Drug of Choice
Feb12

Drug of Choice

When I think about it, there are few terms in the addiction treatment field that are more silly than “Drug of Choice.” As if we get to choose which drug makes the brain go BAM. When you talk to an addict and ask, “What’s your drug of choice?,” what you get is the answer to “What drug that is available to you lately at a price you can afford that makes you feel better with the least side effects?” Quite a mouthful, huh? Would we ask a diabetic if their toxin of choice is sugar? How did they choose sugar? Why didn’t they choose to have an abnormal reaction to arsenic instead of sugar? What a stupid choice! Using the concept of choice, as in which would you choose if they were all lined up, can confuse us and strengthen the stigma and the idea that addicts are normal people who choose to use drugs. If we asked an addict if they chose to have cocaine work the way it works with them or if they chose to have an abnormal reaction to alcohol we’d hear a resounding “no.” “If I had the choice of what my brain reacted to I’d have picked something a lot cheaper and easier to get than cocaine.” Something like wildflowers or dandelions, no doubt. What is it we really want to know when we ask the question? And why? Well, up to now we really haven’t had a good reason. We just needed a word to write down in the “Drug of Choice” box on the assessment. In many cases it meant something, for instance when the person used only one drug. Most of the time however it doesn’t actually mean much with regard to choosing treatment. However because researchers like things that come in boxes there has been a lot of research on “Drug of Choice.” It’s been used to predict treatment outcomes with regard to which treatment is used. One example of such a research question would be, “Do alcoholics or opioid addicts do better when given naltrexone?” By dividing people up by “Drug of Choice” we manage to make one population (alcoholics) which is heterogeneous sound different from another (opioid addicts) which is heterogeneous in a different and overlapping way with regard to neurobiology. It’s really no wonder most addiction research doesn’t make much sense. But still insurance companies ask the question and the government asks the question so we ask the question, as if we get to choose. But modern science actually gives us a new reason to ask a question about “Drug of Choice.” It’s just not the question we’ve...

Read More
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...

Read More
“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...

Read More
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...

Read More
I’ve Got News for the Washington Post
Nov24

I’ve Got News for the Washington Post

I read today in the Washington Post that 4 in 10 Americans say they know someone with an addiction to prescription opioids. I’ve got news for the Washington Post, and everyone else in Washington. 10 out of 10 Americans know someone with addiction and it usually has nothing to do with opioids. I was recently in Washington and most of what I was hearing about was the “opioid epidemic” and the “opioid problem.” Just today another senator came up with a new bill (I think there are about 7 pending) to deal with the problem. Where were these people 10 years ago when people in my field couldn’t get appointments with congressional offices to tell them this was happening. What’s so special now? Well, I hate to be cynical, but what seems to be happening now is that people are dying, and not just any people, but people who “aren’t supposed to be” dying of addiction. All of a sudden addiction, specifically addiction involving opioids, is getting political attention. And people aren’t talking about addiction, but opioid addiction, as if it’s a special kind of addiction or a new kind of addiction or a new problem. Or 25 years ago when politicians were raving about doctors not treating pain well enough so that JCAHCO started rating badly hospitals that didn’t count pain as a fifth vital sign, my colleagues couldn’t be heard when they told of the dangers of opioids. Now that there’s an “opioid epidemic” those same administrators, regulators and politicians are screaming, “Who could have seen this coming?” Well, the Addiction Medicine doctors did, and tried to tell you. About 5 years ago when politicians were raving about pill mills and Addiction Medicine physicians told them to consider what would happen when they closed the pill mills (opioids being opioids and addiction being addiction) without offering treatment to patients, we were told we didn’t understand. Now that there’s a “heroin epidemic” those same politicians are up in arms screaming, “How could we have seen this coming?” Well, you could have listened. Here’s the truth. We don’t have an opioid epidemic or a heroin epidemic. In the 1990s and early 2000s we didn’t have a methamphetamine epidemic. In the 80s we didn’t have a crack epidemic.  And in the 70s we didn’t have a marijuana epidemic. In the 60s we didn’t have a crank epidemic. And before we started calling them epidemics we didn’t have an alcohol problem during prohibition, or an opioid problem in the late 1800s or a stimulant problem after WWII. What we had was an endemic level of addiction, a genetic primary brain illness,...

Read More
Who Can You Trust?
Oct11

Who Can You Trust?

The thought came to me the other day, “Never trust a single issue organization who’s goal is not its own destruction.” I’d like to show you that that’s good advice. I’m an Addiction Medicine doctor. That’s all I do, treat addiction. And I’d be delighted to be out of business. If addiction went away tomorrow, I’d be ecstatic. I’d find another way to make a living. Maybe I’d do a standup routine about the bad old days when we had to treat addiction, or maybe I’d just settle down and be a carpenter like I always wanted. But no matter what I did for a living once addiction is gone, my life, and everyone else’s life would be a lot better. Just think of what addiction costs us. Addiction is the primary motive factor behind the top five leading causes of death in America. It’s probably second to none in causes of lowered GDP. There are more people in jail, rather than working and paying taxes, because of addiction than for any other reason. In fact, all of our taxes would go down if addiction was eradicated. I’d go so far as to say that without addiction, we might be hard pressed to find things to spend taxes on, and the things we did find to spend on would make our lives hugely better. I don’t think you can find many ills in society that wouldn’t be remarkably better if addiction went away, but that’s not the point of today’s article. I was talking about single issue organizations. There are a lot of those: The American Cancer Society (eliminate cancer), The American Heart Association (to eliminate cardiovascular disease and stroke), The March of Dimes (prevent birth defects), Saint Jude’s Hospital (cure and prevent catastrophic pediatric disease), etc. Notice that in each of these cases, inherent in their mission statement, is the assumption that if they are successful, we won’t need them anymore. Who needs a cancer society when there’s no cancer? I think that’s cool. These are organizations I can trust. What I’m looking for is an addiction organization I can trust. You know, one that says their goal is to end addiction. I’d like to support that organization, because frankly, I see no need for addiction to exist. Yes there are recovering people who have “better lives than I ever imagined possible,” but people without addiction also seem to be able to find a wonderful spiritual life with no problem at all. I think there’s enough pain in the world without having an chronic incurable brain illness to push you along toward the light. I have no need to romanticize addiction. The people...

Read More