Hello All,
Those who know me know that I can be pretty passionate about issues I care about. Creating a blog is a way to spare my social media friends from my constant posting and reach those with a more focused interest in, and who can benefit from my passion, knowledge and point of view.
The current political climate and the deaths of many prominent people in the past few years, and several relatives, have fueled my desire to pursue my career passions, practice the way I want and in the settings I want and make the difference in the world I am intent on making. That being said, I am one person and can only reach a small number of people face to face in my practice. Friends, colleagues, family, and my wife have all encouraged me to expand my reach and voice… so here I go.
The deaths in the past few days of Kate Spade and Anthony Bourdain are just the well known examples of what is clearly a rampant and growing problem in America. The CDC recently released data indicating that the suicide rate has gone up 25% in the last 2 decades (and data showing that the suicide rate here in Minnesota has gone up 40% in the last 18 years). Coincidence that they released it after Kate Spade’s death or opportunism? Why does it take the death of famous people for the spotlight to briefly turn to the legitimate and ongoing problems the rest of us are having… before the next news cycle turns the light off?
The level of stress people are under and American’s unique lack of skills to deal with it are clearly factors in the growing suicide rate as well as the opioid overdose epidemic. Certainly the recent toxic political climate and uncovering of shocking levels of what had been latent racism, homophobia and xenophobia are fueling the fires even more.
In this new era in which insurance protections are being eroded, insurance companies and Big Pharma are getting fat and medical practitioners are being forced to adhere to ever increasing productivity requirements, the patients are on the short end of the stick. Thus the above statistics are not surprising.
When the “Bean Counters” are no longer running medicine, perhaps someone will wake up and realize that appropriate, low threshold, accessible, evidenced based , compassionate care is worth the investment and saves money (not to mention lives) in the long run.
The relationship has been taken out of psychiatry. In this environment, practitioners are now trained in mostly providing “medication management” only. Thus the advent of the 15 min “med check”. I work with patients, I don’t “check” meds. The art of psychotherapy in psychiatry has been lost. A casualty of the era of HMOs and managed care. Sadly, and to my dismay, Minnesota was the fertile ground in which this was cultivated ( as well as the “Minnesota Model” for addiction treatment). A fact that pains me about the state I have called home for the last 32 years.
The pendulum has swung too far. The system has also failed in not providing sufficient, if any, training in addictions in medical school and residency allowing stigma to rule the day even in professional settings. It is, after all, stigma, that is the biggest factor in the rising suicide rate and opioid overdose epidemic. From the public to supposed professionals, the ongoing ignorance and stigma prevents people from talking about, getting support for or treatment from friends, family, and mental health professionals. Stigma also seems to be the guiding principle of the government’s efforts to address the opioid crisis. Rather than using the evidence base and best practices that most experts and academicians would recommend, the states and feds have focused on physician opioid prescribing habits as their answer to show the public that they are “doing something”. That train left the station years ago. Heroin and Fentanyl are now the drivers of the epidemic. Focusing on low threshold access to compassionate, evidence based treatment is what is needed. Though it is good practice to train physicians in appropriate prescribing habits, the current focus is forcing many patients who are benefitting from stable doses of opioids for chronic pain into untenable situations and suffering. This will cause many to engage in desperate measures including suicide and diving into the street opioid pool which is now poisoned with Fentanyl and Fentanyl analogues. A death sentence for many. Physicians are now even worried about prescribing pain medication for acute pain and post surgery, leading to much unnecessary suffering. Wisdom, logic and compassion must prevail.
It is time for physicians to rise up and make their voice heard. We must push back against poorly conceived and stigma driven policy and do what is right for patients and their families. We must live up to the bioethics we all learned in medical school of “non-maleficence”. The Latin phrase we all learned and must now dust off and put into practice: Primum non nocere. “First, to do no harm”.
First and foremost, the term alcoholic is stigmatizing and outdated. The current, more neutral, terminology is alcohol use disorder, mild, moderate or severe. More about less stigmatizing language in another post.
Is that age old phrase “once an alcoholic, always an alcoholic” that people have heard in 12 step meetings and rehab forever even true?
The answer is no.
Alcohol use disorder is not a single entity, and has many facets to it. There are certainly people with alcohol use disorder who are not able to sustain safe, low risk drinking over the long run; and for whom abstinence is the best option.What you don’t hear is about the others. 70% of those with with mild to moderate alcohol use disorder will have their disease remit over 10 years as the natural course of the illness , studies show. Not something you hear much in rehab or 12 step meetings. A review of the literature also shows that for every year a person diagnosed with alcohol use disorder is abstinent from alcohol, their risk of having a recurrence (yes, recurrence, not relapse… again more for another post), goes down by 20%. After 5 years of abstinence that persons risk is no greater than the average person in the community of developing alcohol use disorder. An astonishing fact given what you have likely heard.
So what do I tell patients when they come in asking for help with their alcohol use disorder? It is the rare patient that comes in stating they don’t want to ever drink again. Most people, as likely would you or I, say that they would like to continue drinking, but not have the problems with drinking they have had. As with other chronic illnesses, I approach patients in a patient centered way. What are their goals? Mine are not relevant, as a paternalistic approach of telling patients what they need to do about their chronic illnesses rarely works. I am happy to start with where they are at and use the evidence of how things go to illuminate the path. I do inform patients that their ability to achieve sustained, low risk drinking is informed by several factors. ( Low risk drinking as defined by the NIAAA- National Institute for Alcoholism and Alcohol Abuse- is defined as no more than 4 standard drinks per occasion, or 14 in a week for a man. 3 drinks per occasion and 7 standard drinks per week for a woman. See the “Rethinking Drinking” pamphlet on the NIAAA website for more details- https://rethinkingdrinking.niaaa.nih.gov ).
- How severe is their alcohol use disorder?
- How significant is their family history?
- Are they physiologically dependent on alcohol. In other words, do they have withdrawal when they stop drinking?.
If they have all three factors the odds of their achieving sustained, low risk drinking are low, but not zero. Most choose an attempt at this despite the odds. I suggest to patients that we do a series of experiments and base the next steps on the outcomes. I encourage them to log all their drinks daily and measure them so that they know exactly how many standard drinks they have per occasion. ( a standard drink would be 1.5 ounces of spirits, 12 ounces of standard beer or 5 ounces of wine). Set a specific goal for themselves, whether if be low risk guidelines or a goal of their own, and see how it goes for a month. The plan then to adjust the course as we go in order to achieve the goals they have. Keep in mind, these goals often change as we go through the process and learn from the experience. Some realize they cannot manage their drinking, and abstinence is the best course. Others might meet their goals with the aid of psychotherapy, community support groups and medication or continue to make progress in that direction.
Medication for alcohol use disorder? Yes. We have had medications available for the treatment of alcohol use disorder for decades. Unfortunately, due to the stranglehold the rehab industry has had on the treatment of addictions, few are aware of this. Only 10% of people who have a diagnosis of alcohol use disorder are on medication to treat it. There are several FDA approved medications that aid in treatment of the disorder and several that we use in an “off label” manner based on studies showing the benefit. Many more patients would benefit from being offered medication to assist in their treatment rather than the cookie cutter approach of abstinence only and 12 step approaches.
Alcohol use disorder, and all addictions, are chronic medical conditions and need to be treated as such. The era of claiming that they are chronic medical conditions but not treating them that way needs to end forthwith. Can you imagine if the standard of care for asthma was to put patients in the ICU on a ventilator for 28 days and then send them out to the community and tell them “go pray in a church basement and come back to us if you run into problems”? This is the current model of care based on 1950s thinking. To truly treat alcohol use disorder as a chronic illness we need to engage patients in the same way we do for any other chronic illness.
As an addiction psychiatrist I treat patients the same as I would for any other psychiatric illness. Do an evaluation. Come up with a treatment plan. See the patient as often as I need to based on how they are doing and for as long as they require care. Episodic approaches to addiction treatment simply do not work. 28 days of inpatient or residential treatment or 6 weeks of intensive outpatient treatment without ongoing care is simply ineffective. Many studies have shown that the longer patients are engaged in treatment for their addictions the better they do. 1 year of ongoing care, at a minimum, is ideal. Patients and families spend thousands of dollars on upscale treatment centers that have success rates of less than 10%. Not exactly cost effective treatment. This is not an episodic illness and requires ongoing, patient centered care for patients to have any chance of improving or having a remission in their illness. Addictions are one of the few disorders in which patients are fired from treatment because they are having symptoms of the very illness they came for help for. How absurd! Can you imagine if your doctor fired you for not perfectly managing your diabetes, hypertension or heart disease? Why is this tolerated? The simple answer is stigma. The misguided belief perpetuated by 12 step ideology that addictions are a character defect or moral failing. There is no evidence to support this, and in fact, 50 years of data to demonstrate that addictions are complex, neurobiologic disorders with significant genetic components that merit treatment on par with any other chronic medical illness.
It is time to acknowledge the extensive research, ditch the stigma, and not just say addictions are chronic illnesses but actually treat them that way. Patients with addictions deserve evidenced based, patient centered, compassionate and effective care provided in an ongoing manner.
It is time for addiction treatment to step out of the 1950s and into the 21st century.
Stigma kills.
In the world of addictions and addiction treatment the stigmatizing language and attitudes towards patients and people with addiction is rampant and a huge factor in the largely unchecked overdose epidemic. There is too much suffering, illness and death from stigma as a result of lack of care, housing, finances, support, compassion, and access to evidence-based treatment for those suffering from addictive disorders. This must stop in order for us to take ground and help those suffering with addictive disorders and their loved ones.
Language matters. Words are powerful and create and shape the world we live in. Perception becomes reality and can have extremely detrimental consequences to those labeled with stigmatizing and pejorative language.
What is stigma?
According to the English Oxford Living Dictionary, stigma is a “mark of disgrace associated with a particular circumstance, quality, or person.” The Cambridge dictionary defines it as: “a strong lack of respect for a person or a group of people or a bad opinion of them because they have done something society does not approve of.”
So why should we care?
A Pew Research Center survey conducted in August 2016 found that 46% of U.S. adults say they have a family member or close friend who is addicted to drugs or has been in the past. Other studies have suggested that approximately 53% of Americans have one or more close relatives who have an alcohol use disorder.
In other words, your father, wife, son, friend, neighbor or colleague at work is suffering with an addiction. Your stigmatized view along with medical practitioners’, therapists’, the government and communities’ are a significant barrier that will contribute to their suffering and possible death.
What can we do?
“…In discussing substance use disorders, words can be powerful when used to clarify, encourage, support, enlighten and unify. On the other hand, stigmatizing words often discourage, isolate, misinform, shame and embarrass.” – Excerpt from “Substance Use Disorders: A Guide to the Use of Language” published by CSAT and SAMHSA.
An addiction colleague at the Massachusetts General Hospital, Sarah Wakeman, MD, describes using “person-first language” which is medically accurate. It is especially important for medical/treatment professionals to be using this language and setting the example for patients, colleagues, families, the press, government and society as a whole.
The dangers of derogatory and stigmatized words
Druggie!
Many derogatory terms have become the common vernacular when it comes to addiction. “Druggie,” “addict,” “abuser,” “crack head,” “dope fiend” — one could go on and on. There are no other chronic illnesses, except perhaps obesity, where we personalize and stigmatize the person suffering with it as we do with addictions and psychiatric disorders. Imagine if doctors stigmatized people with cancer, blaming the disease on them as a moral failing or character defect?
Findings by Harvard Medical School’s Dr. John Kelly, in two 2010 studies, showed that when exposed to certain (read: stigmatized) terms associated with addiction, people display unconscious bias. Terms such “substance abuser” when used, led to much more punitive attitudes by professionals than use of the more current and appropriate term “person with a substance use disorder.”
Stigmatized names for treatment
In an article written by Dr. Wakeman for The American Society of Addiction Medicine she describes the terms “abuse” and “abuser” as implying “a willful misconduct and have been shown to increase stigma and reduce the quality of care” they receive. She goes on to state “the stigma surrounding the use of pharmacotherapy [medications], in particular Opioid Agonist Therapy, is arguably more potent and harmful than the general stigma about addiction.” Even in the general medical parlance, Opioid Agonist Therapy (the use of Buprenorphine or Methadone to treat opioid use disorder) is referred to as “Medication Assisted Therapy-MAT.” That would be like referring to insulin treatment of diabetes as “Medication Assisted Therapy,” when in fact, it is treatment. Opioid Agonist Therapy is the treatment, not assisted therapy. This devaluation comes only from the rehab-created view that the sole definition of treatment is going to a structured, group-based program for a prescribed period of time, and therefore nothing else fits the bill of being called “treatment.”
A myriad of studies have shown that Buprenorphine and Methadone are the most effective treatments for Opioid Use Disorder and that abstinence-based approaches often pushed by 12-step-based rehab programs, do not work. The recurrence rate for Opioid Use Disorder is over 80% in the first three months of any abstinence-based approach. Unfortunately, a significant percentage of those who have a recurrence will overdose and die. Furthermore, many studies have shown that adding psychotherapy to Buprenorphine and/or Methadone for the treatment of Opioid Use Disorder provides little added benefit, even though it continues to be a recommended treatment modality. The success and benefit of this approach is from the medication alone and from close follow-up care by the prescribing practitioner. By continuing to push Rehab and psychotherapy as the treatment for Opioid Use Disorder, we perpetuate the stigmatizing idea that Buprenorphine/Methadone is “assisted treatment” and not the treatment itself.
Stigmatizing language leads to inherent bias, less access to evidence-based treatment, greater likelihood of criminalizing the disorder rather than providing medical treatment, and less access to needed services such as housing, financial assistance and nutrition; all increasing the risk of worsening illness, suffering, indignity, dehumanization, and, sadly, death.
Call to Action!
This is a societal issue representative of a culture that needs to change in order for us to effectively treat the burgeoning issue of addiction. Society and government attitudes and policies will not change until the language changes. That change must start with the professional community: medical practitioners, psychiatrists, therapists, and other treatment providers. We must step up and lead the way to facilitate low-threshold, compassionate, evidence-based care for patients and families suffering from addictive disorders and provide them with the ongoing care we would for any other chronic medical condition.
Examples of stigmatized terminology and how we can replace these terms with more “person-first language”
Addict ——–> Person with a substance use disorder
Alcoholic ——–> Person with an alcohol use disorder
Relapse/slip ——–> “I had a recurrence of my substance use disorder” or use episode
Drug abuse ——–> Drug misuse, harmful use
Clean ——–> Abstinent, not actively using
Dirty ——–> Actively using
Clean drug screen ——–> Testing negative for substance misuse
Dirty drug screen ——–> Testing positive for substance misuse
Former/reformed addict/alcoholic ——–> Person with a substance use disorder in remission
Opioid replacement, Medication Assisted Therapy (MAT) ——–> Opioid agonist therapy, treatment
Relapse prevention ——–> Recovery skills training
Harm reduction ——–> Continuing to work with patients who have not achieved remission/patient centered care – meeting patients where they are at
Non-compliance ——–> Non- adherent
Unmotivated ——–> Ambivalent about change
Enabling ——–> Unhelpful or unskillful behavior
Treatment (rehab) ——–> Treatment- in all forms, group, individual, ongoing care
Denial ——–> (a river in Egypt), Ambivalent about change, limited insight
Recovery ——–> Remission
