Sunday, June 22, 2014

Clinical Care - The Hype Versus the Reality

As noted in recent posts, I was a participant in a conference that focused on the clinical care of patients with addictions.  The intended audience was primary care physicians.  One of the advantages of a course like this is that there is a lot of cross talk between the presenters and those attending the conference.  After a three hour segment about the treatment of opioid addiction and chronic pain, I was approached by a physician who updated me on the state of treatment of addictive disorders and psychiatric disorders in primary care.  One of the recommendations by our speakers was to suggest that drug and alcohol counselors in their own clinics might provide very useful approaches to treatment that could not be provided by the primary care physicians.  It is difficult to see how busy primary care physicians could suddenly take an hour or two to do group therapy for patients addicted to opioids or benzodiazepines.  Taking breaks from the productivity based schedule to do indicated psychotherapy for patients with histories of trauma is even less likely.  After all, isn't this the medical home model?

This physician was very aware of those constraints.  He had tried to implement these modalities in his clinic, but they were rejected outright by administrators.  We discussed some of my experiences in managed care settings as a consultant to internists in managed care settings.  I had an internist call me and say that he had a patient who was addicted to opioids and needed detox prior to surgery.  I called my boss about the resources available for that.  He told me that we did not have the time available to do detox from high dose opioids.  That problem has continued to worsen.  This physician was also not having any luck with getting detox for pre-op patients.  The opinion at the conference by speakers was that slow and gradual detoxification from opioids and benzodiazepines was the exception rather than the rule.  It is theoretically possible in highly motivated individuals with a relatively unlimited time frame.  The best approach seems to be fairly rapid detox with adequate protection (in the case of benzodiazepines and alcohol) against seizures.  Attempts at "outpatient detox" range from handing the patient a bottle of benzodiazepines in the emergency department to "social detox" in holding areas that monitor people and send them back to the emergency department if it looks like they are going into worsening withdrawal.  There are no acknowledged standards in the area.  Nobody complains about this inadequate care for addiction most likely due to the stigma of addiction and the general plan of many places to "get rid of" addicts rather than providing them with any kind of treatment that might be useful.

The evidence-based psychosocial treatments discussed at the conference highlight further deficiencies in the system of care.  The National Institute of Drug Abuse and their Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) was referenced.  Even a cursory look at these guidelines shows that there is probably no managed care system in the country that adheres to these guidelines.  A couple of examples:

"Research indicates that most addicted individuals need at least 3 months in treatment to significantly reduce or stop their drug use and that the best outcomes occur with longer durations of treatment."  (Principle number 5).

There are certainly plans that offer no coverage for addiction at the extreme end.  Many plans that do, follow utilization review protocols that frequently review the treatment being provided with an eye toward providing the least expensive care.  In some cases people with severe problems and no significant withdrawal or medical problems are discharged.  The default position is that the patient must fail, in many cases several times before treatment is funded.  In many cases there is a focus on whether the addiction or the psychiatric disorder is "primary" in order to shuffle the patient from one pool of money to another (addiction <-> psychiatry).  All of this financial gaming leaves the addicted patient out in the cold.  That starts with inadequate to nonexistent detox to treatment that lacks the necessary intensity to be successful.  It can also create a very negative and counterproductive attitude by the system of care to the patient with the problem.

"Sanctions or enticements from family, employment settings, and/or the criminal justice system can significantly increase treatment entry, retention rates, and the ultimate success of drug treatment interventions." (Principle number 11).

When insured patients are incarcerated or committed for problems associated with an addiction there is usually a strong push to get the patient into public systems of care.  That includes state hospitals, public clinics, and public mental health problems.  The strategy is clear - shift the cost of treating addiction and mental health problems to government run systems.  Most states have taken a page out of managed care and responded by decreasing available treatment centers and hospitals.

All of these business manipulations do not bode well for people who need care for even moderately complex problems.  Certainly the detoxification and treatment of an otherwise healthy 25 year old is much different from a 60 year old with cirrhosis and diabetes.  But the system of care is currently not set up to provide necessary care for the least complex patient.  At a policy conference in Hawaii in 2011, I asked the policy wonks who were there to tell us how the "medical home" would revolutionize care for addictions: "What would keep a managed care company from doing a screening exam and leaving it at that."  His response was: "nothing".  It appears that I am able to predict the behavior of managed care systems much better than the policy wonks.

What would help?

The same thing that many professional organizations have failed to do over the past three decades.  Physician organizations like the American Society of Addiction Medicine (ASAM) need to promote adequate treatment guideline, make them publicly available, and embarrass these companies into using them.  ASAM currently has a complex matrix that is supposed to correspond with levels of care.  They are largely ignored by managed care companies.   ASAM should talk about the heavy drinker coming into the emergency department and walking out with a bottle of lorazepam.  It is rather ironic that NIDA does not step up and say what standards should apply, but any regulation needs to consider the Congressional sausage factory and their negative impact on quality care.

The negative impact of business on quality care is most obvious in the areas of psychiatric services and addiction.  Following the status quo and even going as far as endorsing managed care tactics is good for business, but not for people trying to recover from addiction.  From a policy standpoint, this is a much bigger problem than any issue with pharmaceutical companies, conflict of interest, or even perceived problems with psychiatry.  Denying that basic truth may be the result of three decades of ignoring this problem, but complaining about less important issues will not change the skewed health care landscape or get necessary treatment for people with psychiatric and addictive disorders.

George Dawson, MD, DFAPA


  1. When an individual can respond to a patient's problem on a continuum, it is possible to construct an approach to that patient's problem.
    When it becomes necessary to shove patients into boxes, some patients don't fit into any particular box. Those patients are then ignored, under the myth that "undefinable" is "untreatable" (especially if the definition is made by algorithm.) Not everything codes in ICD-10, or ICD-11 which is coming soon.
    The approach is utterly backwards. If ICD-10 categories are "real," then a patient is something that fits into a pigeonhole under some sort of bijective mapping of a patient to a "defined real thing," i.e. a disease entity.
    That's way too much precision for the real world. The patient is real; the diagnosis is something that's a cluster of approximations with a name.

  2. The continuum model only goes so far. The current addiction diagnosis using either DSM or ASAM criteria is selecting a population based on severity (90+ percentile) so the continuum would run in that zone. Even in the people meeting that diagnosis at points in their life, most people remit spontaneously without treatment but on the other had, we know that among the people who do not, there is a very high morbidity and mortality. Addiction treatment applying ASAM criteria is multifaceted and highly individualized.

  3. Hey on a positive note I got an email from ABPN stating they were dialing back on some of the MOC insanity..did you get this too?

    1. I got the ABPN quarterly update and at first read through was not too impressed - apart from the political implications of being told that we need a completely arbitrary process. I guess I was annoyed by the "360 degree" evaluation. I consider it to be a business tactic designed to give the employer leverage over most reasonable employees. Why would that be relevant to recertification?

    2. In the business world, a 360 evaluation means those lower evaluate their managers and managers at the same level evaluate each other. I am not sure what it means MOC.

      Also, in the three different businesses I have been in, the 360 review was either not implemented or dropped before I got there. They found that it was largely misused for retaliation, in addition to the fact that management didn't like being rated by their employees. With rare exceptions, everyone "manages-up". This leaves little time for managing your direct reports and it shows.

    3. That is exactly the problem with the 360 review. To make it even worse in some places it is completely anonymous so there is no accountability at all. The retaliation can consist of overt lying and fiction. I am aware of situations where it was a complete free-for-all and people who had performed their jobs flawlessly for decades were slandered. I guess they assume that you will "manage" the comments to prevent this.

  4. The 360 degree is one of six options, but yes it is stupid as can be.

    I'm still not going to do it for forensics in two years, but it seems like they're backing off a little.

    This is like Common Core, they're just beta testing it out on everyone and hoping it works. When did this become acceptable?

  5. Here's the problem with patient satisfaction surveys in forensic psychiatry...patient satisfaction has nothing to do with whether or not you did a good job! You would think the poobahs in forensic psychiatry would realize that. What will happen is that doctors will cherry pick those cases in which the patient had an outcome they liked. This is absolutely a waste of time. Getting a satisfaction report from a judge or a lawyer would make more sense.

    But in the other specialities, that option is probably the easiest. But still a waste of time. You can always find five people who like what you did, and that's even easier if you're handing out Adderall and Vicodin like candy.

    If they keep trimming it down to a test and documentation of CME, I have no problem with that. This other stuff is just a shakedown.