Connect on Twitter
May31

Connect on Twitter

I appreciate all who have read my contributions here over the years. I know there hasn’t been much new content in the last year. That’s not because there’s been none, but rather because I’ve become more active on Twitter. You can find me there @addictiondocMD. I don’t know if there will be any new content here after this. Again, I thank all who have read what I’ve written here and wish the best to all those generous people who have written back, commented, and shared their thoughts and their lives with me. God Bless,...

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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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Goodhart’s Law and Addiction
Jul07

Goodhart’s Law and Addiction

In a previous post I wrote about Goodhart’s Law in relation to prohibition. I want to give another example of Goodhart’s Law with addiction, this time with opioids. In a recent report making the national media rounds, Senators have written a letter to CMS, the government agency responsible for Medicaid and Medicare. The letter states that there is growing anecdotal evidence that surveys regarding pain scores are causing doctors to prescribe more opioids. Well, yeah, but this is Goodhart’s Law. “When a measure becomes a policy, it ceases to be a good measure.” CMS measured pain scores. They wanted to improve pain scores. So they instituted the policy that pain scores should go down. Pain scores ceased to be a good measure of quality of care, and instead became the driving force for increased prescription of opioids. By the way the same thing is happening with patient satisfaction scores and the intimidation of doctors who actually feel they’ll lose their jobs if opiate seeking patients write bad reviews of them. The real problem isn’t opioids or pain. The real problem here is the system’s response to the problem. Without ever trying to find the root cause of the problem, they just declared, “Solve the problem.” You just get another problem. I’ve written before about TOC and its usefulness in addiction here and here. This is another good example of where TOC could help. Instead of fixing what the problem looks like on the surface, we could use the TOC thinking processes to find the underlying common cause. We can then plan out how to affect the change and foresee the negative outcomes. Before implementing, we could address the negative outcomes and create an even better plan for change. But that, unfortunately, is not how large organizations like government work. And it is unfortunate, because where TOC is used we see remarkable change very quickly. I would like to see addiction go away tomorrow, and while even that isn’t possible with the TOC thinking processes, using them would make it happen a lot faster than it’s happening...

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A Study From PNAS
Jun12

A Study From PNAS

I just read a piece in Quartz, an international online news reporting service. The article is entitled “A new study of 250 million patients shows medicine is still full of guesswork” and reports on a study published in Proceedings of the National Academy of Sciences. The study makes some assumptions they don’t tell us about. What the study does is aggregate the medical data from 11 sources in 4 countries in a standard way. It’s a great Big Data project and may tell us much. This study of that data though is a study of treatment pathways, and they found interesting things comparing the treatment pathways of diabetes, hypertension and depression. Really the point of this study was to show that study of this issue in an international way is possible and I applaud them for that, but they draw conclusions that go way beyond the data. Here’s a quote from the article “The pathways revealed that the world is moving toward more consistent therapy over time across diseases and across locations, but significant heterogeneity remains among sources, pointing to challenges in generalizing clinical trial results.” They go on to point out that in the case of diabetes over 90% of people get the same first line medication, but that things aren’t “so good” in hypertension. The basic assumption in the study is that what should be happening is that everyone with one of the complex chronic illnesses, all three of which have multiple causes, should get the same first line treatment. And in fact the study shows that over time, more and more people with these three illnesses are being treated with the same first medication. The authors feel this shows an improvement of medical insight. I wonder how many of them have actually practiced medicine. When I read that 90% of people in four countries with adult onset diabetes were started on the same medication my first thought was, “Wow, which one? I bet they have a great marketing department.” It might seem like because Type II Diabetes is a single illness it should have a single treatment, but it doesn’t have a single cause. Illnesses for the most part are final common pathways of multiple pathways. We cannot assume that everyone with the same diagnosis needs the same treatment. What the study actually shows is that medicine is being practiced more and more by fiat of large organizations. Over time doctors are picking the treatment the insurance company wants you to start with, or the one with the best advertising, or the one the government endorses. This was not the case for thousands of years. Dr Osler...

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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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What’s Up in Tennessee? Redux
Feb11

What’s Up in Tennessee? Redux

About a year ago I wrote a blog titled What’s Up in Tennessee? looking at the unenlightened state policies that I thought would make that state’s addiction problem, particularly addiction involving opioids, worse instead of better. It’s been a very popular blog post getting me more comments than almost any other I did last year. Well it’s time to take another look, because Tennessee just stepped in it again. Here’s a recent press release from the State of Tennessee: FOR IMMEDIATE RELEASE Thursday, February 10, 2016                 CONTACT: Mike Machak                 OFFICE: 615-532-6597   Heroin, Buprenorphine Drug Busts on the Rise in Tennessee Tennessee Bureau of Investigation data shows prescription drug seizures declining   NASHVILLE – Tennessee’s nearly half-decade long effort, dedicated to limiting easy access to prescription pain medications and similar opioid-based narcotics, has been successful. Since 2012 the state has seen a steady decline in the use and abuse of these substances commonly prescribed by family physicians. 2015 drug seizure data from the Tennessee Bureau of Investigation (TBI) shows a significant drop in law enforcement confiscations of prescription opioids, ie: pain pills.   Steep Decline of Prescription Opioid Drug Seizures: 2012 – 2014         6,988 Opioid seizures in 2012 4,696 Opioid drug seizures in 2014 *Opioid seizures exclude buprenorphine and heroin; data does not reflect amount of drug seized   This success coincided with Tennessee’s Prescription for Success initiative, launched in 2014. While beneficial in reducing demand for prescription drugs it has resulted in some unintended consequences. Today, the growing appetite in most Tennessee counties is for heroin and the painkiller replacement medication buprenorphine, known under brand names Subutex and Suboxone. They’re now widely prescribed as therapies to ease opioid withdrawal symptoms and cravings. “It’s troubling to see these ‘so called’ painkiller replacement therapies dispensed by unlicensed clinics getting patients hooked and dependent on another drug, just as they were to prescription pain pills, “said E. Douglas Varney, Commissioner for the Tennessee Department of Mental Health and Substance Abuse Services. “Our statewide, multi-agency Prescription for Success strategy did an excellent job of reducing demand for prescription pain opioid medications. But once again I’m very concerned about what’s emerging in our state.” Tennessee Bureau of Investigation data on recent drug seizures for heroin and buprenorphine shows both substances surfacing as new illicit drugs of choice in Tennessee.   Heroin and Buprenorphine Drug Seizures Rising: 2009 – 2014 82 Heroin seizures in 2009 has increased to 341 seizures in 2014 437 Buprenorphine seizures in 2009 has grown to 1,085 in 2014 *Data does not reflect amount of drug seized   “There were very few heroin seizures by law enforcement in 2011 and 2012,” said Commissioner...

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