Response to Stanton Peele in The Fix
Feb10

Response to Stanton Peele in The Fix

On February 2 of this year, The Fix published a piece by Stanton Peele entitled “Legalizing Drugs Challenges the Addiction Brain Disease Theory.” I’ve never heard anything in my understanding of addiction as a brain disease that has anything to do with the legal status of drugs, so I thought I’d take a look. It’s a pretty difficult piece for me to follow, but then, I’m just a simple brain doctor. He starts by asking the question, “What if more, and more open, use leads to fewer addictive problems?” A salient question having nothing to do with the premise promised by the title, but we can start with that. He doesn’t move directly to the answer though but detours through a societal comment in which “no organization has greater prestige and acceptance in America than Alcoholics Anonymous.” Really? The Boy Scouts? The Red Cross? The AMA? Really? No one sees membership in any organization as more prestigious than membership in AA? No wonder all those Distinguished Fellows of  the American Psychiatric Society recently; they all wanted to join AA for the prestige. And more acceptance? No organization is more accepted than AA? Here’s a test. Go on 10 job interviews all of which are exactly the same except for one thing. In each one mention a different extracurricular activity: bowling, charity work, AA, etc. Let’s see which one gets you the job. But Dr Peele isn’t finished the detour yet. He then states that AA says that “alcohol can be deadly and uncontrollable.” Well, AA says that about alcoholics, but also says that people without the illness clearly can drink with impunity. Further AA goes out of its way to not have an opinion about alcohol in society. That is a position the organization takes so that it can be free of entanglement with outside issues and free to be of the most help to alcoholics seeking a way to stop drinking. I think the detour is now over, and Dr Peele gets to his point. He quotes a blog by Stephanie Castillo writing for Medical Daily as an authority of the scientific foundation of the disease model of addiction. He then tries to hit closer to the mark by targeting the support of NIDA director, Nora Volkow, as a foundation of the science underpinning the disease model. Yet again he quotes, not the science, but an article about The Myths of Smoking Pot written by Ruth Marcus of the Washington Post. After this strenuous foundation showing that there is some disease model of addiction that says that drugs are bad, Dr Peele then moves to destroy this unsupported straw man by showing...

Read More
In Defense of the Geographic Cure Seekers
Jan19

In Defense of the Geographic Cure Seekers

A geographic cure is when someone in active addiction looks around at the wreckage of their lives and figures out that everything would be better if they pulled up stakes and lit off to a fresh start somewhere else. According to recovery wisdom, this doesn’t work, because it is predicated on the assumption that we will be leaving the problem behind. Further, because to believe that we’ll leave the problem behind is a denial of the repeated evidence that the problem is within us, the person trying a geographic cure is crazy. I’m not here to tell you that a geographic cure works. It doesn’t work for addiction. But, I am here to explain why it isn’t as crazy as it sounds, and why it makes perfect sense to the person trying it. Anyone who has been reading this blog or has read QAA will remember that lowered reward center dopamine tone is one of the manifestations of the human famine signal. Specifically, dopamine tone going down over time as a result of continued using is a pretty good proxy for food running out. That’s especially true when the brain gets other signals that caloric intake is low because we actually have been eating less because of active drug use. So what is the rational thing to do in a famine? Well, for us it might be to go to the grocery, but for our ancestors, that wasn’t possible. We are a nomadic species, or we have been for most of our history. Our brains being hard wired to assume that the problem is the environment, and to move to a new spot during a famine, isn’t such a bad survival mechanism. Sure it doesn’t make sense if you have some control over your environment, but our species has only had that ability for around 10,000 years, and to the degree we take for granted today, only for a few generations. If our ancestors had helicopters or satellites we might have evolved differently, but for 99.9% of our history, the only way to see over the horizon was to walk there. It makes perfect sense to the brain with addiction that if you’ve used up the resources in this area the best thing to do is to move somewhere else. There’s a reason most humans think the grass is always greener on the other side of the fence. It isn’t a thought from our cortex; it’s a drive from our midbrain, “This place doesn’t have enough sources of dopamine tone – GET OUT!” So next time you run into someone thinking about a geographic cure, remember that it makes perfect sense to them and...

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
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
Rural Addiction
Sep27

Rural Addiction

If you haven’t heard, there’s an epidemic of opioid overdose deaths in America. The US Centers for Disease Control (CDC) said of 2013 that 44 Americans died every day that year from overdoses on prescription pain meds. That’s a lot of preventable deaths. In fact, accidental overdose (poisoning in CDC lingo) has become the leading cause of accidental death, outpacing automobile accidents. As is obvious to all, a large percentage of those deaths by opioid overdose are in people who have addiction. There are two approved medical treatment strategies of addiction involving opioids: agonists and antagonists. Antagonists are chemicals that block the opioid receptor making it impossible for a taken opioid to have an effect. Of course, most people with addiction involving opioids don’t see antagonists as a useful strategy and so they did not take off in popularity until the once-a-month injectable form became available a few years ago. Antagonist treatment is freely available with no limits on prescription, but the once-a-month injection is still an expensive route. In addition, there are two types of agonist treatment: full agonists and partial agonists. Full agonists, such as methadone, are available only in special clinics which require daily attendance, and have evidenced a number of social problems that stem from their facility of congregating an ill population in a single location at a particular time. These problems have led some states to ban or severely limit such clinics. Such states, like North Dakota, South Dakota, West Virginia, Vermont, and New Hampshire, are oddly among those most greatly hit by the opioid epidemic. Such states and the rest of the country could turn to partial agonist treatment for the last decade or so, allowing those requiring treatment to be seen in their own doctor’s office and avoiding the “not in my backyard” worries seen with methadone clinics. It was the hope of the federal government, that by allowing buprenorphine partial agonist treatment in doctor’s offices, we would see the expansion of addiction treatment and the integration of it with primary healthcare. That hope has not come to fruition for at least two reasons. First, partial agonist treatment has been  limited by the number of patients that each willing doctor can treat. That would have worked if the expansion into primary care had worked. The idea was that most doctors in the country would be treating addiction the same as they did anything else, so there was no reason why anyone would need to treat more than 100 patients. This has not proved to be the case, as evidenced by the expansion of the opioid overdose epidemic in the same time without a great increase in the capacity for addiction treatment. Not only have the number of doctors seeking...

Read More