Archive for the ‘Treatment Centers Behaving Badly’ Category

We are More Than Our Disease

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Imagine you are a diabetic, complaining to your doctor’s office manager about poor treatment you’ve received by the doctor’s staff. How would you feel if the office manager said something like this?

“That’s just your disease talking. Your perceptions are wrong because your diabetes wants you to feel resentment and self-pity. Your diabetes wants to give you an excuse to go back out there and eat a bunch of sweets. Your diabetes has you confused. You really weren’t mistreated. Your thoughts and feelings aren’t real.”

Sounds kind of nutty, doesn’t it? Yet people with addiction are sometimes told similar things by their treatment programs.

While it is true that addiction can damage the structure and function of the brain, patients don’t lose all their higher brain functions and often have very accurate perceptions.

This week I encountered a patient who said workers at his opioid treatment program discounted his legitimate complaints about problems he saw at his program. He said he felt like personnel at this program thought because he was an addict, he didn’t know what he was talking about and had no right to complain.

I listened to him, and what he said resonated with me.

I outed myself a few months ago on this blog as a person in recovery. I’ve been abstinent from drugs and alcohol for over sixteen years, and my recovery is one of the most precious possessions I have. And yet, I do remember similar frustrations with my treatment program.

I went to an intensive outpatient treatment program many years ago. It was highly recommended by other doctors in recovery, so I hadn’t shopped around for treatment programs. Besides, who has any idea what to look for in a drug addiction treatment program? I just followed the recommendations of my state’s physicians’ health program.

I do admit that my brain had been damaged by drugs and by withdrawal. I knew my perceptions were not completely reliable, and yet, sometimes I heard my counselors say things that I knew were not OK, and that were offensive to me. I can’t remember exact words after so many years, but the essence of their remarks was I wasn’t able to think clearly, all my perceptions were wrong, and I had no right to be angry about anything, including disagreements with treatment staff.

Which is a rather convenient position to take if you are treatment staff. Essentially, you win any argument with patients, because you can say the patient’s brain is damaged, yours isn’t, so therefore you are right and the patient is wrong.

I remember when I was in aftercare, I overhead a comment made by my counselor to another counselor about another patient who frequently relapsed: “She can’t come to aftercare because she keeps getting drunk.”

His breach of her confidentiality was bad enough, but when I heard him I thought, “Aha! All this talk of disease, but he doesn’t really believe it or he wouldn’t blame her like this.”

Yes, maybe my brains were still scrambled, but I got that one right.

Now I’m on the other side of the treatment fence, and things look different. I think there is a temptation to take the easy way out when faced with a patient complaint, and dismiss the complaint as being irrelevant.

I’m not rising up on a self-righteous scold of all treatment staff; I’m writing this blog as much for me as other staff.

We must always be able to look honestly at our actions and attitudes as addiction treatment professionals. If a patient complains, we need seriously to evaluate our behavior.

For me, it helps to have a good treatment team around me, who are willing to tell me if I’m off the mark with my thinking. I also do my own mini-inventory at the end of each day (OK most days). Did I treat people the way I’d like to be treated? Did I try to do the best thing for them? Sometimes this means making a decision that angers patients or angers treatment staff.

Most importantly, when I’m with a patient, I want to remember he may have drug addiction, but that’s only one small part of who he is. He’s also other important things. For example, this person may also be a son, father, husband, artist, good provider for his family, have a great sense of humor, etc. Treating the addiction should help him get back to being himself. He is so much more than just an addict. Sadly, many of our patients have family who have written them off as “Just an addict,” and are no longer able to appreciate their wonderful qualities and talents.

Addiction treatment personnel: Let’s not make the same mistake.

What I’ve Learned In My Travels

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I just heard from a friend of mine who was the medical director at another opioid treatment program. He’d just been fired. Why? He was told the OTP was going to “go in another direction” with their program. Yep, there’s more to the story, but it’s not for publication.

My friend called me because I’ve also been – kind of – fired by the same program. Now I look back on that time as amusing, but it wasn’t funny at the time.

I had worked for this program for seven years. I loved it; I was enthusiastic about my work and delighted I’d found my niche in medicine. I threw my heart and soul into the work. I worked with wonderful nurses and counselors on the front lines. With few exceptions, they were conscientious people dedicated to doing their best to help the addicts seeking treatment.

And then there were the administrators that ran the program. Let’s just say I lacked the ability to enjoy the personalities of a few administrators at the top of the organization.

I enjoyed these people even less after they – sort of – fired me. One of them called me to his office and said they were going to replace me as medical director with a doctor who started a few months earlier. He was willing to work full-time (I wasn’t) and to work at their main campus (I wasn’t – too close to the administrators). I said fine, I understand, that makes sense. This administrator then said he hoped that I would stay on, and continue to be part of their organization.

I said yes, though I’d have to be guaranteed at least 10 hours of work per week for it to be financially feasible for me. He stammered a non-answer, said he’d have to talk to the agency’s president, and that he’d get back with me. On my way out, I was handed a revised schedule for the present month. When I looked at this new revised schedule…I was no longer on it! All of my scheduled hours had been replaced with a variety of other doctors.

OK. Message transmitted. Message received.

My feelings were hurt. I was deeply wounded that despite my loyalty to this OTP, they didn’t value my work. I never would have left that place had I not been forced out.

I’ve traveled down a few roads since then, and have learned many things. Most of all I’ve discovered that leaving that OTP was one of the best things that ever happened to me and my career. When I worked at other OTPs, I discovered new and better ways to do things. I gradually recognized that the reputation of that OTP may have tainted my reputation. After leaving that OTP, I was asked to speak at conferences. I sensed I was more highly regarded by the other doctors working at OTPs in our state, though I could be wrong about that.

I’ve worked treating opioid addiction for nearly thirteen years, and I’ve worked in five separate OTP systems at fourteen different clinic sites. Every site did things a little differently, and I like to think I’ve learned from all of them. The two OTPs where I work now are by far my favorites. These two systems allow me as a physician to decide what’s best for the patient, and both systems try hard to give the best possible care for the opioid addicts they treat.

And here’s a list of things I’ve learned the hard way from the OTPs I didn’t like so much:

1. If an organization has to repeat ad nauseum that they treat patients with dignity and respect, watch out. Dignity and respect should be assumed. There should be no need to crow about it. And if you really want to know what kind of people the administrators are, see how they treat their employees.
2. Never agree to work for a person who calls herself an Apostle. Duh.
3. When the first paycheck bounces, it’s time to quit. It’s not going to get better.
4. Some administrators speak with forked tongue. If the individual is also a lawyer, he’s likely speaking out the side of his neck with his forked tongue.
5. If the CEO of the for-profit company calls a patient at home to contradict the doctor…it’s time for the doctor to formulate an exit strategy. Quickly. And file a complaint with the state methadone authority on the way out the door.
6. If an OTP treated a previous doctor poorly, they WILL do the same to you. It’s only a question of when.
7. If your OTP is using a DOS-based system as of 2008, the IT department is hopeless. If an update is planned, it probably involves a chisel and stone tablet.
8. Why yes, the head of personnel, who dresses in black when she travels to program locations to fire people, does have a personality disorder.
9. The president of the organization, who has been successfully sued for firing a female employee for refusing to shave her legs, should NOT be the one to do the diversity training.
10. Don’t give sarcastic answers to stupid questions. When an administrator asked me why we couldn’t dose methadone patients with liquid valium to treat co-occurring benzodiazepine addiction, my answer, “Sure. Let’s mix it with some Jack Daniels and give ‘em a fat one to burn on the way home, too,” was not appreciated.

I’ve learned many things the hard way, but at least I’ve learned. Most of all, I’ve learned that other people often have better ideas than me, and that I need to remain teachable to continue to improve as a professional.

Celebrity Overdose Deaths

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Recently, the overdose death of a beloved celebrity restarted discussion of addiction treatment in the mainstream media. I have mixed feelings about such discussions.

On the one hand, I don’t think it’s appropriate for outsiders to comment on whether the celebrity got the best available treatment. It feels reckless for someone to say he should have had this treatment or that, without being privy to the personal medical history of the celebrity. Those details can make a big difference in deciding the most appropriate treatment. Of course in hindsight we can say the treatment chosen didn’t work… but as I’m painfully aware, even the best evidence-based treatments can have disastrous outcomes in individual patients.

On the other hand, celebrity deaths can focus the public on pertinent addiction issues facing society. For example, the death of 1980’s basketball star Len Bias helped change public perception about the risks of cocaine use. Mr. Bias, the second overall draft pick of the NBA in 1986, was the picture of physical health. When this young man died of a cardiac arrhythmia from cocaine use, people stopped looking at cocaine as a harmless party drug. There was a shift to a more realistic view of cocaine as a potentially addictive drug that can cause serious medical problems, including death, even in young healthy people. It’s possible Len Bias’s death, untimely and tragic, saved some number of young people from experimenting and becoming addicted to cocaine.

I am thankful that some light is being shed on the treatment of opioid addiction, even though the cause of this examination is due to a celebrity death. Perhaps something good can come of tragedy.

Realistically, are opioid addicts, including celebrities, being told of all evidence-based treatments for the disease? I don’t have facts or figures, but I’m confident the answer is a resounding “No.”. Most Minnesota model, 12-step based inpatient drug rehabs still discourage patients with opioid addiction from considering methadone or buprenorphine, even though medical evidence proves such treatments to be the most successful. Is this ethical? I don’t think so.

In a recent article from Alcoholism & Drug Abuse Weekly (Feb 10, 2014) on this same topic, even the deputy director of the White House Office of National Drug Control Policy Michael Botticelli says, “For people with opioid dependence, MAT should be the standard of care.”

So how are Minnesota Model facilities, opposed to MAT, able to maintain accreditation if they don’t inform patients of all evidence-based treatments? It’s unethical. Our first obligation is to do the right thing by our patients, based on scientific data.

This wouldn’t be allowed in any other field of medicine.

Each State Gets a Report Card

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You have got the check this out…an organization called Trust For America’s Health, or TFAH, supported by the Robert Wood Johnson foundation, has released a report called, “Prescription Drug Abuse 2013: Strategies to Stop the Epidemic.” You can find the report at their website at: http://www.healthyamericans.org

This report grades each state on its policies for managing the prescription pain pill epidemic.

The report begins with a description of the scope of the problem: current estimates say around 6.1 million U.S. citizens are either addicted to or misusing prescription medications. Sales of prescription opioids quadrupled in the U.S. since 1999, and so have drug overdose deaths. In many states, more people die from drug overdoses than from motor vehicle accidents. The costs of addiction and drug misuse are enormous; in 2011, a study estimated that the nonmedical use of prescription opioids costs the U.S. around 53.4 billion dollars each year, in lost productivity, increased criminal justice expenditures, drug abuse treatment, and medical complications.

The report identifies specific groups at high risk for addiction. Men aged 24 to 54 are at highest risk for drug overdose deaths, at about twice the rate of women, although the rate of increase in overdose deaths in women is worrisome. Teens and young adults are at higher risk, as are soldiers and veterans. (Please see my blog of October 19th for more information about veterans.) Rural residents are twice as likely to die of an overdose as urban residents.

TFAH’s report declares there are ten indicators of how well a state is doing to fix the opioid addiction epidemic. This report grades each of the fifty states by how many of these indicators each state is using. TFAH says these ten indicators were selected based on “consultation with leading public health, medical, and law enforcement experts about the most promising approaches.”

Here are their ten indicator criteria:
 Does the state have a prescription drug monitoring program?
 Is use of the prescription drug monitoring program mandatory?
 Does the state have a law against doctor shopping?
 Has the state expanded Medicaid under the ACA, so that there will be expanded coverage of substance abuse treatment?
 Does the state require/recommend prescriber education about pain medication?
 Does the state have a Good Samaritan law? These laws provide some degree of immunity from criminal charges for people seeking help for themselves or others suffering from an overdose.
 Is there support for naloxone use?
 Does the state require a physical examination of a patient before a prescriber can issue an opioid prescription, to assure that patient has no signs of addiction or drug abuse?
 Does the state have a law requiring identification to pick up a controlled substance prescription?

 Does the state’s Medicaid program have a way to lock-in patients with suspected drug abuse or addiction so that they can get prescriptions from only one prescriber and pharmacy?

I thought several of these were bizarre. Several are great ideas, but others…not so much. For example, I think a law against doctor shopping leads to criminalization of drug addiction rather than treatment of the underlying problem. The addicts I treat knew that doctor shopping was illegal, but still took risks because that’s what their addiction demanded of them. Such laws may be a way of leveraging people into treatment through the court system, however.

And where are the indicators about addiction treatment? Toward the very end of this report, its authors present data regarding the number of buprenorphine prescribers per capita per state, but make no mention of opioid treatment program capacity per capita for methadone maintenance. Buprenorphine is great, and I use it to treat opioid addiction, but it doesn’t work for everyone. And there’s no data about treatment slots for prolonged inpatient, abstinence-based treatment of opioid addiction.

Expanded Medicaid access for addiction treatment is a nice idea… but not if doctors opt out of Medicaid because it doesn’t pay enough to cover overhead. If expanded access is not accompanied by adequate – and timely! – payment to treatment providers for services rendered, having Medicaid won’t help patients. Doctors won’t participate in the Medicaid system. I don’t. I have a few Medicaid patients whom I treat for free. It’s cheaper for me to treat for free than pay for an employee’s time to file for payment and cut through red tape.

In one of the more interesting sections in this report, each state is ranked in overdose deaths per capita, and the amount of opioids prescribed per capita.

The ten states with the higher opioid overdose death rates are: West Virginia, with 28.9 deaths per 100,000 people; New Mexico, with 23.8 deaths per 100,000; Kentucky with 23.6, then Nevada, Oklahoma, Arizona, Missouri; then in eighth place is Tennessee, with 16.9 deaths per 100,000. In ninth and tenth places are Utah and Delaware. Florida came in at number 11, with 16.4 deaths per 100,000.

North Carolina placed 30th in overdose death rates. We’ve had a big problem with prescription drug overdose deaths. From 1999 until 2005, the death rate rose from4.6 per 100,000 to 11.4 per 100,000. But at least our rate has not increased since 2005. The rate in 2010 was still 11.4. It’s still way too high, but many agencies have been working together over the past six years to turn things around. In a future blog, I intend to list the factors I think helped our state.

Use of the ten indicators does appear to correlate with reduced rate of increase of overdose deaths. In other words, states with more laws and regulations have had a slower rise in overdose deaths than states with fewer laws and regulations, though there are some exceptions.

This report also compares states by the amount of opioids prescribed per year, in kilograms of morphine equivalents per state per 10,000 people. Florida, not surprisingly, came in at number one, with 12.6 kilograms per 10,000 people. Tennessee and Nevada tied for second and third place, with 11.8 kilos per 10,000 people. The next seven, in order, are: Oregon, Delaware, Maine, Alabama, West Virginia, Oklahoma, and Washington. Kentucky was 11th, with 9.0 kilos per 10,000. North Carolina doctors prescribe 6.9 kilos of opioids per 10,000 people per year, in 27th place and less than the national average of 7.1 kilos.

It appears to me that amount of opioid prescribed per capita does correlate, somewhat, with overdose death rates.

Let’s look closer at Tennessee, the state who, just a few months ago, rejected a certificate of need application for an opioid treatment program to be established in Eastern Tennessee. In 1999, Tennessee had an overdose death rate that was relatively low, at 6.1 per 100,000 people. By 2005, it zoomed to 10.4 per 100,000 people, and by 2010, rocketed to 16.9 per 100,000 people, to be in the top ten states with highest overdose death rates. Furthermore, Tennessee is now second out of fifty states for the highest amount of opioids prescribed per 10,000 people. Only Florida beat out Tennessee. And lately Florida has made the news for its aggressive actions taken against pill mills, which may leave the top spot for Tennessee.

West Virginia is no better. It was the worst state, out of all fifty, for overdose deaths, at 28.9 per 100,000 people in 2010. Wow. If you think lawmakers are asking for help from addiction medicine experts…think again.

West Virginia legislators recently passed onerous state regulations on opioid treatment programs. That’s right, lawmakers with no medical experience at all decided what passed for adequate treatment of a medical disease. For example, they passed a law that said an opioid addict had to be discharged from methadone treatment after the fourth positive urine drug screen. In other words, if you have the disease of addiction and demonstrate a symptom of that disease, you will be turned out of one of the most evidence-based and life-saving treatments know to the world of medicine. West Virginia passed several other inane laws regulating the medical treatment of addiction.

Getting back to the TFAH study, the report calculates that there are 21.6 million people in the U.S. who need substance treatment, while only 2.3 million are receiving it. This report identifies lack of trained personnel qualified to treat addiction as a major obstacle to effective treatment.

This report makes the usual recommendations for improving the treatment of addiction in the U.S… They recommend:

 Improve prescription monitoring programs. Nearly all states have them, except for Missouri and Washington D.C.

States should be able to share information, so that I can see what medication my North Carolina patients are filling in Tennessee. Right now, I have to log on to a separate website to check patients in Tennessee, so it takes twice as much time. Tennessee is already sharing data with several other states, but not with North Carolina, or at least not yet.

TFAH also recommends linking prescription monitoring information with electronic health records.

 Easy access to addiction treatment.

Duh. The report accurate describes how underfunded addiction treatment has been, and says that only one percent of total healthcare expenditures were spent on addiction treatment. We know how crazy that is, given the expense of treating the side effects of addiction: endocarditis, alcoholic cirrhosis, hepatitis C, gastritis, cellulitis, alcoholic encephalopathy, emphysema, heart attack, stroke, pancreatitis, HIV infection, gastrointestinal cancers, lung cancer…I could go on for a page but I’ll stop there.

Access to treatment is limited by lack of trained addiction professionals. Doctors abandoned the field back in 1914, when it became illegal to treat opioid addiction with another opioid. Even with the dramatic success seen with methadone and buprenorphine treatment of opioid addiction, there are relatively few doctors with expertise in this treatment.

This reports shows that two-thirds of the states have fewer than six physicians licensed to treat opioid addiction with buprenorphine (Suboxone) per 100,000 people. Iowa has the fewest, at .9 buprenorphine physicians per 100,000 people, and Washington D.C. had the most, at 8.5 physicians per 100,000 people.

North Carolina has 3.2 buprenorphine physicians per 100,000 people, while Tennessee has 5.3 physicians per 100,000. This makes Tennessee look pretty good, until you discover than many of Tennessee’s physicians only prescribe buprenorphine as a taper, refusing to prescribe it as maintenance medication. If these doctors reviewed the evidence, they would see even three month maintenance with a month-long taper gives relapse rates of around 91% (1)

I’m really bothered by the lack of attention to the number of methadone treatment slots per capita. That’s information I’d really like to have. But the authors of this report did not deign to even mention methadone. Even with forty-five years’ worth of data.

**Sigh**

 Increased regulation of pill mills.

 Expand programs to dispose of medications properly. In other words, make sure citizens have a way to get rid of unused medication before it’s filched by youngsters trying to experiment with drugs.

I know many tons of medications have been turned in on “drug take-back” days. But I’ve never seen any data about how much medication is addictive and subject to abuse, versus something like outdated cholesterol lowering pills.

 Track prescriber patterns. Another benefit of prescription monitoring programs is that officials can identify physicians who prescribe more than their peers. Sometimes there’s a very good reason for this. For example, a doctor who works in palliative care and end-of-life care may appropriately prescribe more than a pediatrician.

I get uneasy about non-physicians evaluating physicians’ prescribing habits, though. I think this is best left up to other doctors, enlisted by the state’s medical board to evaluate practices. Other doctors are better able to recognize nuances of medical care that non-physicians may not understand.

 Make rescue medication more widely available. In this section, the report’s authors make mention of Project Lazarus of Wilkes County, NC, a public health non-profit organization dedicated to reducing opioid overdose deaths, not only in that county, but state-wide. Project Lazarus is well-known to me, since I work at an opioid treatment program in Wilkes County.

 Ensure access to safe and effective medication, and make sure patients receive the pain medication they need. Obviously, we want opioids available to treat pain, especially for acute pain. Hey, you don’t have to convince me – read my blog from this summer about how grateful I was for opioids after I broke my leg. Opioids were a godsend to me in the short-term, and knowing what I do about opioids, I didn’t use them after the pain subsided.

It was an interesting report, though I saw some unfortunate gaps in their information, particularly regarding opioid addiction treatment availability.

But at least this is another agency looking at solutions and making some helpful recommendations.

1. Weiss et al, “Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence,” Archives of General Psychiatry, 2011;68 (12):1238-1246.

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/

Hazelden Advances into the Twenty-First Century

In last week’s edition of Alcohol and Drug Abuse Weekly, I read that Hazelden’s addiction treatment center now plans to add medications to the treatment they provide for opioid addicts. Presently an abstinence-based, 12-step recovery center, Hazelden plans to have three treatment tracks available for opioid addicts: one offering buprenorphine (Suboxone), one offering naltrexone, and the traditional non-medication program that is now provided.

Better late than never.

Naltrexone, as an opioid block, isn’t controversial, since it is an opioid antagonist and therefore gives no opioid sensation. However, it will block any other opioid from acting on the brain. I call naltrexone the “anti-opioid.” It’s useful as an insurance policy for opioid addicts because if they relapse while on it, they won’t feel any opioid effect. For patients struggling with opioid withdrawal, this medication will not help, and in fact may make their withdrawal worse. Frankly, I thought Hazelden was already using naltrexone.

Their chief medical officer, Dr. Marvin Seppala, said Hazelden decided to use medications to treat opioid addiction in response to the public health crisis of opioid overdose deaths. Now more common than fatalities in car crashes, Hazelden feels opioid overdose deaths, “Demand up-to-date, evidence-based treatment protocols that offer the brightest promise of recovery.”

He says using the buprenorphine will help stabilize patients so that they can better engage in counseling and 12-step recovery. He says the patients will be watched and monitored closely, and will be in outpatient treatment settings while they are on buprenorphine. He also says, “Ultimately, we’ll have people come off these medications.”

I have mixed feelings when I learned all of this.

Predominately, I feel happy and relieved. Finally, a respected big-name, 12-step abstinence based treatment center is going to use medication that’s been proven to prevent overdose deaths. Hazelden is taking a huge step by moving away even a little bit their anti-medication dogma. Hopefully their action will influence the rest of the treatment field that has so far rejected medication-assisted treatment for opioid addicts.

True, Hazelden’s press statement said they didn’t look at buprenorphine as a long-term solution, and set complete abstinence as the goal for opioid addicts, but it is movement movement in the right direction. They should be praised.

On the other hand…the cynic in me raised an eyebrow as I read the article. Really? Up-to-date??  I think not. Suboxone, approved in 2002, was available as of 2003. That’s nearly ten years ago. How many addicts have died because of the addiction treatment establishment’s anti-medication biases, which prevented them from endorsing buprenorphine as a viable option in a timely fashion?

I have buprenorphine (Suboxone) patients who say they wouldn’t be alive if not for this medication. Many of these folks cycled in and out of 28-day treatment programs, good ones, but that path didn’t work for them. Most weren’t told about buprenorphine as a treatment option by these addiction treatment programs. Most learned about buprenorphine from other addicts. That’s sad, and unprofessional.

Change is hard. Once an abstinence-only treatment provider myself, I know how hard it is to take a step back, and say wait a minute…here’s some real proof that this new method may be better, though it goes against my present mindset. But if doctors and other professionals treating addiction want to be taken seriously, we have to constantly re-evaluate what we are doing, to see if we are up-to-date with best practices. We must keep an open mind and a willingness to change. That’s important in all of medicine, but especially true for addiction medicine, where things change rapidly.

After all, isn’t an open mind and a willingness to change what we ask of our patients?

Kudos to Hazelden for taking a step forward.

Closing Down a Methadone Clinic

 

I read the front page article in last week’s Alcoholism and Drug Abuse Weekly with mixed emotions. http://www.alcoholismdrugabuseweekly.com/

The state of Minnesota revoked the license of the only methadone treatment program in the city of Duluth and ordered it to shut down. This order was suspended until the outcome of an appeal by the owners on the clinic, Colonial Management Group.

I felt angry and chagrined.  I support methadone treatment programs, both because they conduct one of the most evidence-based treatment interventions in all of medicine, and because that’s the type of setting where I work. I’ve seen the life changing benefits many patients get from methadone treatment. Closing this clinic would deprive opioid addicts of an effective treatment for their addiction in the city of Duluth, and existing patients would be essentially abandoned.

But bad clinics harm the reputations of good clinics. The list of charges against the clinic is appalling, and if true, couldn’t be ignored. I’d hope that instead of closing the clinic, some other option could be found. CSAT’s Nic Reuter, interviewed for the ADAW piece, said that in extreme cases, a team of professionals could be requested from CSAT, to come to this program and make changes, help turn things around.

I’m also suspicious. A Duluth newspaper had run a weeklong series of articles critical of for-profit methadone clinics just before the order to close was issued. Is this a bad clinic or the victim of a witch hunt? Were the inspectors pressured to find flaws, or were the flaws chronic and egregious?

I’ve worked for one non-profit program with several different clinic sites, and I’ve worked for four for-profit sites. If I graded overall quality of care, I’d rank the non-profit program fourth.  Just because a program is non-profit doesn’t mean it’s well-run, and for-profit clinics often are extremely well-run. From my personal experience, the bias against for-profit programs isn’t justified.

Colonial owns fifty-eight clinics in seventeen states, according to the ADAW article. I’ve never worked at a Colonial clinic, but I do know they’ve had problems in other states.

At one Colonial program near me, I heard from several of their former patients that their clinic once ran short of methadone. According to these two sources, the clinic reduced everyone’s dose until they could procure more methadone. I would die of embarrassment if I worked for a clinic that did such a thing. I would much rather guest dose everyone at a nearby clinic so that the patients didn’t de-stabilize. Guest-dosing would likely cost both clinic and patients extra money, though.

The Colonial programs in my area also allow methadone patients to have prescriptions for benzodiazepines, because I’ve had a few patients transfer for that reason. In my medical opinion, this is prohibitively risky for most patients, though may be appropriate for a limited few.

I’m more suspicious than the average person because I’ve worked at a well-run clinic that was the victim of an apparent witch hunt. I believe the pair of inspectors from the state’s Division of Health Service Regulation arrived with an agenda…to uncover nefarious doings at the methadone clinic. Their routine would have been comedic, if the outcome hadn’t been so awful.

Prior to this encounter, I’ve had positive experiences with the state’s methadone clinic inspectors. They were educated and competent, and often able to suggest ways to do things better and more efficiently, based on what they’ve seen at other clinics. Before I encountered this pair, I viewed inspectors not as adversaries but as potential information resources.

These two were different. They caused one problem after another at the clinic they were inspecting. I wasn’t there, but heard second hand that they interrogated nurses and counselors in an aggressive and demeaning manner. I believe these accounts, because they did the same with me.

After several days spent inspecting and disrupting the clinic, they wanted to talk to me because I was the medical director at that time. First of all, they were an hour and a half late for our appointment, which did not endear me to them. When they finally appeared, their dress and demeanor didn’t inspire confidence that a fair evaluation was about to be done. One of them was openly hostile to methadone maintenance treatment and the other didn’t say anything…but she wore an outfit that could be fittingly accessorized by a lamppost and a public defender, if you get my drift.

The spokeswoman of the two was a nurse – she kept reminding me of that for some reason – who would ask questions along the lines of, “Have you stopped endangering patients yet?” A yes or no answer wasn’t possible. Plus, at first, part of my mind was distracted, marveling at the silent partner’s outfit. I was wondering if I could ever get away with wearing an ensemble like that to work. Probably not, since we couldn’t even wear open-toed shoes…plus, was I a little too long in the tooth to be able to pull it off?….Maybe if I had tattoos like her…

“Why do you let patients keep going up on their dose?” Her aggressive tone snapped me back to attention. “Wouldn’t you agree few people need more than 70mg?” I tried to educate her that best results were seen when patients were at blocking doses, and that 70mg wasn’t a blocking dose for many people. She stared at me over the top of her reading glasses for a long moment. Then she sighed deeply and slowly shook her head side to side as she wrote something on her papers.

Then she said I was providing substandard care by not doing EKGs on patients. This was in 2007, and ironically enough I’d just returned the week before from an ASAM conference where we talked in detail about whether EKGs should be done and under what circumstances. I told her there was no clear consensus yet, but that may become the standard of care. She argued, said no, I was wrong, that was the standard of care now.

She asked why patients with positive drug screens were allowed to remain in treatment. My eyelid started to twitch about them, because it was clear she knew nothing about methadone maintenance treatment, but held a strong bias against it. I told her many patients have positive drug screens, and we see best results by keeping them engaged in treatment. If they’re still using opioids, we actually need to increase their dose, as I described before. And she argued with me about that.

I asked if she’d ever inspected methadone clinic before ours. She said no, but that she was a seasoned state inspector. Hoping to educate her, I asked her if she was familiar with TIP 43, SAMHSA’s published guideline to methadone treatment of opioid addiction. She said no. I jumped up and ratted around in several counselors’ offices, finally finding a copy that wasn’t too dog eared. I gave it to her, hoping she would read it. If she’d read it before trying to inspect a methadone clinic, she’d have known how to do her job better.

The next day, I wrote a complaint letter to her supervisor at the state, describing her objectionable behavior and lack of knowledge. I heard nothing more until a few months later, when a disjointed and rambling report, authored by the nurse inspector, accused my clinic of numerous misdeeds. We were charged with two major level one violations and charged thousands of dollars in fines for substandard care.

Her report was so jumbled that I couldn’t tell specifically what the violations were, but they seemed to focus on a patient in methadone maintenance who had surgery and received post-operative pain pills. Her report said this could have caused a fatality and was substandard care. (So much for my hope that she would read TIP 43!). This patient had actually received great care. Release of information was passed both ways, to and from her methadone clinic. She didn’t relapse on her post-op prescriptions, and had no problems. But this inspector thought she ought not to have been allowed to take opioids post-operatively.

This report was released to local media, and an article based on her report landed on the front page of the city paper. The real facts – that this woman didn’t have the education to be able to know if a clinic was well-run or not – weren’t known to the writer at the paper. Our clinic, coincidently a non-profit, took the case to court. Possibly to avoid a public hearing, the state dropped the level one charges and the fines. The clinic was left with several misdemeanor violations, easily cleared up. Everyone seemed happy but I still object to the misplaced power this woman had. I had looked forward to a public hearing so that flaws of the present system could be exposed and fixed. This inspector had caused harm to our clinic’s reputation.

This year, five years later after that episode, I heard this same inspector, still employed by the state, gave a very negative report of another clinic. The regional director of that clinic described it as an unfair hatchet job, and I have no doubt that’s true. I don’t understand why the state allows such a person to represent them in the field.

So in summary, the Duluth Colonial program may be a bad clinic that should be overhauled and possibly managed by a special team if other treatment options can’t be located for the patients. Or it may have received unfair assessment by someone with a political axe to grind.  Things are not always what they appear to be in the world of medication-assisted treatment.

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