An assessment of where we stand in addiction treatment – starting with an impromptu scorecard using the Principles of Effective Treatment released in 2009 by NIDA. We also discuss the impacts that the Affordable Health Care Act and Mental Health Parity and the Addiction Equity Act of 2008 may have, along with some radical treatment approaches showing up in China and Russia.
Transcript(edited):
HOWARD: Welcome to the CNS Podcast featuring Dr. Darryl Inaba, research director for CNS Productions, I am Howard LaMere. We are going to talk a little bit about treatment today and I’m going to open this topic with a brief recap of a NIDA (National Institute on Drug Abuse) article from a couple of years ago that describes addiction as a complex illness, characterized by uncontrollable drug craving, compulsive drug seeking and doing things in spite of the negative consequences that come about as a result. It also goes on to point out that treatment should be readily available to those who ask for it – a place we are far, far, far, far from. It lists about a dozen effective treatment principles – that no single treatment is appropriate for everyone, treatment needs to be readily available, and effective treatment needs to address the multiple needs of the individual, not just his or her drug abuse because there are so many things involved. Remaining in treatment for an adequate period of time is critical. Counseling is critical. Medication has become an even more important element than in times past and new strides are being made there all the time. Individual treatment plans must be assessed continuously, drug addicted individuals also are likely to have other mental health disorders that need to be addressed. Medical detox is often appropriate for a stage. Treatment does not need to be voluntary to be effective. Drug use during treatment must be continuously monitored. And finally, drug treatment programs should assess patients for the presence of other diseases such as HIV, AIDS, hepatitis B and C, tuberculosis, and other infectious diseases. So that’s just kind of a rundown of basic principles of effective treatment. Darryl, you can respond to that or how do you want to talk about treatment today?
DARRYL: Well, …this is purely unscientific, just my person viewpoint, but I viewed the NIDA, 15 or 16 principles of effective treatment when they first came out and did sort of a scorecard or a report card on how the U.S…as a society was adhering to and addressing those principles and basically, I found that we’re failing on almost every one of those. It is the way the government works. They put out these lofty goals – you should do this and that…
HOWARD: You are directed on what to do, but…..that’s as far as it goes.
DARRYL: Yes, all of these things are great but then who pays for it? But then when I looked at it in terms of individual programs like our Addiction Recovery Center and my experience at the Haight Ashbury Clinic and I found- surprisingly – that over half of the recommendations weren’t being met at all, but a number of them were being addressed as best the programs could because they recognized that these elements must be in place in order for people to stay clean, but since they weren’t funded, they would have to case manage, they would have to hustle, they would have to make arrangements or agreements with other programs, with other professionals to get the level of care a particular clients needs. As we move into the Addiction Equity Act, although there are no written regulations yet – someday we’ll mandate it and move into more medicalization of treatment. There will be more medical interventions and approaches that are now woefully lacking. But I tell you, the other surprising thing – Tom McLellan and other people who have done research into treatment outcomes often compare today with outcomes of 6 years ago – amazingly, people who are in treatment for addictions and alcoholism have as good as an outcome rate and do fairly well in treatment compared to treatment of other chronic persistent disorders like diabetes, like heart disease, like asthma and things like that. So, it’s a credit to the field that although we don’t have a lot of resources, we seem to know what’s right and do whatever we can and have viable outcomes despite the fact that we have the least amount of resources available to provide adequate treatment for our clients.
HOWARD: Now it would seem to me that as the law kicks into effect, assuming that it is kicking into effect, it requires insurance companies to pay for substance abuse treatment, addiction treatment. It would seem like that might generate more money for the providers to provide more programs. Does it not?
DARRYL: Well…
HOWARD: And, or ….am I in a lofty world of the best possible?
DARRYL: The legislation was passed in 2008, signed by President George W. Bush… but as of now – January of 2013, absolutely no federal regulations have been written about the Addiction Equity Act which means no state is going to act – so it’s sort of in limbo, it’s been forgotten and abandoned by the administration and if the law does kick in, it would require more access to treatment funded by private sources like insurance providers. But I’ve seen studies from Kentucky and elsewhere that report a woeful lack of access to care for even people who have insurance to cover it. When they apply for treatment, they’re denied…they’re denied. They are told “You don’t need that residential care. You don’t need that intensive outpatient care” You know, they sometimes pay for education or something else like that. Many people appeal that saying, no, I want to get treatment. I want to get help and the appeals are routinely denied. So right now, the access of care is horrendous and the government is footing the bill for the publicly funded programs. But still, only 1 out of 26 or so people who need and want access to treatment are able to access it in a given year.
HOWARD: Of course, it’s one of the victims of the deficit and budget cutting activities – the government supported programs, whether they’re local or regional. If the legislation is implemented would that generate more private treatment options? And – according to your checklist – how do states compare, or other countries – is anyone doing it any better?
DARRYL: Well, supposedly the Portuguese are there’s some movement in Great Britain, in places where there is a recognition that treatment saves money – it is more economical than making the drugs illegal and keeping addicts in jail. That is what economic studies have shown all along and what the insurance companies should be listening to, but they fear the opposite as do governments. The fear is it will cost too much upfront rather than looking at the money saved down the road.
HOWARD: But, it has been shown that spending 1 dollar saves 7 dollars.
DARRYL: Absolutely! Every study on every treatment evaluated for outcomes shows that money is not lost treating addicts and yet there’s just this consciousness in American society by insurance companies and by our government that says, saving money isn’t making money or having money. It’s just another way of disguising spending money. In San Francisco we were able to talk the mayor into providing treatment on demand for a few years and we thought this was very advantageous – but there was little follow up.
In order for providers to qualify to be sanctioned under the The Affordable Care Act, they must demonstrate a history of positive outcomes from the type of medical intervention that they do, have quality care, and implement evidence based programs – all the while decreasing the cost of treatment. So it is certainly counter intuitive in a way, you know. …it’s sort of …American…you know, you increase quality, increase outcomes, but…..you decrease funding for it or you decrease costs for it.
HOWARD: You always get what you pay for.
DARRYL: Right. That’s what my thinking is!
HOWARD: Pretty much ….
DARRYL: In a strange way though, that is how money works in our society, especially with pharmaceutical firms. It is one of my pet peeves that they can produce and paten the most expensive medication ever to treat an addict – show it to be far superior to other medications and other ways of treatment, engage economists to show how – overall – costs are decreased (even though the medication is expensive) because patients won’t relapse, or wind up in the hospital….so it saves money. These companies have the resources to produce something that will result in them becoming the beneficiaries of this huge act in which we start spending a lot more money in care in order to save more money and get the best outcomes because they have the best way of demonstrating the concept.
I’m glad you brought up treatment today, Howard, because there were some stories in the news that really stirred my interest as somebody who’s been involved with addiction treatment pretty much his whole career and for over 40 years. One story involves China, although it was banned a few years ago…physicians there are continuing to treat various addictions by killing the nucleus accumbens in the brain – killing the go button in the brain.
HOWARD: That seems a bit radical.
DARRYL: This surgery involves inserting electrodes to kill or destroy the cells in the nucleus accumbens. I don’t know if they’re targeting both the core and the shell or just the core or just shell or just parts of it, but they seem to believe they can control addiction by killing the so called “pleasure center”, which I refer to as the survival center where all addictive drugs are set into motion to create that obsession and the craving for drugs.
HOWARD: …that organ is involved in other activities, is it not?
DARRYL: Absolutely and that’s why, I don’t understand….
HOWARD: How can you decimate it?
DARRYL: I guess if you have a totalitarian regime, I guess you can justify it by saying overall it’s cost effective. So what if a few of your citizens, the 30% or 20% who are prone to addictions become anhedonic, ….have no motivation in life whatsoever, are depressed, are out of it – it is worth it because they won’t be abusing drugs anymore because their compulsion center for the drugs has been eliminated . A few years ago in South America they were doing brain surgery and singulectomies….they were taking the singula out…that’s sort of the bonding area of the brain – the theory was that the addict has a bond or forms a relationship with their drug and if they can kill that part of the brain that processes relationships, they can kill that addiction. I’m sure that they did and they did it real well. But, because they didn’t kill the survival or the pleasure center, they had a lot more relapses than the Chinese and people had major emotional problems. This is a radical approach to treating addiction, but it shows how desperate some people are and how society is beginning to realize how powerful this condition is for those who have it.
Psychologist and psychiatrists are actually taking the rod to curing addictions at the patient’s request at an institute in Siberia. Addicts are coming in for sessions where they get swatted very painfully across the buttocks or across their bare backs with rods 40 to 60 swats per session. They claim there is a lot of science involved with it and there might be because …by doing this they stimulate the brain to start producing more and more of its endorphins to overrule the opiate addiction or whatever type of addiction the individual has…..
HOWARD: So…replacement therapy.
DARRYL: Well, yes…that could happen. I don’t know…they do warn the patient that if the patient starts to feel sexual pleasure, they will stop the treatment immediately. In some people, the endorphins could be an over replacement of a drug and cause stimulation in other areas. But the article I read reported patients swore to the fact that they felt fine within their own skin…they didn’t feel cravings. An alcoholic had an emergency bottle of Vodka in his refrigerator and once he started getting swatted, it remained there because he has no desire to drink. A heroin addict, talked about how she owes her life to this type of therapy. A funny side note – one of the clients who was undergoing this therapy didn’t tell his wife and she saw the welts along his back and accused him of having an affair with the lady down the street. So, there are some side effects to watch out for. I think in this country – hitting people with rods would probably get you in trouble.
One last thought – something that seems kind of intuitive was a recent study conducted by Yale published in American Journal of Medicine – patients were treated with state of the art buprenorphine therapy…buprenorphine replacement therapy or buprenorphine detoxification and some of those in the group got cognitive behavioral therapy and some did not. Now in this country some form of cognitive behavioral therapy is one of the main stays of treatment in every treatment program, but this study found that when you’re treating opiate addicts with buprenorphine, there’s no benefit to cognitive behavioral therapy there is no added benefit from it and if you’re talking about saving costs – why pay for that extra cognitive behavioral therapy? All we need is a doctor to prescribe the buprenorphine. I see dangers in that as well. The article did mention that the doctors who were giving the buprenorphine in the Yale study were addiction savvy doctors who were providing the patients with some counseling on their own, so maybe that’s why…
HOWARD: Yes, it seems like there should be some counseling to go along.
DARRYL: I feel strongly about that ..
HOWARD: ….to go along with it..
DARRYL: And I feel that’s probably an artifact of their study or that’s a….dimension they that wasn’t part of the control. They factor in the probability that the doctors themselves might be providing some of that therapy. So, there are stories about the use of Naltrexone for treating heroin addiction and alcoholism showing efficacy in treating gambling addiction. I know that there is a link between nicotine addiction and a specific gene that also is linked to depression. Many people who are nicotine addicts may be self-treating their depression with the use of nicotine. The British Journal of Psychiatry reported that when people quit smoking nicotine it effectively decreases their anxiety levels. So nicotine has an impact on anxiety as well as depression. Abilify, an antipsychotic is being used as a new treatment option for methamphetamine addicts which I think is much more viable treatment. There are still studies and people who swear that Ibogaine, a psychedelic from Africa, is effective for the treatment of opiate addiction. So we can see that treatment is not a precise thing. We don’t have a one thing that fits all, but we continue to see improved outcomes. If better outcomes are because of the interest, I’m all for it and like to see different approaches because sometimes we have to get rid of our biases if we can to allow new effective treatments come into play.
HOWARD: Right. That was good. We’ll revisit this treatment topic from time to time because it’s very central to everything.
DARRYL: Thanks for bringing it up, Howard. I’m glad we talked about it because it is something that interests me and I hope our listeners are too. We’re always happy to bring up new ideas for treatment.
HOWARD: That wraps our pod for today. Thanks for visiting and check back soon for the next in the series and visit our website.