How doctors treat doctors with drug use problems: Addiction treatment that works

Physician Health Programs (PHP) are reporting an astonishing success rate when it comes to providing addiction treatment for addicted doctors:

  • Only about 20% of doctors ever test positive after being admitted to the program within a 5 year period.

  • More than 70% maintain their license and continue working within the same 5 year period.

These are the kind of addiction treatment results we want!

I’ve been saying for a long time that I believe in the theory promoted by Dr. McLellan, who until recently was the deputy-director of the Office of National Drug Control Policy (ONDCP). Doctor McLellan promotes a long-term view of addiction treatment, more like a chronic disease than anything that can be cured in a few visits (although this view only holds for some addicts).

I’ve also known for a while that the American Medical Association is supposed to be having great success at addiction treatment for addicted doctors. I’ve been meaning to contact someone at the AMA to find out how they did it. Now I don’t need to thanks to this recent bit of addiction research.

Addiction research on treatment for addicted doctors

A recent research article surveyed the vast majority of PHP’s and found that, not surprisingly, the things that we know work in addiction treatment do indeed produce results. The solution may not be easy, but it’s pretty simple:

  • Early detection and assessment brings the addicted doctor, their family members, colleagues, and employers together. Getting the problem out in the open early makes it easier to deal with than having to be secretive about it. The doctors get  an option, leave the profession or sign up for a 5 year treatment program to deal with their addiction.
  • Formal addiction treatment using the most appropriate and effective treatment centers In contrast to our criminal justice addiction pipeline, the majority of physicians (69%) receive 90 day residential treatment, while the rest receive intensive outpatient treatment. The PHPs also receive frequent status reports on each physician in treatment to assure adherence. To find treatment that works, use our Rehab-Finder.
  • Long-term support and monitoringAfter treatment, the physicians continue with aftercare that includes 12-step support, regular counseling meetings, and monitoring that includes random drug testing.

That’s it!  So simple yet so effective.

As addiction research continues to improve, I’m sure we’ll be able to bring these numbers up even higher than the 70% success rate currently reported. Still, you have to admit, 70% is amazing!!!

So if you want to know how to stop drinking and drugging, do like the doctors do and commit to long-term addiction treatment.

There are obvious differences between most addicts and the doctors in these programs (most people don’t have such a clear distinction between losing their livelihood and getting help), but the solution is most likely very similar.

More proof we need more money for addiction treatment:

We need to press our representatives to increase funding for addiction treatment and addiction research so that we can find the most efficient, yet effective, way to offer this kind of addiction treatment to the general population. By reducing the problems, we’d be able to cut into the $500 Billion a year drag addiction is putting on our economy. The effort will pay back for itself in no time.

Citation:

DuPont, R.L., Carr, G., Gendel, M., McLellan, A.T., Skipper, G.E. (2009). How are addicted physicians treated? A national survey of physician health programs. Journal of Substance Abuse Treatment, 37, 1-7.

Addicts’ brains depressed but normal users… normal.

A paper that’s about to be published in the journal Science has found at least part of the difference between the brains of addicted individuals and those that use recreationally.

The question as to why only some people get addicted to drugs has been a difficult one to answer. Still, there’s no doubt that only a relatively small fraction of those exposed to drugs develop the compulsive, often destructive pattern of use we associate with addiction. The pattern holds in animal research too – even though all the animals in an experiment get the same amount of drugs, delivered in the same way, only some of them develop addictive drug taking. It seems there’s something different about addicts’ brains, but what is it?

What’s different about addicts’ brains?

We’ve found quite a few things that differentiate addicts’ brains from those of normal research participants. These include lower density of a certain type of dopamine receptor (D2), reduced activity in specific brain parts like the OFC (orbitofrontal cortex) that are important in decision making and behavioral control. Still, if we start with what is supposed to be a pretty similar group of rats and give them all the same drug, for the same time, in the same amounts, why do only some get addicted?

This recent study found that a specific neuronal process called LTD (Long Term Depression), that is important in learning (or what we call plasticity) is suppressed in addicted animals for far longer than in animals that end up not not displaying addictive behavior. Even though all animals displayed this sort of deficiency in LTD right after learning to take drugs, only the addicted animals showed it when tested two months later.

Since the difference was seen in an area of addicts’ brains called the Nucleus Accumbens, a very important area for learning about rewards, it seems likely that it plays an important role in addicts’ inability to change their behavior after they’ve started using drugs. Past research has already identified this as a problem with something we call “reversal learning” but it seems we may have just found at least part of the mechanism.

Now we have to figure out why some animals show this sort of pattern and others don’t. Genetic variability seems like a good place to start here.

Citation:

F. Kasanetz, V. Deroche-Gamonet, N. Berson, E. Balado, M. Lafourcade, O. Manzoni, P. V. Piazza, Transition to addiction is associated with a persistent impairment in synaptic plasticity. Science 328, 1709–1712 (2010).

About Addiction: Smoking, Alcohol, Painkillers, Prescriptions

This are new, interesting articles about addiction. Check out the links to the articles, and give us your feedback.

Smoking and related issues

Health Day: Smoking increases the risk of age-related macular degeneration, a disease that robs people of their sight.

Reuters: When cigarette smokers quit smoking, chronic stress levels may go down. This should give smokers reassurance that quitting will not deprive them of a valuable stress reliever.

Reuters: A nicotine mouth spray may help prevent cigarette cravings three times faster than nicotine lozenges or chewing gum. This might help smokers who are trying to quit smoking.

Cesar Fax: The percentage of national tobacco retailers selling to minors appears to have leveled off. The average national retailer violation rate decreased from 40.1% to 10.8%, and stabilized at 10.8%.

wcstv: Under a proposed deal reached by Governor David Paterson and Albany legislators, cigarette taxes would increase by $1.60 per pack. In New York City, the price of one pack of cigarettes would cost over $10 in many stores. The hope is that this huge price increase will help smokers quit smoking and reduce overall levels of smoking in New York.

About addiction to alcohol, painkillers, and prescription medication

Hazelden: Abuse of alcohol, painkillers, and prescription medication is rising dramatically among older people. Signs of alcohol abuse and drug addiction are different in older adults than in younger people.

Science Daily: Religiosity can moderate genetic effects on alcohol abuse during adolescence but not during early adulthood. The heritability of an alcohol abuse phenotype depends upon the social environment within which it is measured.

Medical News TODAY: Sleep problems can predict the onset of alcohol abuse in healthy adults and relapse in abstinent alcoholics. Puberty is related to sleep problems and later bedtimes, which are associated with alcohol abuse.

Health Day: Exercise may be an effective treatment option for alcoholism. In addition, alcoholism disrupts normal daily circadian rhythms, which can lead to disrupted sleep patterns.

About addiction and mental illness

KansasCity.com:  To study drug addiction and mental illness researchers, at the University of Missouri-Kansas City, have received a $1.8 million federal grant. One of the leading researchers states that conditions such as drug addiction and depression are major problems across the globe.

The brain after cocaine – White matter damage and addiction treatment

The brain damage left behind after long-term cocaine use can apparently tell us quite a bit about how well a cocaine addict will do in addiction treatment – as long as we assess the right kind of damage.

Different kinds of brain matter

I’ve talked before about the fact that use of cocaine, and other drugs, can bring about long-term changes in the brain that sometimes include the actual destruction of neural pathways. What you may not know is that brain matter consists of several different components including the cell bodies of neurons (known as gray matter) and the tracts of axons that transmit messages across the brain (known as white matter). There are other parts as well, but those are the two important ones to know for this article.

Gray matter is important because brain transmission isn’t possible without a cell body, which is its operations center. But white matter is equally important because without it, the messages don’t get anywhere. It’s like having a telephone without a communication network – The phone can work perfectly and no one will ever hear you speak.

Until recently, it’s been pretty hard to measure the structure of white matter because it consists of very thin bands that twist and turn throughout the brain. But recent advancements in fMRI imaging and analysis have allowed us to look at it by measuring the direction in which water molecules flow through white matter. It’s called DTI (Diffusion Tensor Imaging) and it’s pretty complicated, but all you need to know is that it lets us know a lot about the integrity of axons in the brain.

White matter and cocaine

Use of cocaine has already been shown to cause damage to brain white matter. A recent study conducted at Yale examined whether the degree of damage can tell us anything about how well people will do in addiction treatment. Researchers took 16 participants and gave them a host of tests as well as some brain scans before sending them off to an 8 week treatment program. The addiction treatment utilized was outpatient and provided different individuals with different combinations of CBT, medication (antabuse), individual, and group therapy. At the end of treatment, the number of clean urine tests (out of 56 total tests) was used as a measure of treatment success. The more clean urines, the better, something I think we need to adopt overall instead of the all-or-nothing view that abstinence is the only form of improvement.

The bottom line: Using three different measures, the researchers found that individuals with more damaged white matter provided less clean urines throughout the addiction-treatment period. Another important fact – the damages areas that were found to be associated with treatment success were found all over the brain. Interestingly, brain damage wasn’t associated with the length of drug use, but it may have been associated with the extent of use (in terms of years and amount used), something the researchers didn’t report on.

Brain matter and addiction treatment outcomes

One day, we’ll have a battery of tests that will let us tailor treatment more effectively towards specific addicts. Genetics, brains scans, and more, will be able to tell us where an addict is especially weak so that we can focus on those areas first. Some may need specific help with impulsivity and weakened learning systems whereas others may be better off with treatment that addresses past trauma and an oversensitive stress response system.

As this research shows, brain scans can offer us a glimpse into the aspects of an addict’s brain that have been compromised. But we’re not there yet – right now, all we know is that certain genes, brain function patters, and experiences, are associated with a greater risk for addictive behavior or a lower chance of recovery. Getting better at more specifically tailoring treatment is still a little farther than we’d like.

Citation:

Jiansong Xu, Elise E DeVito, Patrick D Worhunsky, Kathleen M Carroll, Bruce J Rounsaville & Marc N Potenza (2010). White Matter Integrity is Associated with Treatment Outcome Measures in Cocaine Dependence, Neuropsychopharmacology 35, 1541–1549.

NIDA and ONDCP – American policy on addiction research

At this year’s College on Problems of Drug Dependence (CPDD) Annual Meeting, I got to hear, and talk to, some of the most influential players in the American addiction research field. Here are a few highlights from their talks and our discussion:

Dr. Nora Volkow of NIDA talked about a shift from Genome Wide Association Studies (GWAS), which have been the most recent popular advance in genetics addiction research and into more Deep Sequencing work. The hope is that this will allow us to begin untangling some of the GWAS findings that have seemed counter-intutitive or puzzling. Deep sequencing should let us see what genes really are associated with addiction specifically, not just as markers.

Dr. Volkow also brought up the numerous issues of medications for addictions including the Nabi Nicotine Vaccine, Vivitrol (a Nalexone depot that helps opiate users who wouldn’t take it otherwise), and a host of new medications that are being developed or considered. An interesting idea here was the use of drug combinations which are showing great promise in providing enhanced treatment results (similar to HIV treatment that benefited greatly from drug cocktails). These include combining vernicline and bupropion for smoking and naltrexone and buprenorphine for cocaine (that’s not a type even though both have been typically thought of for opiate addicts).

Dr. Tom McLellan, who I personally believe is one of the most informed and thoughtful people we have when it comes to addiction research in this country, talked about our need to expand the reach of treatment to the drug abuse earlier in the problem cycle. While about 25 million people are considered drug addicts in this country, more than 65 million are drug abusers. By finding ways to reach those people in primary care (as in doctor offices) settings before they develop the full blown addiction we’re used to talking about we can do better. He also mentioned the idea of anonymity in recovery playing a role in the continued stigmatization of addiction, a topic I’ve written about recently.

Stay on the lookout for more amazing new addiction research knowledge!

One is too many, a thousand not enough: Does a slip or relapse mean the end?

Breaking news: When alcoholics who have gone through treatment have a drink after a certain length of sobriety, most don’t go off the deep end.

Slip scares and abstinence relapse

RelapsingThe old AA adage: “One drink is too many, and a thousand not enough,” refers to the fact that alcoholics who are sober are assumed to return to their evil ways after even a small slip (known as a relapse). This notion is meant to warn AA members to resist temptation lest they find themselves right back where they started. Or worse.

Most research into sobriety considers a person a success only if they remain sober throughout the study period. The followup periods last anywhere between 6 months to a year (or sometimes more). Have a drink, and you’ve lost. Game over. No one’s ever really looked at what people who have relapsed actually do after the relapse. Which is why the recent findings reported in the journal Psychology of Addictive Behaviors are so intriguing.

Recent relapse research findings

When looking at the behavior of 563 participants, the researchers found that 30% stayed sober for the entire 12 month follow-up period. This leaves a whopping 70% who had at least a drink in the year following treatment. However, the vast majority of those who drank in the first year after treatment (82%) developed moderate, infrequent, drinking habits. In fact, only about 6% started drinking heavily and frequently after their relapse. Even of those who drank, as many as 25% were completely dry for at least an entire month after their relapse.

The bottom line on relapse?

These findings suggest that at least for a year after becoming sober, a relapse is not necessarily the detrimental, destructive, event it has always been feared to be. It is surely possible that these drinking habits change, but according to these findings, if drinking frequency goes anywhere after the initial relapse, it’s down, not up.

I’m not trying to make light of relapse here, and I’m certainly not saying that relapsing is a positive thing. Nevertheless, given the fact that relapse is almost always a part of the recovery process, I’m suggesting that having a relapse shouldn’t scare everyone involved. It doesn’t seem to in any way suggest a necessary demise.

Citation:

Witkiewitz, K. & Masyn, K. E. (2008). Drinking trajectories following an initial lapse. Psychology of Addictive Behaviors, 22, 157-167.

Better rehab services – Addiction research at work

Fact: Addiction treatment success rates are often lower than 20% ! Addiction research shows that quarterly follow-ups may help us improve success by offering continuous support and recognizing problems earlier.

Addiction is a chronic disease

diabetesWhat do you do when you are sick? Typically, you would go to the doctor, get some treatment and expect a quick fix.  What would you do if you suffered from an addiction?  Most healthcare and insurance companies would expect you to do the same – get a quick treatment and be cured!

The thing is that addiction is much more similar to many chronic diseases like diabetes and hypertension. The compliance rates and follow-through with treatment for these conditions is fairly low. For example, only 27% of patients with high blood pressure have their hypertension under control and only 46% of diabetics have their diabetes effectively managed.  For these kinds of conditions, short term interventions (less than 3 months) have produced positive findings only 38% of the time while long term ones (12 months or more) produced success rates as high as 100%. Still, addiction treatment rarely extends past a few months.

Today’s rehab services

More than half of patients entering addiction treatment are there for their 3rd, 4th,  or 5th treatment episode. Still, most patients who leave treatment return to use within 30-90 days of their release. This use is associated with 6-11 times the risk of dying!!!

Relapsing

Addiction success is most often reached after 3-4 treatment attempts. Recent research may help us reduce the number of treatments needed, or at least the length of time between first drug use and successful recovery (currently estimated at 27 years). These numbers point towards a scary conclusion: Rehabs are abandoning addicts to fend for themselves too early leaving them, and society at large, in danger.

Better rehab services through addiction research

Recent research shows that following the few months of treatment with simple quarterly checkups allowed counselors to catch relapses sooner and get the patient back into some sort of treatment more quickly. The checkups included short phone calls and scheduled face-to-face meetings that allowed counselors to assess a patient’s condition. Although it might sound as if more days in treatment are a negative thing, the number of checkups and increased amount of time in treatment actually improved overall results.  Patients who received RMCs experienced more sobriety and less severe symptoms of abuse than those who received treatment as usual.

So even if more treatment costs more money, addiction is something that can be helped if dealt with appropriately.  It doesn’t have to follow the same non-compliance rates as other chronic medical disorders. If you are seeking addiction treatment, make sure that your provider plans to include follow up services AFTER you leave treatment.

Citation:

Christy K Scott & Michael L. Dennis (2009). Results from two randomized clinical trials evaluating the impact of quarterly recovery management checkups with adult chronic substance users. Addiction, 104, 959–971.