Wednesday, November 7, 2018

The NEJM "Addiction As Learning And Not Disease" Article - Clinical Realities

I had anticipated posting a piece on the biological realities that were minimized in this review but I am currently waiting for a graphic that I acquired permission to use.  I have not heard back from the publisher.  In the interim, I will post some information on the clinical reality of treating people with severe substance use disorders or addictions to illustrate why learning is really an inferior paradigm to use in analyzing the problem.   It really comes down to treating all of the features of a profound loss of normal functioning.  These features are not subtle and include insomnia, anxiety, depression, cravings, compulsive use, and protracted withdrawal.  The following comments considers only those people with addiction that is defined as DSM-5 severe substance use disorder and compulsive use of any addictive substance.  By definition that means I am not considering people with less severe problems, such as the average college drinker or cannabis smoker who lacks these features, can easily stop, and invariably stops when they move on with their life after college.  I could post a series of vignettes but for brevity - I can roll all of those problems into one problem, that is generally recognized as the most significant drug problem in American today and that is opioid use disorder.

Consider the following hypothetical and all of the potential solutions and the implications for addiction as a disease or a learning opportunity.

40 year old man with chronic back pain, benzodiazepine use disorder and opioid use disorder.  Prior to admission he was using 10-16 mg clonazepam per day and 240-300 mg of oxycodone per day for 5 years.  The use disorder developed as a direct result of prescriptions of oxycodone 10 mg TID for back pain and clonazepam 0.5 mg TID for back spasm.  The patient was admitted to a residential treatment facility and detoxified with buprenorphine and phenobarbital over a period of 10 days.  On day 15 he is referred for assessment of depression and anxiety.  

He has no history of insomnia, depression, or anxiety prior to the onset of the substance use problems. Since the detox was completed (on day 10) - his anxiety is "through the roof", he is unable to sleep, and he is depressed and somewhat hopeless.  His concentration and focus are so impaired at this point that he can't retain information presented in groups or individual discussion and he feels like treatment is a "waste of money" because he has not learned anything.  He is craving benzodiazepines but also opioids to some extent.  He has drenching night sweats and has to change his shirt 2 or 3 times a night.  He describes muscle and joint pain.  He is concerned that he will relapse immediately upon discharge due to all of these symptoms.  He asks about taking trazodone for sleep, an antidepressant for depression, and gabapentin for anxiety.  He suggests that if the problem cannot be solved - he will go back to his primary care MD and get another prescription for benzodiazepines and that he will "try to control it this time."  

At this point the best intervention (s) to address these symptoms include (choose as many as you like):

a)  Continued 12-step facilitation groups
b)  Cognitive behavior therapy for insomnia (CBTi)
c)  Cognitive behavior therapy for substance use, anxiety and depression.
d)  A family program to educate the patient and his family about the relevant dynamics
e)  An NA group to deal with cravings
f)  Prescribe trazodone for sleep
g)  Prescribe an SSRI for anxiety and depression
h)  Prescribe gabapentin for anxiety
i)  Prescribe a benzodiazepine for anxiety
j)   Prescribe buprenorphine/naloxone (BUP/NAL) for opioid withdrawal and medication assisted treatment (MAT) of opioid use disorder.

Numerous learning and medical interventions for the problem and I have seen several to most of them applied in this scenario.  I have seen many applied repeatedly well past the point of failure to the point that a person may be leaving treatment more symptomatic than they came in.  That is a significant failure because the patient leaving in that circumstance is highly vulnerable.  This scenario is highlighted generally ion the movement to make sure that persons with opioid use disorder are prescribed BUP/NAL and given naloxone intranasal or injection when they make the transition from treatment setting or secure environments where they have had no access to opioids like jails.  That emphasis is important because of the overdose risk with opioids but the risk for relapse to using any substance requiring treatment is very high and potentially leads to a fatal outcome.

The other clinical consideration of addiction as disease is that it is multidimensional.  As highlighted in this case - it is not a simple question of detox, stabilization and discharge.  Significant physical symptoms of illness, intoxication, and withdrawal can persist well beyond any expected period of detox.  Significant sleep problems can persist for years beyond the detox period.  Striking psychiatric symptoms are all part of the mix and physicians not suspecting these disorders can attempt to treat them as depression, dementia, bipolar disorder, anxiety disorders, panic attacks, and even attention deficit-hyperactivity disorder.  Some treatment literature talks about a vague syndrome of protracted withdrawal symptoms that is often used to described any unusual symptoms or perception during the recovery period.  Addiction is a modern day great imposter of psychiatric disorders.  Clinicians following people with all of these symptoms can discuss general guidelines with people about how long it takes various symptoms complexes to resolve before a psychiatric disorder should be considered.   In some cases the symptoms are of sufficient severity that they need to be treated acutely and the issue of disorder versus disorder cause by the substance needs to be worked out in the long term.

A long standing debate in the treatment of substance use disorders is the role of physicians and medical treatment.  Medicine has always had a role in detoxification especially when it comes to potentially life-threatening detox or detox that involves significant discomfort.  The epidemiology of addictive disorders and psychiatric disorders points to an obvious reason to try to treat both disorders at once and a place for psychiatric treatment. Medication assisted treatment to reduce relapse has been the most recent medical innovation.  All of these roles are consistent with a disease model that seeks to correct or address a loss of normal function in the human body or brain.

I am an advocate of psychosocial therapies not just in addiction, but in just about all areas of psychiatry.  Further I am an advocate of 12-step recovery because it is cost effective, it works, and it has the realistic long term goal of abstinence.  In addiction treatment, those therapies work best if a person is detoxified, cognitively intact, all of the associated comorbid symptoms are treated, and (where possible) craving and relapse potential are reduced as far as possible to break up the cycle of compulsive irrational substance use.

Given all of those considerations what is the correct answer to the question?  None of the verbal therapy or experiential (a though e) options work, but I have seen them applied even when the person was in significant distress and no progress was being made.  There are no known talk therapies that adequately treat intoxication, withdrawal, or many of the intermediate states associated with early recovery that in some cases extend for 1-3 years.  What about the symptomatic treatment of psychiatric symptoms?  Not the best options either.  In this case, I have seen patients on multiple antidepressant, anxiolytics, trazodone, atypical antipsychotics, and even stimulants for the symptoms described.  In many cases the associated medications led to additional morbidity.  So treating this multidimensional illness as a single or a collection of psychiatric disorders is also the wrong answer.

The correct answer in this case is  j) Prescribe buprenorphine/naloxone (BUP/NAL).  In practically every case like this that I have been involved with since the advent of BUP/NAL prescribing the anxiety, sleep disturbance, depression, and physical symptoms all resolve or at least the portion of the illness that is directly attributable to opioid use.  In this case the patient was also using a benzodiazepine with a long half life and may also need to address those symptoms.  Protracted withdrawal from benzodiazepines has been described since the late 1980s and the symptoms can also last for a long time.

The clinical approach to addictive disorders provides clear information on why addiction is a disease whether you happen to accept any of the models proposed by Volkow and Koob or not. At every step of the way in the above example, the underlying systems are described in either of the main addiction texts.  There is clearly a loss of normal functioning that does not respond to talk therapy or other learning interventions.  In fact, these interventions presented to a distressed person typically create more problems than solutions. Although it is possible to insert neurobiology into any medical or talking intervention these days, learning interventions for the above problems can be expected to have little to no effect on the major problems that this patient is experiencing.    

All of those problems at any stage of addiction are a loss of normal functioning or a disease state. With addiction the loss of normal functioning is not trivial. It is disabling, severe, and life threatening. Any quality treatment program should be able to address them and not depend solely on a learning environment to assist these patients.

George Dawson, MD, DFAPA


  1. I see and hear vignettes like this above, and just wonder, where in hell are providers in 2018 thinking YEARS of excessive benzo abuse can be detoxed in WEEKS, and then wonder why these patients struggle and relapse with some substance/prescription abuse because they have not really effectively been responsibly somatically treated in the first place??

    Maybe I was fortunate in my training, maybe I am just living in a bubble, but, here's the detox formula that has worked when patients have followed it with a provider who insists on this protocol: For every 6 months a patient has been on an equivalent dosage of diazepam 30 or more mg a day, it takes at least a month of weaning per use of lorazepam (Ativan) or clonazepam (Klonopin) by 20-30% of dose every 7 days.

    So, for those not clear what this means, lets's say we have a patient who has been on 8mg of xanax (alprazolam) for 2 year and now voluntarily wants off. First, the detox will take at least 3 months, by an equivalency of 0.5 alprazolam equals either 1mg lorazepam or 0.25 of clonazepam, so, the patient should start on at least 8 mg of lorazapam in divided doses a day (which is very high and thus not very realistic), or, and more effectively with this large dose of xanax, go with clonazepam of 3-4 mg a day again in divided dosages. I have found switching to clonazepam is the better choice more often because one does not have to go to ridiculously large dosages of lorazepam, and, there is not so much of euphoric quality to clonazepam, so that is taken out of the equation as well.

    Then, using the clonazepam example, go from 4mg a day divided (1.5 AM, 1 at 3PM, and 1.5 at 10PM, being sure to be close to 8 hrs apart per dose) for 7 days, then down to 3mg a day (1TID) for 7-10 days, then to 2.5 (1/0.5/1) for 7 days, then 2mg (0.5/0.5/1mg, always leaving HS dose highest per sleep issues) for 7 days, then 1.5 for 10 to 14 days (0.5 TID or 0.5 AM and 1HS), then to 0.5 BID for 7 days, then to 0.75 a day still divided for 7 days, then to 0.5 HS for at least 10 days, and then have other interventions for the inevitable complaints of insomnia and MUCH therapy work on anxiety management that has to be fairly enforced if the patient wants to be medication managed further hereon.

    Do the math, that ends up being at least 2 to 3 months, as you have to account for the patient having psychosocial issues that could legitimately account for anxiety issues that could either prolong the current detox regimen protocol at the time, or go back to a SLIGHTLY higher dose for a week or two, then resume the taper schedule, and also the patient has to be working on the role of benzodiazepine dependence as a substance abuse issue, so should be in some type of Substance Abuse Program ongoing.

    By the way, responsible psychiatrists should NOT tolerate patients on controlled substances NOT being in psychotherapy, this is such a joke these days that irresponsibly sells a meds only model to the issues at hand creating this iatrogenic nightmare, per anxiety, depression, and pain issues, that always fails in the end solely medicated until proven otherwise. (to be continued)...

    1. Interesting formula for outpatient detox. I agree that in the ideal world protracted low increment detox is preferred. Professor C Heather Ashton DM, FRCP at has advocated this approach for years and has written many benzodiazepine specific protocols.

      Another protocol involves conversion from benzodiazepines to an equivalent amount of phenobarbital and then reduction of the phenobarbital dose. Smith and Wesson provided the original rationale for this approach in that they saw seizures from dose reductions of the lowest unit dose per week. I have seen the same thing with a decrease in alprazolam 0.5 mg per 5 days as recommended in the package insert.

      More rapid residential detox occurs because there are people taking high doses of one or more benzodiazepines and they not only cannot decrease the does but they continue to escalate the dose and in some cases overdose. Switching to long acting benzodiazepines as you suggest is also a good idea.

      While I certainly agree that psychotherapy is necessary, the practical consideration is that many of these patients will be seeing a psychiatrist for a much longer period of time than they typically see a therapist. Many of the people I see have already seen 3 or 4 therapists, some for extended periods of time.

  2. Part two of my comment limited by the 4000 character limit:

    By the way, Dr Dawson, I don't know the extent of your practice interactions, but let me fill you in on what is going on in Maryland and Pennsylvania Community Mental Health Clinics (CMHCs) of late with those wonderful Buprenorphine providers out there shilling their product. They are keeping these "patients" on this opiate product much longer than needed, becoming Methadone 2.0, and then are trying to force these patients on CMHCs, as no private provider nor non-state funded clinic will accept these patients, under the guise that Suboxone users need psychotherapy. And then what happens, most therapists after taking these patients on almost always demand a psychiatrist be involved because the patient has anxiety, depression, and the new Dx du jour, PTSD!!! And want these patients medicated, as do the patients, who want, BENZOS!!!....

    Tip to people either in residency or just coming out, the more you care and the more you try to adhere to responsible and appropriate standards of care, expect to be abused and screwed. Those principles and boundaries you were hopefully taught, don't apply to the real world of psychiatry that is soon to become 2019.

    Suboxone and it's clever derivations will be misused, abused, and over applied in the next few years, until, the Buprenorphine providers have negative fallout, and then what, the next alleged savior arises for opiate addicts that was failed by Methadone and Bup?

    The more things change, the more they stay the same. Isn't that true, Dr Dawson? Eventually, we will see substance abusers find the most long lasting impact in effective recovery going to meetings for years, and not just expecting quick fixes to just substitute for quick fix lousy choices that led to addiction in the first place. But, you folks out there all keep thinking there are quick fixes, and then wonder why 90% of addicts fail repeatedly, until they collapse and start crawling out of the pit they dug, or are left to be buried in it...

    Yeah, this is the reality of working in trenches, sorry it ain't pretty and sweet.

    1. I agree the buprenorphine landscape is problematic across the country right now. The message in the course to get certified (at least when I took it) was that it should be prescribed for anyone with an opioid use disorder irrespective of their associated psychiatric or substance use problems. Now there are people beating the drum that everyone with OUD should be on it and that there should be safe injections sites, widespread availability of methadone, etc. There are addictionologists in Europe who advocate for prescribing benzodiazepines with methadone.

      Depending on the model you adhere to - the harm reduction being practiced often seems so high risk that it is essentially no harm reduction at all.

      One of the main points of the post is that psychiatric treatment will not necessarily cover all of the manifestations of chronic opioid use.

      But I am sure that you and I and other psychiatrists out there are asked to cover these symptoms with medications that are typically prescribed by psychiatrists. I think that buprenorphine use can minimize that polypharmacy and in many cases can be very gradually reduced by physicians who know what they are doing.

      The bottom line is that we don't know enough about the long term course. I have written to some of the top experts and nobody has come up with the long term outcome of opioid users although I do have numbers for both buprenorphine and methadone specific mortality. If I can get the numbers on the natural history of opioid use disorder I can come up with a graphic.