Monthly Archives: July 2011

The 27 Club

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Music fans awoke to tragic news on Saturday morning; singer and songwriter Amy Winehouse was found dead in her London apartment, after having canceled a string of performances due to erratic behavior and problems with substance abuse. She was 27 years old.

The cause of her death is not yet clear, but speculation is already rampant that it had something to do with drugs or alcohol. One of her most famous songs, “Rehab”, spoke to her struggle with substance abuse, and in fact she had been released from a rehab program in Britain just a few weeks before her death. Her often shocking and erratic public behavior, as well as statements from her family, have made Amy Winehouse’s name synonymous with substance abuse problems during much of her career. Her death is a terrible tragedy, but I find it to be all the worse because it was so very preventable. Statements from her father indicated that she was on the “road to recovery”, but had suffered several “steps backward” related to alcohol use. As someone who sees patients struggling with their addictions every day, I can’t help but recognize the patterns of relapse and suffering that characterize poorly controlled addiction. It is as yet unclear whether her death was caused by substance overdose, but I feel it is a fair bet that her substance use contributed in some way to the circumstances of her death, just as I would assume that any other chronic illness, like diabetes or high blood pressure, would have contributed.

As reporters and bloggers discuss Ms. Winehouse’s death, they have also been ceaselessly bringing up the “27 Club”, the number of famous musicians who all died when they were 27 years old. The most famous of these musicians are Jimi Hendrix, Kurt Cobain, Janice Joplin, and Jim Morrison; of these four, two (Jimi Hendrix and Janice Joplin) were confirmed to have died of drug overdoses, and substance abuse was suspected to have played a role in the suicide of Kurt Cobain. In our culture, we seem to take it for granted that substance abuse, its dangers and overdoses, are something of an occupational hazard for young, influential musicians; as though heroin, narcotics, alcohol, and other substances are simply a part of the lifestyle.  This is a terrible misjudgement; to allow their addiction problems to go untreated until they become lethal is both criminal and cruel. If a star were suffering from any other illness, they would receive the absolute highest quality care available; so why do we allow them to suffer so needlessly from addiction until it finally cuts short their lives?

This isn’t the first time in my years of treating addiction that I’ve seen some media figure suffering from this disease and been outraged by the misinformation and despicable lack of care they receive. The rehab centers frequented by celebrities, especially those who televise their patients’ pain, are laughable and cruel. It is my sincere hope that once addiction is established in the public consciousness as a medical disease, we will be able to get help to all those who suffer from it, including stars, so that we will no longer have to read about these high-profile preventable deaths. We also must remember that for every highly-publicized death from substance abuse or overdose, thousands and thousands of people in less visible positions also die from the same disease. If even the wealthiest and best-loved musicians can’t get care that helps them adequately control their addiction, what can we do for those who don’t have the same money or fame?

 

Limited Care

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In 2000, the Drug Abuse Treatment Act (DATA) allowed for qualified physicians to use buprenorphine to treat addicted patients, but limited each physician to only having 30 buprenorphine patients at a time. In 2006, the law was amended to allow certain physicians to increase their patient load to 100, which is where it currently stands.

The 30 patient limit was imposed primarily due to a variety of concerns that had originated decades earlier when methadone was first made available for treating addicted patients.  This limit was considered reasonable at the time it was passed as it was felt that there would be many physicians that would seek out the training necessary to provide this form of treatment, and thus enough space and openings would be available in multiple physician practices to absorb the demand.

It is clear from the statistics, and from my own personal experience, that this has not happened. Patients who suffer from addiction make up a distinct population with particular needs and problems associated with their care, and it can be very difficult for physicians in other specialties to take on addiction patients in addition to their own. The incentive to take on addiction patients shrinks even further when these physicians are confronted with a limit that will prevent them from taking on enough patients to build an addiction-centered practice on. I am very lucky in that I have managed to set up a practice that allows me to focus exclusively on addicted patients, but other physicians are forced under the limit to juggle the needs of addicted patients with the separate needs of patients with other illnesses, which may not be sustainable for them.

All of this contributes to a vacuum of care for addicted patients that allows many of them to fall by the wayside, or drives them to seek expensive and ineffective modes of treatment. I’ve discussed this issue a great deal in other posts, and I’ve talked about how the field of addiction care will not be standardized until more physicians are brought in. This is unlikely to happen while the 100-patient limit sets an arbitrary boundary on how involved a physician can be in this field.

We have also seen in the past five years that the fears that drove the creation of the limit were unfounded. Buprenorphine has several qualities as a drug which make it less abusable, less harmful, and less likely to be diverted than methadone was, and many of the problems that existed when methadone was the primary medication in the treatment of addiction have now been overcome. Moreover, buprenorphine has been on the market for over a decade, and so it is highly unlikely that giving qualified physicians license to prescribe it to more patients will cause any catastrophe. On the contrary, the stellar success that has been achieved by buprenorphine maintenance is a strong indicator that its use should be increased where indicated.

ASAM, the American Society of Addiction Medicine, came out with a statement condemning the 30-patient limit shortly before it was raised to 100 patients. The raising of the limit was a step in the right direction, but it has not solved the problem of a shortage of care for addicted patients. The shortage is an artificially imposed one, and it will continue as long as physicians are limited in the amount of patients they can have under their care. As long as the limit is in place, new physicians will be less willing to get the training and put in the effort to deal with addicted patients, and existing addiction care physicians will be unable to help the sick to the best of their ability.

While it would be irresponsible to invite physicians who don’t understand the situation of addicted patients to prescribe them medication indiscriminately, I do believe very strongly that physicians experienced in the field of addiction should have the artificial restrictions removed from their practices.

The NAABT, the National Alliance of Advocates for Buprenorphine Treatment, is trying to get the limits lifted this upcoming election cycle. They need patient and physician stories that illustrate the negative effects the patient limits are having on the treatment of addiction. If you have something to say, please send it to them. The following is a description of their plan, taken from the official NAABT website:

We plan to present all letters and data to the Department of Health and Human Services, where the Secretary has the authority to end the limit. We also are searching for a representative in Washington that will support our efforts and sponsor a bill to end this unnecessary and unprecedented rationing of lifesaving healthcare.

This coming election year will be a great time to bring forward this example of rationing healthcare.

Mailing address:
NAABT, Inc.
P.O. Box 333
Farmington, CT 06034

Email address:
MakeContact@naabt.org

Fax: 860-269-4391

Standard of Care

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The foundation of medicine is standardized care; the idea that all medical personnel with a certain level of training will have access to the same or similar information, and will be able to administer the same treatments, no matter where they are or who they are dealing with. Usually a particular problem will have several treatment options that have been studied and proven to be effective, and that treatment is what you will receive no matter where you go.

It isn’t perfect, but it is something doctors take very seriously, and it is a major factor that helps to protect patients. For example, if a patient has chest pain, it doesn’t matter who they call within the medical system. A general physician, a gynecologist, a dentist, and an optometrist will all say the same thing: go to a cardiologist, who will be able to administer the correct standard of care. No matter where the patient first enters the medical system, they will end up in the same place; that cardiologist’s office, which is the best place for them to be.

Addiction medicine is a new field, and standardization of care hasn’t taken place yet. The major care providers generally don’t communicate with each other as they do in other fields. This is partly because of the stigma on addiction that sometimes keeps physicians from broadcasting that they take care of addicted patients; it is also due to the differences in ideology that still divide medicine-based care providers from non-medicine-based programs, and the fact that many treatment facilities are competing against each other for a market share of patients.

For this reason, patients will often not receive the same advice no matter who they first call. Any particular treatment facility will be very motivated to convince the patient that that program is the best, and may not always give the patient a comprehensive overview of all treatment options. I have patients every day who had no idea that medicine was available to treat them, because the first place they called to get help told them that a non-medicine-based approach was the only way. Conversely, physicians may try to prescribe medication without a proper assessment to determine if a particular patient might benefit more from a counseling-based approach.

Medical personnel shouldn’t be devoting their energy to being salesmen, but until a universally recognized standard of care is put in place, differing schools of treatment must compete and sell themselves to patients. This creates an environment where patients may not necessarily recieve the treatment that is best for them, if another treatment is advocated by better salesmen.

Obviously this arrangement isn’t ideal for anyone; patients are not being helped effectively, and treatment programs are landing themselves patients that may not fully benefit from the treatment they offer. In fact, no rehab treatment facility has been proven to produce better results than any other, and patients should be wary of sales pitches from care professionals, and should double-check all information they receive.

It is regrettable that a patient should be forced to hold that kind of mistrust when it comes to their medical care, but I am confident that the field of addiction medicine will be brought up to the standard of care within a few years, as more physicians enter the field and bring with them the drive for standardization, certification, and accountability.

Truth and Consequences

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I’ve talked a bit before about the behaviors that characterize the disease of addiction. These behaviors — stereotyped parts of addiction like cheating, lying, stealing, and neglecting important things in favor of drugs — are symptoms of the biochemical imbalance caused by long-term addiction.  The reason many addicts display these behaviors isn’t because addicts are weak or bad people; it’s because these behaviors are part of their disease.

These behavioral symptoms mean that the patient population of addicts has needs that are different from those of people who have other chronic diseases. A physician who treats a large number of addicted patients has to be aware that they might be lying to him about their usage or history, simply because lying has become a pattern over the course of their disease. This is a truly bizarre experience for a physician to have. In every other field of medicine, patients know that it is in their best interest to tell their doctor everything they can, because the doctor won’t be able to make good decisions about a patient’s care without complete information. Because the doctor-patient relationship is usually one of complete honesty, physicians are used to trusting their patients, and so they often are completely oblivious to the possibility that an addicted patient might lie due to their disease.

I’ve been practicing addiction medicine for 15 years, and it is still very strange for me to see patients who swear to me they haven’t used any opiates, then test positive for opiates in their urine. I’ve spent more than a decade learning about the specific needs of the addicted patient population, and it still astounds me how casually and frequently this kind of patient can lie, even when it’s against their own best interest. It goes beyond simple questions about whether or not patients have used; often, lying has become such a second nature to the patient that he or she will lie about anything, even things that have nothing to do with their addiction or treatment.

The relationship between a physician and addicted patients has to be built on verifiable evidence such as random drug screenings. This is in sharp contrast to the sort of trust that is usual between physicians and patients with disease that don’t have behavioral symptoms, such as high blood pressure. For this reason, it’s my opinion that physicians who don’t have appropriate training shouldn’t try to treat addicted patients, since their previous experience will mislead them when they try to handle the problems that addicted patients have. Even physicians who intend to treat only addiction patients should be careful about the relationships they build, since even my 15 years of experience are not always enough to let me detect all the lies my patients tell.  One of the specific challenges of this disease is the need for vigilance and concrete evidence in assessing the effects of treatment.