The Kissinger Cross and Beginner’s Mind
Jul22

The Kissinger Cross and Beginner’s Mind

The Kissinger Cross I learned about the Kissinger cross from an economist named Jim Rickards (twitter: @JamesGRickards). You may have guessed that the Kissinger Cross was named after former Secretary of State Henry Kissinger, but you might be struggling to figure out what it has to do with addiction. No, it isn’t that it’s his cross to bear. It’s something else all together. Kissinger said that when we enter a new situation we have all the options that exist but we don’t have any information on which option is best. As we learn more about a situation our knowledge rises, but with that knowledge comes a decrease in the options available. Some just don’t look good with that new knowledge. So he said there are two lines to be drawn as time moves on, the down sloping line of options and the up sloping line of information. The more we learn, the fewer options we have, so in the end, we know everything but can’t do anything. What the Kissinger Cross is, is the point at which the two lines cross. We no longer have all the options but we still have a lot, and we don’t know enough, but we know a good bit. It’s a chancy thing making decisions with incomplete information, but life is a chancy thing. What Secretary Kissinger gave us was a system with which to figure out when to act that is graphical, at least somewhat objective, and can be put on paper for clarity of thought. It’s a good idea, but what does it have to do with addiction? Well, it has to do with everything, but that’s not the point of your question, is it? You want to know what the Kissinger Cross has to do with the problem of addiction in our society. Well, it can provide us with a solution, but only if we use it correctly. To illustrate that, you’ll have to come with me on a little thought experiment. A World Without Addiction So imagine that we live in a world with no addiction, or, since you won’t be able to imagine that, just imagine that we’re not from this world. We arrive here and see addiction for the first time. We don’t know anything about it; it’s a completely new situation. We can do anything about it we want. We can shoot people, give them lemonade, pet the dog, or go home. We have all the options in the world, but we don’t know what to do. We’ve never seen addiction before. We don’t know what it is, what causes it, what it costs. We just know we’re...

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You’re Sick and You Almost Died, So Don’t Come to my Wedding
Jul09

You’re Sick and You Almost Died, So Don’t Come to my Wedding

The other day I heard from a friend about his son who has addiction. There was a recent overdose on opioids in which he almost died. Luckily there was someone with him to get him help, and he survived. He’s now in treatment and doing well. I was glad to hear he was doing well, but what really struck me in the conversation was that after word of his overdose had gotten around the extended family, my friend’s son was uninvited to his cousin’s wedding. You’re probably asking why, and I’d love to tell you. I don’t know why. My friend didn’t know why. Were they afraid he’d make a scene and stop breathing during the reception? Where they afraid he’d vomit on the wedding cake? Where they ashamed he was a person with addiction? I have no idea. But the first thought I had when I heard the story was the title of this article: “You’re sick and you almost died, so don’t come to my wedding.” That’s what overdose in someone with addiction means. It means they are ill, and now they almost died, if they’re lucky. Of course a lot, and increasingly so, aren’t so lucky and do die. Would we ever call up Aunt Sally during her breast cancer chemo and tell her not to come to the wedding? Would we call up cousin Sal and tell him that after his recent near death experience with diabetic ketoacidosis, we’d rather he stay home? No, we would not. In every other case, where a relative was potentially terminally ill, we’d welcome the chance for just one more family memory. Not so with addiction. I wrote recently about what people with addiction die of, the disease, ignorance, or cruelty. Too many have to live that way too. Hopefully, one day, we will be able to say that more and more people with addiction live with health and hope and love. Until then social isolation will continue to make the illness worse (the biology of this is described in my book) and we’ll continue to wonder why these addicts don’t just learn from their isolation. “After all, if we were snubbed, we’d change, right?” So we try to stem that ignorance every day. Just keep telling people you know the truth about addiction. It’s just an illness. It’s just biology. It’s just an act of nature. It just happens. If enough people understood, perhaps we could get to health, and hope and love.   Copyright 2016 Howard C Wetsman...

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The ICU
Feb28

The ICU

The young woman walked out of the ICU knowing she’d never see her friend again. At age 26, this was the second time she’s said good-bye to a childhood playmate in this ICU.  When the first of her friends to die was lying there with a machine breathing for her, there was a constant stream of friends and family coming to say good-bye. Now that her second friend was dead but for the machine pumping air into his lungs, there was the same stream of loving people to say good-bye. Both of her friends had struggled with genetic illnesses all their lives, both had done their best to stay alive, both succumbed. The first one died of cystic fibrosis; the second, of addiction. The friend with CF did everything she knew how to do. Took all the medication her doctors told her to take, ate only the foods her doctors told her to eat, exercised, stayed fit, everything. She had a loving family that got her to the best doctors who gave her the best care. But CF doesn’t have a cure, and it doesn’t have a treatment that does more than extend life into the 20’s. It’s genetic, and it’s unfair, but so is every illness you’re born with. The friend with addiction was really no different except for one thing. When his loving family took him to the best care, he heard that medication wouldn’t help. He heard that he should be able to “recover naturally,” that he didn’t need medication. The best doctors that his family sought out didn’t tell him about evidence based medical treatments for his genetic illness. Instead they told him his illness was caused by drugs and would go away if he just stayed clean and became spiritually fit. So in his 4th or 5th rehab he went to a religious based program to get that spiritual fitness. I don’t know his spiritual status when he died, but I know he couldn’t breathe on his own. I wrote a piece recently about what we die of when we die of something that has a treatment we aren’t offered. The young woman’s first friend died of cystic fibrosis and our inability to treat the illness better. Everyone did everything they could. It’s just beyond us at this point in time. But I’m not sure that the second friend died of addiction. There is a treatment available that has been shown to improve survival rates, but he was told it’s a bad thing to be on. There’s a known neurobiology of his illness, but his treaters were willfully ignorant and disdainful of that knowledge, believing that their spiritual superiority was enough...

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Response to Dawn Roberts’ Question about Buprenorphine Taper
Jan13

Response to Dawn Roberts’ Question about Buprenorphine Taper

First, let me say this about conflicts of interest regarding buprenorphine taper, because it’s going to come up. I receive no money of any kind from any maker of buprenorphine. I was on speaker panels for both RBP and Orexo in the past but have not been for over a year. I get no consideration from any pharmaceutical company. Ms Roberts asked in her piece in The Fix “Why is there no official medical protocol to detox people off Suboxone?” I’d like to answer that question. The question seems to suppose that getting off buprenorphine after being maintained on it for opioid dependence is entirely about medical withdrawal management. It is not. What happens when most people get off of buprenorphine is that the medication that was suppressing the symptoms of addiction is going away, and those symptoms return. This is separate and distinct from withdrawal symptoms, but most people don’t make this distinction. What are these symptoms? They are symptoms of low dopamine tone in the midbrain. Well more than half of the patients who have ever come to see me for addiction treatment tell me they’ve had these symptoms since before their first drug use, and it was the relief of these symptoms that was, at least in part, what made the drug so useful. An incomplete list of them are: not enjoying things as much as others who are experiencing the same thing (relative anhedonia), poor memory, poor focus, irritability, and difficulty making attachments to others. If these things start to return along with withdrawal symptoms, it’s easy to think the whole thing is from withdrawal. So there will never be a single protocol for tapering buprenorphine, because in most people, the taper will have to be customized with additional specific treatments for the original symptoms. Agonism of the mu receptor, even partial agonism like buprenorphine, causes additional tonic release of dopamine, and this makes people with low dopamine feel better, even if their original problem wasn’t at the mu receptor or within the opioid system. I’ve seen many patients who weren’t able to get off that last 2mg until we added specific medication for the pre-existing symptoms. In addition to the quest for a specific protocol, Ms Roberts seems to imply that the pharmaceutical companies coopted the government in some nefarious plan to make buprenorphine. In a less paranoid world some might say that the people at NIDA and SAMHSA saw the rise in opioid use over the last two decades and worked for a solution to increased cases of opioid dependence that they could implement because they had no control over the DEA approval...

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“Real Recovery” – What is it?
Dec13

“Real Recovery” – What is it?

I have colleagues that use the terms real recovery or true recovery and, lately, as the use of medications for addiction treatment have become more accepted, I’m hearing it more and more. Frankly, it’s getting annoying. So let me say clearly here and now, I do not know what real recovery is. At least I don’t know what real recovery is for anyone else, not for you, not for my colleagues, not for any of my patients. Is someone in real recovery if they are taking a medicine and not going to meetings? Does real recovery depend on the quality of their relationships? Does real recovery depend on their economic productivity? Does real recovery depend on anything that anyone outside of them can come up with to judge them on? I think not. So how should we define recovery in someone who is living with a chronic illness? Let’s ask nature. Going on From Here There are three ways any of us can go regarding  any aspect of our lives from this moment on. We can get worse; we can stay the same; or we can get better. There just aren’t any other possibilities in the next moment. No matter which direction we go in that moment, unless we cross a permanent line called death, there will be another moment with the same three possibilities. Can we all agree that getting worse is not recovering? Can we agree that getting better is? I hope so, but our field  has swung for the fence for so long, there are many of us who live by the motto, “The good enough is the enemy of the best.” So like beauty, we believe recovery is in the eye of the beholder, or in this case, the mind of the beholder. So many believe that if a person is just improving and hasn’t achieved the beholder’s level of recovery, then it isn’t real. I doubt we’re justified to believe that. What possible business of mine could it be what you think your recovery should be? So if you think your recovery is sufficient with slow improvement, or even just staying steady, who am I to claim that you aren’t in real recovery because you haven’t hit my goal yet? And while we’re on the subject of who gets to decide, can we mention something else that is the individual’s choice? I’m referring to what to measure. I have seen people who were introverts told they haven’t improved their relationships enough because they weren’t more like the extrovert who was judging them. I have seen people told that they weren’t in real recovery because they weren’t living...

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What Do IOP Sessions Cost an Insurance Company?
Dec06

What Do IOP Sessions Cost an Insurance Company?

Understanding Insurance Inside a mental health carve out, insurance people decide to deny care to people with addiction more because of the cost of that care than the total cost to the insurance company. Here’s an example. We did a study of around 100 admissions to our IOP and around 50 people who chose not to admit. We asked them two questions: How many time have you been to the emergency department (ED) since your discharge from treatment (or since your assessment if you didn’t go to treatment anywhere) and how many days have you been in the hospital in the same time period. The rest of the methodology is described here. But what I want to describe here is more about the people that came to Townsend and the effect on their insurance companies. One more piece of background first. In our treatment we don’t have a fixed length of stay. Instead, we use our Disease Acceptance Scale (DAS) and the effect of that scale on the outcomes of the above study are described here. In addition to what we’ve already published we also found another relationship in the study population. As you might expect, the DAS went up with the number of sessions of IOP that the patient attended. That makes sense if treatment works; more treatment, better effect. In fact we found that 12% of the variance of the DAS at discharge (DCDAS) was predicted by the number of sessions. The equation for that was DCDAS=10.61+0.18*Sessions; p=.0003. Now we need a little math. Math Alert – the squeamish should skip this The equation describing the relationship between the DCDAS and ED visits was EDVisits(per100days)=.29-.015*DCDAS and the equation describing the relationship between the DCDAS and hospital days was HospDays(per100days)=4.89-.26*DCDAS. Now for the math. We substitute the DCDAS equation for DCDAS to predict ED visits and Hospital days. EDVisits(per100days)=.29-.015*DCDAS =.29-.015(10.61+.18*Sessions) =.29-.16-.0027*Sessions =.13-.0027*Sessions and HospDays(per100days)=4.89-.26*DCDAS =4.89-.26(10.61+.18*Sessions) =4.89-2.76-.05*Sessions =2.13-.05*Sessions We valued the average ED visit at $1200 and the average Hospital Day at $1500, which is very conservative, meaning that every 100 days after DC each session saved the insurance company $3.24 in ED costs and $75 in hospital bed-day costs. That translates to $285 per year saved for every session of addiction IOP they allow, and that’s only for ED and hospital costs. So let’s think about that. If an insurance company pays $350 a day for IOP, they’re getting $285 of that back EVERY YEAR. So the first year they are getting back $285 which is an 81% return, and the next year they get another 81% return. Can you find an investment that pays that well? No More Math – arithmaphobics may return This leaves...

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