A recent article in Addiction Professional magazine – Dr Westley Clark, Director of the Center for Substance Abuse Treatment at SAMSHA shared some thoughts and observations on ethical practices and considerations in addiction treatment. The article mentioned several things, among them the number of tests performed (e.g. urine) paying bounty for new patients, using call centers, gifting interventionists, claiming insurance will pay most of the costs, taking kickbacks from those overcharging, like labs, promising a cure, selling proprietary supplements, and using brain scans, among others. We also look at new research which seems somewhat contradictory, on the relationship between the anxiety and stress centers in the older mid-brain, an extended part of the amygdala, and the VTA, also in the same region, which is where most of our dopamine is produced. Another new study highlights the profound changes and effects of alcohol drinking in first year of college students. PODCAST.
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Transcript (edited):
Podcast #146
HOWARD: Welcome to the CNS Podcast featuring Dr. Darryl Inaba, research director for CNS Productions, I am Howard La Mere. There are a few stories this week about how the brain operates and teens and alcohol. But first, a short list of topics….
DARRYL: There were several things of interest …in Addictions Professional magazine, Dr. Wesley Clark, the director of the Center for Substance Abuse Treatment had some comments on questionable treatment practices and as addiction treatment and addiction itself becomes more and more medical, and moves more into mainstream primary care medicine, I think we are going to get pushback and a deeper look at how treatment is administered and whether or not it’s ethical, and appropriate and not gouging or cheating either insurance companies or the patients themselves. And so the ethics of medicine are going to move more toward asking is this a medically necessary intervention you’re doing? Things like the frequency of urine tests are being examined – although we find that the more tests you do, the more positive the outcomes – because there is a worry that if too many tests are ordered the patient is being overcharged. But I think that Wesley Clark is really pointing out some deeper issues and I found his list of concerns on ethical practices to be very interesting. Some of which I understand, some of which confuse me. Things like paying bounties for referrals I find questionable, or using call centers to share patient prospect information or sharing that information between treatment providers.
HOWARD: That doesn’t sound right.
DARRYL: No. That’s definitely a questionable ethical practice. We have professional interventionists in this field and some programs are giving large gifts to them or paying them on top of the fees paid by the families if the patient if referred to their programs by the interventionists. Also – claiming that a patient’s insurance will be billed for services – some programs say, sure, we honor your Blue Crosswe honor this…. knowing that insurance is only going to cover a small portion of what their actual charges are going to be and so the patient is lured into treatment believing that they’re covered, only to get a huge additional bill. There are kickbacks being paid to labs, to doctors when drug testing, urine testing and monitoring are really overcharged and if higher revenues can be collected by directly billing the patient privately or their insurance, then some of that money is kicked back to the doctor who ordered themthings like that. That definitely, I think, leans towards the criminal than unethical. I thought this was interesting because we see these television ads saying, “this program will cure you of your addiction… We can cure addiction”, and as we know, addiction is a chronic persistent medical disorder that there is no cure for. You just have to monitor it. You have to treat it and you have to intervene with it for a lifetime but we can’t really cure addictions. So any program that promises a cure is being looked at with a very callous eye in order to determine what that all means. There are a couple other things that I find are in the gray areaone is the programs that use nutritional supplements which is a big movement in pharmacogenomics…. understanding how someone’s genetics leads them into possibly predisposed to methamphetamine addiction or heroin addiction and advocating using proper nutrients to help build their brain back, by supporting the various neurochemicals that are wiped out by a particular addiction. But using those products as a proprietary nutrient supplement provided by the program and then charging the patient a lot of money for those nutrients is considered a very, very unethical practice.
HOWARD: Do patients have any recourse? A bigger question is – how is this different from the rest of medical practice? This sounds kind of like of patent medicine of course, addiction medicine is now properly certified, but in the context of addiction treatment, do people have any recourse in this?
DARRYL: You know, I don’t think these products are illegal..
HOWARD: So it’s buyer beware?
DARRYL: Yes, and I don’t know if it is questionable or unethical from the point of view of medicine. For instance, right now there are doctors who own stock in Perdue Pharma or in Eli-Lilly or some other big pharmaceutical company and are also doing funded research those companies and there’s no prohibition of that, but researches must publically state their connection any time they speak about it or any time they are involved in any discussion of it. They must disclose that they are on the payroll, or being sponsored by or otherwise involved with one of the medications patients are dealing with. There are programs I know of that are using nutritional supplements and special combinations of nutritional supplementsthat are their own proprietary brand and they are charging their patients for them. If they’re charging everybody the same amount, I’m not sure it’s illegal or unethical or anything like thatbut if they are charging patients exorbitant prices there might be some recourse to that. There’s another thing that struck me as very strange – Dr. Wesley Clark talked about brain scans and other unproven treatments and billing the patient. The use of brain scans is increasing even though there is a lot of controversy surrounding this. A lot of professionals, doctors, scientists in this field are saying there really is no proof that what we see in brain scans correlates to what researcher or clinicians are saying is happening. You see these horrendous things that look like holes in the brain, but are simply brain cells that are turned off in Dr. Daniel Amen’s brain scans of drug addicts and the interpretations seem to be jumping the gun a bit. None of that has really been proven. I’ve always thought the scans were important because they show a difference between a healthy brain and somebody who’s a drug addict, but what it all means
HOWARD: It really looks like Swiss cheese though.
DARRYL: It does.
HOWARD: It really does.
DARRYL: But what does that mean? Basically, Dr. Clark considers this still in the realm of research right now and is not in favor of using these in treatment. They are very expensive – from 4 to 6 thousand dollars a scan – if a patient can afford this and they want to see how their brain is reacting to counseling and treatment – that could be a valuable, but very expensive, thing but Dr. Clark sees it as unethical because they’re still unproven and if the scans are for research, the patient shouldn’t be charged for doing research on them.
HOWARD: Right, right.
DARRYL: There was other news about Canada controlling Oxycontin which has resulted in an increase in the abuse of the prescription opiate drugs that aren’t being controlled or that were not taken off the market. I’ve seen a story about the FDA approved buprenorphine implant to be used in treating opiate addiction, and the State of Oregon has introduced a bill to examine the production, sales, taxation on marijuana and marijuana infused products. I know you want to talk about some other things, but a couple of interesting studies showed a link between early childhood pot use and nicotine addiction. There was some interesting animal research that showed rats who were pre-exposed to marijuana or to the THC in marijuana, actually became heavier nicotine addicts than rats who were not there was a big difference between the two. So, those are some of the interesting things I had on my short list.
HOWARD: There are a couple of stories of interest from Science Daily – one of them focused on college freshmen drinking binge drinking and just drinking in general in their first year and the effects on the brain. And a story published in Nature this last week about research conducted by the University of North Carolina medical school regarding two areas of the brain interacting to trigger divergent emotional behaviors. We’ve talked a lot about the reward reinforcement complex in the brain and the area – part of the amygdala – which is involved in processing memory and emotions. It turns out that there’s a finger or two that runs between the two. One area modulates fear and anxiety and the other is involved in the reward phenomenon. This is brand new stuff, Darryl and it seems interesting to say the least.
DARRYL: I did see those articles, Howard and I found them both very interesting. The study from the University of North Carolina School of Medicine looked at two areas of the brain involved with alcohol and it focused on one portion of the amygdala which we know is the emotional memory center – which is located in the unconscious mesocortex of the brain. That part of the brain is triggered into hyperactivity whenever it’s exposed to certain addictive substances like alcohol and that hyperactivity usually results in some form of anxiety aversion, avoidance behaviors so it would be counterintuitive to something that causes greater dependency or hypnotizes a person into continued use. But at the same time, that area of the amygdala – called the bed nucleus of the stria terminalis, sometimes abbreviated to BNST – that area of the brain that becomes hyperactive activates the ventral tegmental area, the VTA area that is located toward the brain stem, and we know the VTA is responsible for producing and regulating dopamine, the addiction reward reinforcement chemical. And the release of dopamine causes the release of endorphins, which is associated with the reward function. This seems counter intuitive or confusing – implying that drugs and certain behaviors can activate both the hyperanxiety and aversion reaction in the amygdalathe emotional reaction, and at the same release the reward chemical, dopamine, in the VTA which affects the nucleus accumbens and make you feel rewarded. It is curious how this works in terms of addiction and it prompts me to make some projections here. One projection is that there may be some involvement in some dysfunctional way in people who are into say, masochistic ideas or activities – they experience anxiety, they feel an aversion, or have negative feelings, but at the same time they get a rewardsort of like people who are addicted to cutting themselves which causes pain but also produces relief from a reward stimulus generated by that same emotional part of the brain, so maybe it has something to do with that. The research went on to look at GABA and glutamate which has always been confusing to me as well. In terms of GABA being the inhibitory and glutamate being the excitatory major neurochemicals in the brain, that the addiction pathway in the brain shows that there is a release of dopamine that activates the reward center, nucleus accumbens. It also activates the stop switch in the orbital prefrontal cortex, predominantly on the left side of the brain. And from that area of the brain comes a feedback of neurons with the neurochemical, glutamate, which I always thought was an activating, so I couldn’t understand why you would get an activating neurochemical that fed back through these connecting loops from the orbital prefrontal cortex through the fasciculus retroflexus the lateral habenula to the nucleus accumbens and would be the off message to the activated go message. Well, the way they presented it in this research, glutamate actually makes the nucleus accumbens more hyperactive, causing a lot of aversion, a lot of anxiety, and a lot of negative effects that turns it off which deters a person from the desire to continue generating that reward mechanism. whereas GABA, because it’s alternative major neurotransmitter – the inhibitory neurotransmitter, actually increases the effect of dopamine in the reward area of the brain. And so glutamate gives prominence or saliency to the stop switch whereas GABA gives more saliency to the go activity and that was explained to me more readily. But this is confusing. Things get turned around, upside down, twists one way, clockwise, counterclockwise, whatever. When you’re dealing with neurochemistry and brain activity, but as we slowly unravel all of these bits and pieces of research, we get a better understanding of some things but it curiosity in other areas. The other study was conducted by a research team at Penn State and involved fMRI studies done on first year students to determine their brains’ reaction to alcohol. And all that did is confirm for me what we already know – that within a very short period of time, the alcohol impacted the brain causing connectivity changes. From the first to the second semester the students’ alcohol use and their alcohol cue exposure remained steady but the connectivity among the cognitive control brain regions dramatically decreased. This could be applied to nicotine as well, that it attacks the connectivity between the stop switch and go switch and although the immediate action didn’t cause a lot of physical damage in the brain what it did do is it decreased the connectivity and so the more you smoke or the more you use alcohol, the less ability your control area has to send a signal back to the “go” area of the brain to “stop”.
HOWARD: And then that turns out to be a long range phenomenon, right?
DARRYL: Right. I’m not sure how strong that resiliency is. I don’t know of any studies yet to show how much of the connective tissue, like the fasciculus retroflexus or lateral habenula, can reconnect, can grow more neurons once a person goes into recovery or modulates drinking or quits cigarettes so better interaction and more direct communication can occur between the go and stop areas of the brain. It does seem that that abstinence does induce some sort of resilience in those connective brain tissues. But, if someone continues to expose themselves to specific drugs that impair that connectivity, then it gets worse and worse and ultimately a person loses any control over their use of those substances.
HOWARD: Interesting studies, and worthy of further research, so we’ll keep our eyes open for more on these topics, but we’re out of time today so thanks for listening. and tune in again next time. Meanwhile if you have comments, questions, or suggestions, we’d love to hear them. Stop by the website, cnsproductions.com and leave us a note.
DARRYL: Hey, thanks Howard. Interesting stories this week.
HOWARD: Thanks to you. That wraps our pod for today. If you have comments, questions, or suggestions, we’d love to hear them. Leave us a note on our website, cnsproductions.com and check back soon for the next in the series.