Saturday, November 19, 2016
The Surgeon General's Report on Addiction
Last week, the current Surgeon General Vivek H. Murthy, MD came out with the first report from that office on addiction. The full text is available on line at this link. The document is 428 pages long but it is full of a lot of unnecessary text. As an example the first 64 pages are essentially an introduction and a listing of personnel who worked on the report as well as references. The last 85 pages are references and appendices. I don't know the chain of command but both the US Department of Health and Human Services (DHHS) and the Substance Abuse and Mental Health Services Administration (SAMHSA) have their imprint on it and that is not necessarily a good thing. The Surgeon General came out with a letter earlier this fall about how to stop the opioid epidemic that I commented on. That letter was brief, to the point, and could have been expanded into a more concise document than the current report.
There is a lot wrong with this report. Just from an administrative side, it is clear that the report sends a strong public relations message about what the government is doing to advance the treatment of addiction and a lot of that message is flat out spin. I am always interested in detoxification from addictive drugs so I naturally searched on that and found this paragraph:
"Until quite recently, substance misuse problems and substance use disorders were viewed as social problems, best managed at the individual and family levels, and sometimes through the existing social infrastructure—such as schools and places of worship, and, when necessary, through civil and criminal justice interventions. In the 1970s, when rates of substance misuse increased, including by college students and Vietnam War veterans, most families and traditional social services were not prepared to handle this problem. Despite a compelling national need for treatment, the existing health care system was neither trained to care for nor especially eager to accept patients with substance use disorders." (p 1-19).
That is really not what happened. It is not even close. Services to treat addiction were rationed just like services to treat mental illnesses. With the federal and state governments giving carte blanche to managed care companies - hospitalizations that required detoxification could be denied even if the patient had a significant psychiatric disorder. Trauma surgeons were also affected by this discrimination. People with serious traumatic injuries who also had positive toxicology for drugs or alcohol were denied payment for a hospitalization that required extensive surgery and prolonged hospital stays. The very thin system of care for addictions and mental illness were outside of the funding stream of mainstream medicine because that is exactly where the government and the business world placed it. In the entire document there is one reference to prior-authorization (p. 6-24) and then only to say that it is one of many strategies used by states to ration Medicaid resources used for treating addictions.
On the issue of training, in about 1992 I had accumulated a series of cases that involved inpatient detoxification that were denied payment by a managed care intermediary representing the state government. All of these denials have appeal processes that are stacked against physicians and patients. In this case I was told I would need to argue all of them in front of an administrative law judge. I took a vacation day and was ready to do that. On the day before the hearing, I was notified that the judge had made a summary decision in favor of the managed care company and I did not have to show up for the hearing. This is obviously not a training issue when I am doing detoxification, a managed care company is telling me to discharge patients (2/3 of whom also have significant mental illnesses), and the state is backing them up.
In the entire document there are 4 paragraphs on detoxification - referred to as "Acute Stabilization and Withdrawal Management". (p. 4-12 - 4-13). It really minimizes the medical aspects of detoxification and the potential complexity of the situation to the degree that it seems to have been written by a nonphysician. The clear intent is to stress that detoxification by itself is not treatment for an addiction but only a necessary first step. In the process it also minimizes the medical and nursing expertise necessary to get people through the detoxification phase. After an entire chapter on neurobiology there is no mention of the craving and dysphoria that often prevent people from completing detoxification or cause them to immediately relapse afterwards. There is no mention of the medical comorbidity that needs to be addressed along with the detoxification process. There is no mention of the complexity involved in detoxifying people from multiple addictive substances - a common scenario these days. There is no mention of why allowing people to detoxify themselves at home with addictive substances may or may not be a good idea. There is no mention of why "social detoxification" in non-medical detox centers run by municipalities may or may not be a good idea. There is no mention of the psychological aspects of detoxification and why it presents one of the most significant obstacles to care in the treatment of addiction. In short, detoxification would seem to have a much more prominent role in a report about facing addiction than it does in this report. The treatment of addiction would have been better served if all of these issues would have been addressed and the minimum medical requirements for detoxification could have been established.
On the less wrong but not perfect side of things, there is a lot of neurobiology in the report, both in terms of basic science and medication assisted treatment. The neurobiology is fairly intense for the average reader who is part of the target audience. Even at the level of physicians who I lecture to and train the concept of the extended amygdala is comprehended by very few people. I could probably say the same thing about the amygdala. In fact, I attended a course of brain dissection by one of the pioneers of this concept Lennart Heimer, MD. At the end of that two day course, in a room of highly motivated and interested people I think that few understood the importance of the concept. My point in all of this is the old adage - you can know just enough neurobiology to be dangerous. At some point all of these names just become pseudo-explanations, especially for people with a poor understanding of science. I have talked with people who knew all of the jargon and started to explain their own addictions with it. That was not a good scientific or clinical approach and I wonder if the public may have been better served by an approach that focuses on the conscious state of the addict. We still do not know how that is derived from the underlying neurobiology - even though the neurobiological explanations make it seem like we do.
Criticism aside, there are some things that the report does well. It provides a fair outline of the NIDA based continuum of care guidelines for addiction treatment for people with severe addictions. The specific section can be found starting on page 4-13 and the section: Principles of Effective Treatment And Treatment Planning. The average person or family interested in seeking treatment for someone with an addiction is often faced with a staggering array of treatment services and a lot of associated politics. The news media is often a source of increasing confusion rather than clarity. A recent example is the rise of certain treatment methods that claim very high rates of success, or that are critical of more traditional treatment approaches like 12-step recovery (AA, NA, TSF (Twelve-Step Facilitation Therapy) and residential treatment. Managed care companies continue to ration residential treatment 1 or 2 or 5 or 7 days at a time. From the report:
"A typical progression for someone who has a severe substance use disorder might start with 3 to 7 days in a medically managed withdrawal program, followed by a 1- to 3-month period of intensive rehabilitative care in a residential treatment program, followed by continuing care, first in an intensive outpatient program (2 to 5 days per week for a few months) and later in a traditional outpatient program that meets 1 to 2 times per month. For many patients whose current living situations are not conducive to recovery, outpatient services should be provided in conjunction with recovery-supportive housing." (p. 4-18).
That recommendation on the continuum of care should be kept in mind by anyone who is seeing an addiction specialist from any discipline in their office on an outpatient basis and finds that they are not able to stop using drugs or alcohol. That would include physicians or other prescribers who are providing medications and possibly making the situation more dangerous because of the combination of prescribed and addictive drugs. There is a temptation to say that with new innovations in medication assisted treatments that all that is necessary is seeing a physician and getting medications to treat the addiction. A close read of any of the FDA approved package inserts on these medications addresses the complexity and points out that psychosocial treatments like the ones in the above paragraph are necessary. There is no strictly medical cure for addiction.
It is also fairly common these days to see Alcoholics Anonymous and their principles being bashed in various forums like the popular media or web sites that seek to aggregate professionals. They appeal to people who don't like the model for various reasons, consider it antiquated, or claim more success using some other treatment. Some of these sources are also confused, often by neurobiology or an ignorance of the treatment literature and claim that there is no evidence that 12-step recovery works. The report provides solid evidence to the contrary. TSF is listed as a treatment intervention with a solid evidence basis and results as good as any and it works as a stand-alone intervention or in combination with other treatment modalities (p. 4-28 to 4-30) that are often suggested as competing treatment models.
That's my overall take on the report. Like most government documents it is a lot of unnecessary reading so I may have missed something and I can't comment on everything. It is clearly the product of committees, meetings, and bureaucrats. Documents like these serve a variety of purposes in addition to the stated purposes of educating the public and establishing public health policy. As a person who lived through it, this is also a serious rewrite of history. That history is decades of what has been called "health care reform". In this country that means hiring proxies to ration healthcare. When that happens the most disenfranchised patients get the most rationing. Those patients have always been people with addictions and mental illnesses. The real intervention needed in the addiction treatment landscape is establishing some controls on companies who are set to profit from denying care for addiction treatment and the governments that encourage it.
That is the single-most powerful intervention that we need in the addiction treatment field and it was nowhere in the report.
George Dawson, MD, DFAPA
U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS, November 2016.
I have no connection with any of the parties of agencies who wrote this report. I am obviously a psychiatrist with a life long commitment to treating mental illness and addiction and extensive personal experience with the rationing of these treatment services. I am currently employed at a treatment center that uses most of the treatment modalities specified in this report including medication assisted therapies (MAT).