Archive for the ‘Books’ Category

Bibliotherapy: Women and Addiction

aaaaaaaaagood book

I’m sorry to post another re-run this week, but i just moved, and my time and energy have been taken up with unpacking. I haven’t made time to write a fresh blog entry this week. Meanwhile, here’s an entry from a few years ago:

If you’ve looked at my blog before, you’ve likely seen that I like to recommend books. I prescribe books as medicine. Looking over my sagging bookshelves, I saw a number of my favorite titles that are specific for women and addiction. While some are a bit dated by now, even those contain information that’s helped me better understand how women, especially pregnant women, have unique needs in their recovery from addiction.

For example, in the past, when I talked to a pregnant patient who was still using drugs, I would tell her every awful thing her drug use could possibly be doing to the fetus. I thought I could scare her into sobriety.

Studies show this approach is associated with a worse outcome for baby and mother than a compassionate and hopeful approach. Pregnant addicts carry a tremendous burden of shame and guilt, as arguably the most stigmatized people in our society. Even other addicts look down on pregnant addicts. So when physicians add to their shame, they tend to run. They leave treatment (physically or mentally), and everyone suffers. With a gentler approach, these women tend to participate in their own treatment.

Duh. Don’t we all do better with gentler approaches?

Anyway, here’s a list of books about women and addiction. Some I have mentioned before, like Women Under the Influence, by the National Center on Addiction and Substance Abuse at Columbia. This is maybe the most comprehensive book, full of references, about addiction in women. Happy Hours by Devon Jersild is more conversational, with excerpt from interviews with women addicted to alcohol, but it also contains solid information. One of the most entertaining, because it is a well-written story told by a female alcoholic is Drinking: A Love Story, by the late Caroline Knapp.

Parched, by Heather King, is similar to Ms. Knapp’s writing, and also worth a read. This book is a well-written, entertaining documentation of an intelligent woman’s descent into alcohol addiction. Thankfully, she also describes her recovery. This is a better-than-average addiction memoir, and hasn’t gotten the recognition it deserves.

Using Women: Gender, Drug Policy, and Social Justice, by Nancy Campbell, written in 2000, is an unusual and fascinating book. It describes how society has viewed female addicts throughout history and how they are frequently judged more harshly than male addicts. Throughout the decades, addicted women don’t do what’s expected of them by their society, and society’s expectations often shaped U.S. drug policies. The author contends that female addicts cause more outrage because they stray so far from assumed female roles. The book is filled with cool black and white photos of sensationalized news stories from the girl addicts of the 1950’s to the crack moms of the 1990’s.

Women, Sex, and Addiction: A Search for Love and Power, by Charlotte Davis Kasl, PhD, 1989, focuses more on the way the inequities of power in relationships shape female behavior with sex and drug use and addiction. The author discusses all sorts of addiction, not just sex or drug addictions. For many female addicts, codependency and sex are strongly intertwined. The book also has sections of lesbian and bisexual lifestyle and addiction, and male codependency and addiction. Some sections were interesting and helpful, and others…not so much. The author uses older terminology, from the time when codependency was more in vogue.

Women on Heroin, by Marsha Rosenbaum, 1981. This book follows the careers of 100 female addicts in a street study. The author talked with a hundred women of many ages and various races to hear what their lives are like, being addicted to heroin. One theme of the book is that initially, drug use gives the illusion of empowering the women, but eventually the need to support their habit steals their power. Women resort to criminal means to support their habits, and this is more difficult for women caring for small children. Treatment programs often don’t consider children can be a strong motivating factor for a woman to get clean, but not if she loses her kids while she goes off to treatment. Lots of quotes from the women she interviews are scattered through the book.
All counselors working with female patients need to read this book to more fully understand how effectively to engage women into treatment. Besides containing useful information, it’s just a really interesting book.

Crack Mothers: Pregnancy, Drugs, and the Media, by Drew Humphries, 1999. Here’s a book bound to stir controversy. The book describes how the “crack baby” was a media invention, not a medical reality. While some children born to women addicted to cocaine had medical issues, we now know these kids didn’t grow up to be the permanently and hopelessly damaged human beings as conjured by the media. This book talks about the racist prosecution of pregnant minority addicts, and how they tended to be the ones to be jailed, while middle and upper class pregnant addicts were able to use their resources to avoid prosecution. In some cases, pregnant women had asked for treatment but were turned away because it wasn’t financially accessible, and they were jailed instead. I thought this book was very interesting and I read it in just a few days.

Substance and Shadow: Women and Addiction in the United States, by Stephen Kandall, The author is a renowned neonatologist, and this book is scholarly, filled with references. I’m reviewing the book from memory, since I loaned it to a friend and I can’t remember who has it. The author talks about the paternalistic methods of physicians in previous centuries, and how their attitudes increased the risk for female addiction to opioids. Then he traces the history of drug policy in the U.S., paying special attention to how women were treated – or not treated – differently. This book is a bit more intense, and not as light or quick reading as most of the others listed.

A Woman’s Way Through the Twelve Steps, and A Woman’s Way Through the Twelve Steps Workbook, by Stephanie Covington, 2000. Compared to the method of working the twelve steps outlined in either AA’s Big Book, or NA’s Step Working Guide, this workbook is a little “fluffy.” It’s a softer way of looking at the steps, and may be quite beneficial for women who have been traumatized by abuse in the past. For some women, harsh rhetoric occasionally heard in 12-step meetings can triggers memories of abuse, verbal or physical. For women who are turned off by more traditional steps guides, this book and workbook offer an alternative. I liked the book better than the workbook. For some people, this could be a great resource.

A Really Good Book – For Free

aaaaaabook

If you haven’t read CASA’s (Center on Addiction and Substance Abuse, at Columbia University) masterpiece publication from June, 2012, titled “Addiction Medicine: Closing the Gap between Science and Practice,” you should do so. This publication can be downloaded for free, and has essential information about addiction and its treatment. http://www.casacolumbia.org/addiction-research/reports/addiction-medicine

Casa also has other free and informative publications about other issues, like how to reduce the risk of addiction in teens (“The Importance of Family Dinners” series), the cost and impact of untreated addiction on society (“Shoveling Up”), substance abuse and the U.S. prison population (“Behind Bars” series), and the availability of drugs on the internet ( “You’ve got Drugs” series). All of these contain useful and thought-provoking data.

“Addiction Medicine: Closing the Gap between Science and Practice” outlines all aspects of what is wrong with addiction treatment in the U.S., along with recommendations about how we can fix this broken system. When it was published in June of 2012, I thought it would be would be widely read and discussed. However, I’ve only heard it mentioned once, and that was at an ASAM meeting. I wish popular press, so eager to write sensationalistic pieces about addiction, would write more fact-based information.

Every politician should read it. Every parent should read it. Physicians and treatment center personnel should read it. Anyone who is concerned about the extent of addiction and its poor treatment in the U.S. should read it.

CASA describes their key findings of the drawbacks of the U.S. system – or non-system – of addiction treatment. This nation is doing many things wrong, to the detriment of people afflicted with addiction, their families and their communities. Our mistakes are based on ignorance, misperceptions, and prejudice. All of these impede our ability to help our people with addiction. The CASA report describes these factors and how they have contributed to our present situation.
Our nation hasn’t waged a war on drugs, but rather on people who use drugs.

The CASA report describes how public opinion about addiction isn’t based on science. Science proves addiction is a brain disease, yet this fact is still debated. We know that continued use of addicting substances alters the structure and function of the brain, affecting judgment and behavior about the continued use of drugs even when bad consequences occur. We know that half of the risk for developing addiction is determined by genetic makeup. Yet surveys show that about a third of U.S. citizens still feel addiction is due to lack of willpower and self-control. Why are public attitudes so disconnected from science?

Addiction is a complicated diagnosis, existing as it does at the end of the continuum from occasional drug use to regular use to compulsive use. People often compare a drug user with a drug addict. They say that since the drug user was able to stop when he wanted that the drug addict should be able to stop when he wanted. This compares apples to oranges. If someone can comfortably stop using drugs when given a good enough reason to do so, this person isn’t an addict. They may be a drug abuser, a problem user, and at high risk for addiction, but they haven’t crossed the line into uncontrollable use.

The CASA report pointed out that most addiction treatment and prevention isn’t done by physicians and health professionals. Most addiction treatment is provided by counselors who, for the most part, aren’t required to have any medical training. Only six states require a bachelor’s degree to become an addiction counselor, and only one (Alabama, go figure) requires a master’s degree.

Even when physicians are involved in the treatment of addiction, most of us have very little, if any, training in medical school or residencies about addiction prevention or treatment. Ironically, most of our training focuses on treating the consequences of addiction.

In medical school and residency, I spent countless hours learning about the proper treatment of cirrhosis, gastritis, anemia, pancreatitis, dementia, and peripheral neuropathy from alcohol addiction. I had little if any training about how to treat alcohol addiction, and none about how to prevent it.

We know brief interventions by physicians during office visits can reduce problem drinking and are an effective way to prevent problems before they occur. Yet few physicians are trained to do this brief intervention. Even if they are trained, primary care physicians and physician extenders are being asked to do more and more at each visit with patients, and asked to do it with less and less time. Primary care providers may not be adequately paid for screening and brief intervention for problem drinking and drugging, and valuable opportunities are lost. Yet that same patient may consume hundreds of thousands of healthcare dollars during only one hospital admission for medical consequences of problem alcohol use.

When I practiced in primary care, I often thought about how I never got to the root of the problem. I would – literally – give patients with serious addiction strikingly absurd advice. “Please stop injecting heroin. You got that heart valve infection from injecting heroin and you need to quit.” I could see it was ineffective, but I didn’t know any better way at the time. I assumed if there was a better way to treat addiction, I’d have learned about it in my training.

Wrong. The doctors who trained me couldn’t teach what they didn’t know themselves.

In my Internal Medicine residency, I admitted many patients to the hospital for endocarditis (infected heart valve) contracted from IV heroin use. Each time, this required six month of intravenous antibiotics. Back then we kept such patients in the hospital the whole time. You can imagine the cost of a six week hospital stay, not that these addicts had any money to pay. Just a fraction of that amount could have paid for treatment at a methadone clinic, the most effective way to treat heroin addiction, and prevent dozens of medical problems.

But I never referred them to the methadone clinic available in that city. I didn’t know anything about methadone or the medical-assisted treatment of opioid addiction, and apparently my attending physicians, responsible for my training, didn’t know about it either. It was a shame, because in those years, the late 1980’s, we were making new diagnoses of HIV almost daily among IV drug users. Since then, a study showed a patient using IV heroin drops his risk of contracting HIV by more than threefold if he enrolls in a methadone clinic.

I didn’t learn about the evidence-based treatment of opioid addiction until I agreed to work at a methadone clinic for a few days, covering for a friend of mine when he wanted to go on vacation. I was amazed to learn about decades of evidence showing the benefits of such treatment.

Most addiction-related medical expenses are paid for from public funds. In fact, over ten percent of all federal, state, and local government dollars are spent on risky substance use and addiction problems. Sadly, over 95% of this money is spent on the consequences of drug use and abuse. Only 2% is spent on treatment or prevention.

Untreated addiction costs mightily. People with untreated addiction incur more health care costs than nearly any other group. An estimated one third of all costs from inpatient medical treatment are related to substance abuse and addiction. Untreated addicts (I include alcohol addicts with drug addicts) go to the hospital more often, are admitted for longer than people without addiction, and require more expensive heath care than hospitalized non-addicts. The complications these people suffer could be from underlying poor physical health and lack of regular preventive healthcare, but most of the cost is incurred treating the medical problems directly caused by addiction and risky substance use.

Family members of people with untreated addiction have higher health costs, too. Families of people with addiction have 30% higher health care costs than families with no addicted member. I presume that’s from the stress of living and dealing with a loved one in active addiction. Often family members are so caught up in trying to control the chaos caused by active addiction that they don’t take time for routine health visits.

The costs of untreated addiction aren’t only financial. Addiction and risky drug use are the leading causes of preventable deaths in the U.S. Around 2.9 million people died in 2009, and well over a half million of these deaths were attributable to tobacco, alcohol, and other drugs. Overdose deaths alone have increased five-fold since 1990.

We know addiction is a chronic disease, yet we spend far less on it than other chronic diseases.
For example, the CASA report says that in the U.S., around 26 million people have diabetes, and we spend nearly 44 billion dollars per year to treat these patients. Similarly, just over 19 million have cancer, and we spend over 87 billion for treatment of that disease. In the U.S., 27 million people have heart disease, and we spend 107 billion dollars on treatment.

But when it comes to addiction, we spend only 28 billion to treat the estimated 40.3 million people with addiction, and that includes nicotine!

Most of the money we do spend is paid by public insurance. For other chronic diseases, about 56% of medical expenses are covered by private payers, meaning private insurance or self-pay. But for addiction treatment, only 21% of expenses are paid from private insurance or self-pay. This suggests that private insurance companies aren’t adequately covering the expense of addiction treatment. Indeed, patients being treated with private insurance for addiction are three to six times less likely to get specialty addiction treatment than those with public insurance such as Medicaid or Medicare. Hopefully we will see a change since the parity law was passed. (which told insurance companies they had to cover mental health and substance addiction to the same degree they cover other health problems)

In the U.S., we don’t treat addiction as the public health problem that it is. Some people still don’t believe it’s an illness but rather a moral failing. Doctors, not knowing any better, often have an attitude of therapeutic nihilism, feeling that addiction treatment doesn’t work and it’s hopeless to try.

Families and medical professionals often expect addiction to behave like an acute illness. We may mistakenly think addiction should be resolved with a single treatment episode. If that episode fails, it means treatment is worthless. Families want to put their addicted loved one into a 28-day treatment program and expect them to be fixed forever when they get out. They’re disappointed and angry if their loved one relapses.

This reminds me of an elderly man I treated for high blood pressure many years ago. I gave him a month’s prescription of blood pressure medication, and when he came back, his blood pressure was good. I was pleased, and I wanted to keep him on the medication. He was angry. He said he was going to find another doctor. He thought the one prescription should have cured his high blood pressure so that he would never have to take pills again, and was disappointed with my treatment.
If we keep our same attitude toward addiction treatment, we are doomed to be as disappointed as my patient with high blood pressure. Addiction behaves like a chronic disease, with period of remission and episodes of relapse.

We have a lot of work to do. As this CASA publication shows, we have to change public attitudes with scientific information and do a much better job of training physicians and other health care providers. We should pay for evidence-based, high-quality addiction treatment, rather than spend billions on the medical problems caused by addiction as we are now doing.

Check out this landmark publication at CASA’s website: http://www.casacolumbia.org

Book Review: Clean: Overcoming Addiction and Ending America’s Greatest Tragedy, by David Sheff

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You may recognize this author’s name, as he wrote Beautiful Boy, a gripping account of his son’s addiction to methamphetamine and the effect the addiction had on the whole family. This second book on addiction is more scholarly than personal, but still thought-provoking.

Clean is well-researched. It’s written with great attention to information and opinions given by experts in the field of addiction, and to scientific research in the field. The author successfully assimilated the information and distilled it into understandable paragraphs. The book is divided into seven sections, titled “America on Drugs,” “Why We Use,” “When Drug Use Escalates,” “Getting Clean,” “Staying Clean,” “Treating a Chronic Illness,” and “Ending Addiction.”

In the first section, “America on Drugs,” Mr. Sheff explains why some humans, particularly adolescents, are more susceptible to addiction. He explains why adolescents begin to experiment with drugs, and describes why drug use is more perilous in young adults. The human brain is still developing until age twenty-five or so, and the structure and function of these immature brains may be more impaired by drugs than more mature brains seen in adults over age twenty-five. The author points out that ninety percent of people in the U.S. who develop addiction start using drugs before the age of eighteen. In other words, the younger someone is at first drug experimentation, the higher the risk of addiction.

The author points out that we tend to see drug addiction as bad behavior rather than the disease that science has clearly proven it to be. (The U.S. puts more of its citizens in jail than any other country in the world as a proportion of the total citizens. Cuba, Rwanda, and Russia all have much lower rates of incarceration. The majority of inmates in the U.S. have addiction that remains untreated while they are incarcerated, all because of the criminalization of addiction. Thus the “war on drugs” is really a war on people who use drugs.)

The author not only outlines risk factors for initiating drug use, but also the risk factors for moving from drug use to drug addiction. These factors include the pleasures of drug use, stress, trauma, poverty, family issues, learning disabilities, behavioral disorders and mental illness. Combinations of these risk factors cause a situation ripe for the development of addiction

Then the author has a long chapter containing ways that parents can offset risk factors for addiction in their children, along with ideas for schools and communities, too. All of this is important information, but the positioning of this chapter was a little jarring to me. It felt like a long chapter about prevention was wedged into a book otherwise devoted to treating addiction. I agree it’s an important topic, perhaps deserving a separate section or even a separate book.

Another section of the book describes warning signs of addiction, and provides information about how professionals assess for addiction. There’s a chapter about interventions and how they can be done – as well as some dangers involved with staging interventions.

I liked the chapter about detox. The book explains the different ways of detoxing, and says detox is only the beginning of treatment, an important idea for families and addicts to understand.
The author goes into some specific details about the types of therapies addict receive in the course of treatment for addiction.

The next section of the book is all about getting clean: the difficulties addicts and their families have in finding appropriate treatment. The book describes what usually happens in a drug addiction treatment facility, and gives some ideas about things to look for in a good treatment center.

Twelve step recovery occupies a lengthy chapter in this book. I thought the author was even-handed and presented what we know about these programs, including that they don’t work for everyone

Part of the book describes evidence-based treatments, and that’s helpful, but the author doesn’t mention that many treatment programs don’t use – or under-use – evidence-based treatments. He also describes warning signs which may indicate a program should be avoided. He talks about the cost of treatment, and some of the difficulties of insurance payment for treatment.

There’s plenty of scientific information in the book, and it’s mixed with anecdotes of addicts and family experiences. The information was accurate; I didn’t detect any blatantly bad science.

I enjoyed the chapter titled provocatively titled, “Treating Drug Problems with Drugs.” Aside from a few misstatements and minor misinformation, it’s great. Granted, this chapter is nine pages long, in a three-hundred and thirty-one page book, but that’s better coverage than most popular books on addiction treatment give medication-assisted treatment of opioid addiction (which is, as you know I’m fond of saying, one of the most evidence-based treatments in all of medicine, let alone addiction medicine). This chapter talks mostly about methadone but there are several pages on buprenorphine, too. Sadly the brand name “Suboxone” is used repeatedly in this chapter instead of the more appropriate “buprenorphine” but hey, I’m not gonna quibble too much. I’m just happy this information was included.

The author does point out some of the weaknesses of our prevailing addiction treatment system, but he does so in a gentler manner than in the book, Inside Rehab, by Anne Fletcher. I reviewed Inside Rehab earlier this year on my blog, and I preferred it to Clean. In Fletcher’s book, she’s emphatic to the point of being spew-y; that made her book interesting. Sheff’s book is accurate but more docile and polite. Inside Rehab is more of a “Hey wake up!” in tone.

Both books are good additions to the plethora of books about addiction and recovery, and I recommend both to any readers interested in the subject.

Book Review: “Inside Rehab: the Surprising Truth about Addiction Treatment – and How to Get Help that Works,” by Anne Fletcher

Inside Rehab

This meticulously-researched book is excellent, and I highly recommend it to people entering treatment, and to their families. I also think everyone working in the field of addiction treatment needs to read the book and ponder the truths it reveals.

The book is more scholarly than I was expecting; the author researched studies, statistics, data, and talked to experts in the field of addiction treatment. She visited addiction treatment programs, and though half of them were located in her home state of Minnesota, she did investigate a wide variety of addiction treatment approaches. She talked with the people who worked at these programs and also talked to a large number of people seeking recovery from addiction. Some people had success with treatment, and some didn’t.

The “surprising truth” she refers to in her title isn’t surprising to anyone who read the milestone report issued last summer from Casa Columbia, the New York City think tank that studies addiction treatment. I did a blog on that report (see August 9th, 2012), one of the most important, evidence-based, exhaustive statements made about the state of addiction treatment in this country. I hoped this paper would be talked about and its conclusions taken seriously, but the addiction treatment field appears to have greeted CASA’s landmark paper a collective giant yawn, and gone back to business as usual.

Repeatedly, this author refers to CASA’s report, and her investigative book mirrors CASA’s findings closely. In fact, I would describe Ms. Fletcher’s book as an expanded, more interesting version of that CASA report.

“Inside Rehab” explains how addiction treatment has been abandoned by the medical field long ago. The lack of addiction science in past decades contributed to this exodus, as did the rise of the 12-step movement and the Minnesota Model. Doctors get very little training about addiction and its treatment, and the medical field views addiction not as a medical problem but as a social problem. Most doctors are happy to direct addicts to counselors rather than begin treatment with evidence-based medications. The author points out that even treatment centers rarely use or recommend medications that are proven to work, like naltrexone, acamprosate, disulfiram, buprenorphine and methadone. The author talks about how science takes a very long time to be implemented into real-life practices. This would not be tolerated in any other field of medicine.

The author says many treatment centers have not incorporated evidence-based treatment approaches, and have stayed stuck in the past, using the same treatments now as were used in the 1980’s. She’s right. Older methods that don’t show any benefit are still being used, like educational lectures, aggressive patient confrontation, and the like. The author points out how the addiction treatment field is still dominated by thinking that’s guided by folk wisdom, much of it from laypeople in recovery themselves, rather than science. Few programs offer evidence-based treatments like CBT (Cognitive Behavioral Therapy), MI (Motivational Interviewing), contingency management, community reinforcement approach, and even twelve-step facilitation. Programs promoting 12-step philosophy rarely use the actual Twelve Step Facilitation method as tested in research studies with demonstrated benefits. Instead, they use kind of a freestyle method. It may work; it may not.

The author correctly points out that workers in the field of drug and alcohol addiction treatment often have little training and may lack professionalism. Addiction treatment workers with little education can end up trying to treat people with some of the most complex medical problems, particularly people with addiction and co-occurring mental health issues. Counselors have been allowed to “grandfather in” and obtain certifications because of the length of time they’ve been working in the field, rather than returning to school for additional education.

The author talks about the lack of licensing requirements for the addiction counselors, and how certification organizations like CARF and JCAHO both only ask facilities to comply with state regulations. These organizations could instead call for higher standards for certification, including minimum standards for education.

She is rightfully critical of the “one size fits all” approach to people with addiction. Many treatment programs claim to individualize their treatment to fit the individual, but in reality, everyone gets assigned to the same groups, with little or no attention to specific issues. The claim of individual treatment in some cases appears to be more of a marketing ploy than an actual practice.

She criticizes over-reliance on 12-step recovery as a treatment for all people. I was happy to see Ms. Fletcher included the evidence showing 12-step recovery participation does improve the chances for abstinent recovery. But she feels patients shouldn’t be forced to go to 12-step recovery if they don’t want to go, and I agree with her. She also points out that non-12-step groups likely also improve recovery, though there’s been little if any research on them. She feels treatment programs need to offer these non-12-step options to patients in addiction treatment.

I agree with that too, but unless you live in California, those meetings are hard to find. Women for Sobriety, one of the groups she mentioned in the book, had eight meetings per week held in the state of North Carolina when I investigated that organization a few years ago, trying to find alternatives for a patient of mine who didn’t like 12-step meetings. That’s compared to 12-step meetings, which have hundreds, possibly thousands of meetings per week across the state. Alternative to AA and NA may work…but there are difficult to find, at least in my area. Online meetings may be of some help.

She made some insightful remarks about how when treatment facilities try to associate themselves with AA, it’s AA that suffers. That’s a good point. Some AA members aren’t happy to have their meeting flooded with patients from a local treatment center, who in some cases don’t really want to be there. Some meetings won’t sign attendance forms for a probation officer that’s forcing someone to go to AA. Some groups believe it’s against one of AA’s traditions that says people should come to AA because they’re attracted to it, not enticed or forced to go. I’ve heard AA members talk derisively about inpatient treatment rehabs where the only treatment offered is AA-type group meetings. They argue that people could do this on their own, for next to no cost. If someone seeking recovery lives in a big city, he could probably get to four or five meetings each day. One might wonder how much advantage is there to an inpatient program that costs tens of thousands of dollars where little more is offered than AA-type group meetings?

She has chapters devoted to the treatment of adolescent addicts, an area rife with controversy. Not all adolescent drug abusers will continue on their way to becoming addicts, yet some will. How can we tell who needs treatment and who doesn’t? We don’t have distinct answers yet, and it may lead to over- treatment of adolescents.

I do have a few minor complaints about the book. She’s quoted people who have been to treatment, who describe shoddy treatment they’ve received. I’ve no doubt much of it is true, but some of it sounds exaggerated, to say the least. I might take these descriptions at face value, but I’ve heard many patients tell exaggerated stories. For example, I had a patient (not an addict) tell me her last doctor beat her with a hammer. I was incredulous, but she insisted it was true. As I asked for specifics, it became apparent her previous doctor didn’t beat her with a hammer; he checked her reflexes with a small rubber mallet.

So…patient statements are helpful, but may not be as accurate as Ms. Fletcher believes. I understand the point Ms. Fletcher’s interviewed patients are making, and most of what they say may be true. Or it may not be true.

In one vignette, an addict criticized his doctor for not being willing to “help him out” with prescribed opioid medication to help him avoid opioid withdrawal and taper his opioid use. Unfortunately the book’s author pounced on that bandwagon, apparently unaware that it’s a crime for a physician to prescribe opioids from an office setting to treat addiction, unless it’s Suboxone from a licensed provider. I was sad she criticized the doctor, and that she seemed eager to believe the worst about the physician, when in fact the doctor could be charged with a crime if he complied with the patient’s request.

My other beef with her book is her relatively brief coverage of medication-assisted treatment with methadone and buprenorphine. She does mention these medications throughout the book, and correctly points out how traditional Minnesota model treatment centers aren’t using this evidence-based medication. But I think medication-assisted treatment of opioid addiction deserved a chapter of its own. It’s the most evidence-based treatment, possibly in all of medicine, and is actually being discouraged by most big-name treatment centers. That’s an outrage. (Even though Hazelden last year announced they would start to use buprenorphine, they are using it only for detox, and still discourage maintenance. See my blog post from Nov. 20, 2012.)

I had mixed feelings when reading the book. I agreed with most of what the author said, yet it’s hard to read about criticism of the field when I’m a part of it. I found myself wanting to be defensive, but in the end Ms. Fletcher has written some much-needed truths. The book is directed at the educated layperson, and the information is accurate. If addiction treatment professionals aren’t offering the best of treatments, patients need to take the initiative and get into programs that do offer the best, state of the art treatment. That’s the concluding message of this book. Ask questions before you go to treatment, and vote with your feet and your dollars.

It’s a great book. I wish all addiction treatment providers could read it, along with all medical students, doctors, nurses…OK, everyone should read it.

You can read more about the author of the book here: http://annemfletcher.com/

Craving: a Book Review

cravingI just read a great new book related to addiction.

“Craving: Why We Can’t Seem to Get Enough” was written by Omar Manejwala, M.D., a friend of mine, a nationally renowned addiction psychiatrist, and an expert on compulsive behaviors of all kinds. This nonfiction book is, as the title suggests, all about the phenomenon of craving. It is published by Hazelden and will be released today. You can go to this link to buy the book: http://www.amazon.com/dp/1616492627/?tag=ommamd-20

Dr. Manejwala has been the medical director of Hazelden and other prestigious addiction treatment facilities, and has worked with all sorts of addicts including addicted healthcare professionals. He’s even appeared on television on show like 20/20.

This book is about more than just drug addiction; his information about craving pertains to any substance or activity. I love his definition of craving as a desire so strong that when unfulfilled “produces powerful physical and mental suffering.” (p2) His description of craving is eloquent and easily understood.

In this book Dr. Manejwala explains abstract ideas and concepts in plain language. I’ve heard him give lectures on addiction-related topics and I’ve always been impressed his skill of distilling the complicated into understandable bits. His writing also shows this gift. Though his book is easy to understand, it’s not dumbed down, as too many books on addition written for the public tend to be.

The first part of the book defines cravings and compares them to weaker wants and urges. He tells us why cravings matter: cravings lead all of us to indulge in behaviors that undermine success. In subsequent chapters, Dr Manejwala gives some simple information about brain anatomy and neurotransmitters, and shows how the brain’s structure and function affect our ability to make choices.

In a later chapter he shows how cravings can drive not only behavior, but also thought patterns, in some really interesting ways. When a person intends to act on a craving that is obviously destructive, all sorts of irrational and false beliefs can pop up, and seem to make perfect sense. These thought patterns keep the person stuck in destructive behaviors for long periods of time, leading to negative life consequences.

Another chapter shows how addictive behaviors tend to be related; that is, how a person with alcohol addiction is more likely to have or develop addictions to other drugs. That person is also more likely to develop a behavioral addiction like gambling, compulsive overeating, or compulsive shopping. This chapter explains why these behaviors can occur together.

My favorite chapter is about the brain’s plasticity. The term “plasticity,” when applied to the brain, means the brain is changeable. Our thoughts, actions, and experiences actually change the structure and functioning of the brain. This is important, because it means there are things we can do to change our cravings. Dr. Manejwala explains how thoughts, behavior, and even spirituality can free us from cravings. This fascinating chapter has some great references, too.

The next chapter tells more about how spirituality is important to recovery. The author explains why 12-step recovery and other spiritual approaches work to reduce cravings. He explains specifically how groups help reduce urges and improve behavior in ways that can’t be done by a lone individual.

Later chapters explain how insight into problem behavior is only a start in the direction of change, and how many people mistakenly think facts alone will reduce cravings. This chapter clarifies how apparently irrelevant decisions can actually be subconscious decisions to act on a craving. In this chapter, healthier substitute activities are suggested. The latter chapters have solid advice on where to go to find help with problem behaviors, and have specific tips to help with cravings for smoking, alcohol and other drugs, sugar, gambling, and internet addiction.

This gem of a book is relatively short, at 190 pages, and highly readable. I’m keeping it on my bookshelf for the references listed in the back.

This book will help addiction professionals be better able to explain cravings and addiction to patients. Anyone who has ever tried to squelch a craving – unsuccessfully – by willpower alone will be interested in this book.

Don’t miss this book if you’re interested in book about addiction and recovery.

Finding a Better Way to Treat Addiction

In my previous blog, I mentioned a great new resource that CASA has published about the condition of addiction treatment in this country. The book, “Addiction Treatment: Closing the Gap between Science and Practice,” is available for free as a download at http://casacolumbia.org

I’ve been reading this document in detail, finding facts that support what I see in the real world of treatment. In the U.S., our approach toward funding of addiction treatment is exactly backwards. We spend a relatively small amount on prevention and treatment of the actual disease of addiction, but billions on the constellation of medical issues caused by addiction.

Most addiction-related medical expenses are paid for from public funds. In fact, over ten percent of all federal, state, and local government dollars are spent on risky substance use and addiction problems. Sadly, over 95% of this money is spent on the consequences of drug use and abuse. Only 2% is spent on treatment or prevention.

Untreated addiction costs mightily. People with untreated addiction incur more health care costs than nearly any other group. An estimated one third of all costs from inpatient medical treatment are related to substance abuse and addiction. Untreated addicts (I include alcohol addicts with drug addicts) go to the hospital more often, are admitted for longer than people without addiction, and require more expensive heath care than hospitalized non-addicts. The complications these people suffer could be from underlying poor physical health and lack of regular preventive healthcare, but most of the cost is incurred treating the medical problems directly caused by addiction and risky substance use.

That data is consistent with my experiences when I worked in primary care. I always felt like I was slapping Band-Aids on gaping wounds when I treated people with alcohol or other drug addictions. I never felt like I was treating the real problem, and I wasn’t, as this report so eloquently indicates. My practice had a handful of “frequent fliers” who came to the ER several times per month with the same addition- related illnesses, over and over. I admitted one patient to the hospital at least twenty times over four years for the treatment of alcoholic gastritis. Each hospital visit lasted four or five days until he was well enough to go home and drink again. Another patient was admitted about every two months after he got pancreatitis from another bout of binge drinking. This went on for years.

This was in the early 1990’s, in my former life as a doctor of Internal Medicine. I didn’t know what to do with these people. They frustrated me. Maybe I told these patients to go to Alcoholics Anonymous, and probably I asked the social worker to arrange inpatient treatment if possible. But I didn’t have the knowledge or tools to really help these people, and instead only did what I was trained to do: treat the medical problems caused by addiction.

In my Internal Medicine residency, I admitted many patients to the hospital for endocarditis (infected heart valve) contracted from IV heroin use. Each time, this required six month of intravenous antibiotics. Back then we kept such patients in the hospital the whole time. You can imagine the cost of a six week hospital stay, not that these addicts had any money to pay. Just a fraction of that amount could have paid for treatment at a methadone clinic, the most effective way to treat heroin addiction, and prevent dozens of medical problems. But I never referred them to the methadone clinic available in that city. I didn’t know anything about methadone or the medical-assisted treatment of opioid addiction, and apparently my attending physicians, responsible for my training, didn’t know about it either. It was a shame, because in those years, the late 1980’s, we were making new diagnoses of HIV almost daily among IV drug users. Since then, a study showed a patient using IV heroin drops his risk of contracting HIV by more than threefold if he enrolls in a methadone clinic.

Family members of people with untreated addiction have higher health costs, too. Families of people with addiction have 30% higher health care costs than families with no addicted member. I presume that’s from the stress of living and dealing with a loved one in active addiction. Often family members are so caught up in trying to control the chaos caused by active addiction that they don’t take time for routine health visits.

The costs of untreated addiction aren’t only financial. Addiction and risky drug use are the leading causes of preventable deaths in the U.S. Around 2.9 million people died in 2009, and well over a half million of these deaths were attributable to tobacco, alcohol, and other drugs. Overdose deaths alone have increased five-fold since 1990.

We know addiction is a chronic disease, yet we spend far less on it than other chronic diseases.

For example, the CASA report says that in the U.S., around 26 million people have diabetes, and we spend nearly 44 billion dollars per year to treat these patients. Similarly, just over 19 million have cancer, and we spend over 87 billion for treatment of that disease. In the U.S., 27 million people have heart disease, and we spend 107 billion dollars on treatment.

But when it comes to addiction, we spend only 28 billion to treat the estimated 40.3 million people with addiction, including nicotine. Most of the money we do spend is paid by public insurance. For other chronic diseases, about 56% of medical expenses are covered by private payers, meaning private insurance or self-pay. But for addiction treatment, only 21% of expenses are paid from private insurance or self-pay. This suggests that private insurance companies aren’t adequately covering the expense of addiction treatment. Indeed, patients being treated with private insurance for addiction are three to six times less likely to get specialty addiction treatment than those with public insurance such as Medicaid or Medicare.

In the U.S., we don’t treat addiction as the public health problem that it is. Some people still don’t believe it’s an illness but rather a moral failing. Doctors aren’t educated about addiction is medical school or residencies, and we often have an attitude of therapeutic nihilism, feeling that addiction treatment doesn’t work and it’s hopeless to try.

Families and medical professionals often expect addiction to behave like an acute illness. We may mistakenly think addiction should be resolved with a single treatment episode. If that episode fails, it means treatment is worthless. Families want to put their addicted loved one into a 28-day treatment program and expect them to be fixed forever when they get out. They’re disappointed and angry if their loved one relapses.

This reminds me of an elderly man I treated for high blood pressure many years ago. I gave him a month’s prescription of blood pressure medication, and when he came back, his blood pressure was good. I was pleased, and I wanted to keep him on the medication. He was angry. He said he was going to find another doctor. He thought the one prescription should have cured his high blood pressure so that he would never have to take pills again, and was disappointed with my treatment.

If we keep our same attitude toward addiction treatment, we are doomed to be as disappointed as my patient with high blood pressure. Addiction behaves like a chronic disease, with period of remission and episodes of relapse.

We have a lot of work to do. As this CASA publication shows, we have to change public attitudes with scientific information and do a much better job of training physicians and other health care providers. We should pay for evidence-based, high-quality addiction treatment, rather than spend billions on the medical problems caused by addiction as we are now doing.

Check Out CASA’s New Free Publication

If you’ve never browsed CASA’s website, you need to do so. CASA, which stands for Center on Addiction and Substance Abuse, at Columbia University, has helpful information about addiction and its treatment that you can download for free. They have information about how to reduce the risk of addiction in teens (“The Importance of Family Dinners” series), information about the cost and impact of untreated addiction on society ( “Shoveling Up”), in formation about substance abuse and the U.S. prison population (“Behind Bars” series), and the availability of drugs on the internet (the “You’ve got Drugs” series). All of these contain useful and thought-provoking data.

This summer, they published a masterpiece: “Addiction Medicine: Closing the Gap between Science and Practice.” I’ve read most of this book, and admire the clarity and call to action it presents. This publication outlines all aspects of what is wrong with addiction treatment in the U.S., and how to fix it.

Every politician should read it. Every parent should read it. Physicians and treatment center personnel should read it. Anyone who is concerned about the extent of addiction and its poor treatment in the U.S. should read it.

CASA describes their key findings of the drawbacks of the U.S. system – or non-system – of addiction treatment. This nation is doing many things wrong, to the detriment of people afflicted with addiction, their families and their communities. Our mistakes are based on ignorance, misperceptions, and prejudice. All of these impede our ability to help our people with addiction. The CASA report clearly describes these factors, saying they all contributed to our present situation. We have declared a war on people who use drugs, not on drugs.

The CASA report describes how public opinion about addiction isn’t based on science. We now have science that proves addiction is a brain disease. We know that continued use of addicting substances alters the structure and function of the brain, affecting judgment and behavior about the continued use of drugs even when bad consequences occur. We know that at least half of the risk for developing addiction is determined by one’s genetic makeup. Yet surveys show that about a third of U.S. citizens still feel addiction is due to lack of willpower and self-control. Why are public attitudes so disconnected from science?

Addiction is a complicated diagnosis, existing as it does at the end of the continuum from occasional drug use to regular use to compulsive use. People often compare a drug user with a drug addict. They say that since the drug user was able to stop when he wanted that the drug addict should be able to stop when he wanted. This compares apples to oranges. If someone can comfortably stop using drugs when given a good enough reason to do so, this person isn’t an addict. They may be a drug abuser, a problem user, and at high risk for addiction, but they haven’t crossed the line into uncontrollable use.

The CASA report illuminates what addiction medicine physicians have been saying for years: addiction treatment and prevention isn’t treated by physicians and health professionals. Most addiction treatment is provided by counselors who, for the most part, aren’t required to have any medical training. Only six states require a bachelor’s degree to become an addiction counselor, and only one (Alabama, go figure) requires a master’s degree.

Even when physicians are involved in the treatment of addiction, most of us have very little, if any, training in medical school or residencies about addiction prevention or treatment. Ironically, most of our training focuses on treating the consequences of addiction.

In medical school and residency, I spent countless hours learning about the proper treatment of cirrhosis, gastritis, anemia, pancreatitis, dementia, and peripheral neuropathy from alcohol addiction. I had little if any training about how to treat alcohol addiction, and none about how to prevent it.

We know brief interventions by physicians during office visits can reduce problem drinking and are an effective way to prevent problems before they occur. Yet few physicians are trained to do this brief intervention. Even if they are trained, primary care physicians and physician extenders are being asked to do more and more at each visit with patients, and asked to do it with less and less time. Often, primary care providers aren’t paid to do brief interventions, and an opportunity for prevention is lost. Yet that same patient may consume hundreds of thousands of healthcare dollars during only one hospital admission for the consequences of with alcohol addiction.

When I practiced in primary care, I often thought about how I never got to the root of the problem. I felt like I was slapping Band-Aids on gaping wounds. I would – literally – give patients with addiction strikingly absurd advice. “Please stop injecting heroin. You got that heart valve infection from injecting heroin and you need to quit.” I could see it was ineffective, but I didn’t know any better way at the time. I thought if there was a better way to treat patients, I’d have learned about it in my training.

Wrong. Instead, I learned about this vast body of scientific literature about addiction treatment by accident, when I worked at an addiction treatment center for a few days, covering for a doctor friend of mine.

In coming blogs, I’ll outline more of the points made by this timely publication. In the meantime, read it for yourself at  http://www.casacolumbia.org

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