside.

From the inside it’s different. I know many people who believe they have days and weeks and months and years of sustained abstinence. What we see, from the inside, is our subjective view of what spikes our dopamine, and as the midbrain is incredibly powerful at forming our perceptions of what is necessary, we may only see what it wants us to see. What becomes clear over time, with sustained recovery and active involvement of other recovering people in our introspection, is that things we thought were necessary are now seen as rewards that can be abstained from. So abstinence changes from time to time for each person. Therefore one could say, “I am abstinent from alcohol and nicotine today,” and in two years say, “I am abstinent from alcohol, nicotine, compulsive overeating, and righteous indignation today.” So what matters more than abstinence is the seeking of abstinence and the recognition that for the person with addiction the illness is not as simple as a drug or a medicine, but is as complex as the brain. It changes over time, and we and our recovery have to change also.

So to those who worry about medication in people with addiction I’d ask this, “Does it cause a dopamine spike?” If so, it’s probably something that should not be part of the patient’s care plan. If it doesn’t but you worry that one day it might, then continue to bring it up with the patient in their treatment and teach what you know about the progressive nature of the brain. If you’re worried about people on medicine not making great spiritual progress, don’t be. The evidence for that just isn’t there, and besides, can you think of anything more spiritual than coming to understand that I now have to abstain from one more thing? Medication actually makes that an easier, more likely thing to happen in my experience.

But in any case, let’s stop worrying about the chemical name or specifically where it acts and start looking at the whole patient and their life long care plan as they envision it today. It’s a chronic illness so you aren’t going to cure them anyway. If you’re doing this right you’ll be there with them for a long time. Just keep teaching and more will be revealed.