Inside Addiction Treatment With Dr. Marvin Seppala
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As the chief medical officer at Hazelden Betty Ford Foundation, Dr. Marvin Seppala is a national expert on addiction treatment and pharmacological therapies. With a strong belief in the integration of evidence-based practices, Dr. Seppala is helping to pave the way towards the establishment of outcome-oriented standards of practice in the drug and alcohol treatment industry. Serving as an adjunct assistant professor at the Hazelden Graduate School of Addiction Studies, Dr. Seppala offers the rare balance of leading one of the most significant treatment institutions in the world while being able to speak in layman's terms on the complicated disease of addiction.
While providing insight into the present shape of the drug and alcohol treatment industry and what needs to be improved, Dr. Seppala’s present goal is to address head-on the prescription drug crisis that continues to burn like a countrywide wildfire. The great hope in the face of the staggering cost is to find workable solutions that can be instituted as best practices in residential and non-residential treatment facilities across the country.
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In 2014, when Hazelden and the Betty Ford Center joined forces to form a rehab super-team, it caught a lot of people in the industry by surprise. It was as if the Dallas Cowboys and the Pittsburgh Steelers had come together to form a single NFL franchise. How did this merger come about? What have been the long-term effects so far? Would you describe it as a positive outcome for the greater recovery community?
The Betty Ford Center board contacted the Hazelden board to see if there was any interest in joining forces. The initial discussions were somewhat tenuous, yet they found that there was such a commonality in regards to the two organizations and the two boards, particularly in regards to treatment philosophies and their passion for recovery. It quickly led to the process moving from initial inquiry to let’s see if we can make this happen.
Overall, when you treat chronic pain with opioid pain medication, you are using a highly addictive substance to treat a condition that is not going away.
We have learned a great deal from each other, and we are improving best practices across the organization. I can give you a concrete example of such improvement. We have three adult residential treatment facilities at Hazelden in Center City, Minnesota, at Hazelden Springbrook in Oregon and at the Betty Ford Center in Rancho Mirage, California, and things are done slightly differently at each site. We now bring our clinical teams together and talk over the differences in terms of the treatment approach at each site. Based on those meetings, we decide which the best practice is and which shall be set as our standard. We also look at what is being done in other programs and updates in recent literature to see what can be applied, and that has resulted in real improvements in how we do things across the whole organization. The results really have been wonderful.
We certainly have more of a recognized name now. When I fly around the country, people often did not know what I was talking about, in regards to just Hazelden, if they didn’t work in this field. If they worked in the field, they absolutely knew about us. Outside of the field, however, there was a lack of awareness. The Betty Ford Center, however, is a highly recognized name, and there has been a broad recognition of who we are and what we do. I believe we have a broader voice as well. It’s allowed us to reach a lot more people, both in regards to advocacy issues for recovery, for educational issues related to this disease and how it’s treated and how it’s paid for as well as just plain resources to help more people with addiction. There’s a lot of good that’s come out of this and it’s still quite young. You realize this merger is only a year old. We believe many more benefits will come from it.
As the chief medical officer of Hazelden, your responsibilities include overseeing all interdisciplinary clinical practices while maintaining and improving standards of care. In terms of these practices, do you see different treatment disciplines attempting to carve out their specific territory and shying away from working with other disciplines even if standards of care can be improved? Are the older forms of treatment modalities, like traditional psychotherapy, resistant to modern kinds of treatment modalities, like holistic approaches and art therapy?
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Honestly, I have a great job. I get to wake up in the morning and focus on how we can improve the care that we provide for the people that come to us for help. It’s a wonderful job to have. As I say that, I know that throughout our organization, there is so much passion for addiction treatment and for recovery and for all of the people that are affected by the disease. When you can harness that kind of passion, you can make remarkable change. But it can be challenging at times.
We are an old organization. Hazelden has been around since 1949 so it’s easy to get caught up in the belief that there’s a certain way to do things and that’s just the right way, even if that perspective is independent of the evidence that is all around you. Still, the organization has been through a lot of change in the last five years. During the economic downturn, there was real concern across the country, and Hazelden was not excluded from that worry. We realized things needed to start changing. With the economics of healthcare now, we have to get ahead of theses changes, particularly where the government is moving in regards to the treatment of addiction. We have to improve our outcomes and the overall quality of care while reducing costs at the same time. We don’t expect people to just keep paying us more and more. We have to figure out ways to be more efficient in terms of the delivery of treatment services while continuing to get better and better outcomes. Some people would say that is the very definition of value. If your outcomes improve and your costs decrease, the evolution of your value is accomplished.
There is always some resistance associated with any change whether it’s me changing personally or the organization changing as a whole. We have to communicate a great deal. We certainly have to address and describe the why: Why are we doing this? Why are we changing that? Why are we going down this particular path? Like I said, if we are making decisions that are in keeping with the ideal of doing a better job for the people coming to us for help, then, even when there are differences of opinion, we can usually move past them.
We have implemented a system throughout the organization in regard to employee engagement. You honestly can’t get anywhere if you aren’t engaging your employees, if you aren’t doing things that make them believe that their work is worthwhile and perhaps even making a difference. With that attitude becoming more and more pervasive around the organization while recognizing that the professionals providing the care will have the best ideas about how to improve it, then we are moving forward with the support of those people and their ideas. Not necessarily with my ideas; as the chief medical officer, I am often too far removed from what we do.
If I come up with an idea, it could be completely out to lunch because it’s not even realistic. Yet, the people doing the work have great ideas, but such ideas often get lost because our organization is so big. We’ve had to discreetly put in systems that allow the ideas from the ground floor to move forward so they reach the people at my level that actually can help push forward and make them happen.
As the author of a Clinician's Guide to the Twelve Step Principles, you developed a detailed guide designed specifically to help doctors and treatment professionals understand the 12-step method of addressing alcoholism and addiction. How does such a guide help clinicians learn how to use their professional skills and medical training in concert with the predominantly spiritual 12-step approach to recovery? Where do you find commonalities and what are the differences that have proved difficult to reconcile?
That book was really a labor of love. I poured a lot of my own experience and heart into it to try to provide information for people who knew nothing about the 12 steps, particularly my mental health colleagues—psychiatrists, psychologists and the like—as well as all other physicians. They are faced with addiction on a regular basis, may or may not refer to 12-step programs, but really tend not to understand them at all. Healthcare professionals as a whole—nurses, doctors, therapists and social workers—get very little organized information and education about addiction in the course of their mental health studies. It’s improved slightly, but not much.
I wanted to write something that informed such people about these free programs and readings that have been shown to be effective in helping a lot of people stay sober. I wanted to reveal the information so when these healthcare professionals are working with a patient and matters involving the 12 steps come up, they can speak to them with some actual knowledge. I wanted to help them avoid undermining a patient who is working on the 12 steps during therapy or confound them by describing things in ways that seem contrary to the 12 steps.
What’s interesting is that I wrote the book some time ago and since then mindfulness and other alternative practices are now pervasive in certain parts of medicine like cardiology. They recognize the importance of using mindfulness practices and spiritual practices in ways that simply were not the case when I wrote the book. The discussion of spiritual issues has become much more common.
What’s ironic, however, is that when you look at psychology and psychiatry where you think such practices would be an inherent part of the general examination of a person’s health and psyche, there’s a void in regards to spirituality and even the positive emotions. Although there is starting to be a shift towards recognizing the importance of the positive emotions, it still does not enter into the major textbooks and has not been incorporated into the educational normative for most psychologists and psychiatrists. Instead, we basically have a pathological approach to the understanding of childhood development and adult activity that continues to be taught to our psychologists and psychiatrists. In contrast, looking at life from the perspective of what are the reasons for positive emotions and what goal do they play in a human being’s life is not necessarily an aspect of training in those disciplines. The 12-step program is a perfect example of how well that positive perspective can work in a person’s life. I believe mental health practitioners really could gain a great deal from that understanding.
As a specialist in treating chronic pain management, you wrote the book, Pain Free Living for Drug Free People: A Guide to Pain Management in Recovery. In the book, you and your co-author Dr. David P. Martin describe how people in recovery who suffer from pain, whether it's acute, chronic, or the result of an ongoing condition such as cancer, face a special challenge when trying to manage that pain. How can people in recovery use effective pain medications without triggering a relapse? What is the specific approach at Hazelden for managing chronic pain in clients with addiction issues?
This is an increasingly common problem because we have more and more people in recovery from alcoholism and addictions side-by-side with an aging population. The longer we are around, the more problems with pain we are going to have. Medical statistics suggest that the number one reason that people go to a doctor is for pain. As a result, we’ve got more and more people in longer-term recovery having pain problems and needing really good advice about this question. A good way to address pain in recovery without triggering relapse is to work with an expert that knows and understands both pain and recovery. Of course, it can be hard to find someone like that in certain locations, but it can make a big difference. It’s great to have an addiction specialist speak to your surgeon, to your anesthesiologist, or to your internist about the risks you face as a person in recovery using opioid pain medications.
If opioids have to be provided and often they do, a real structure needs to be put into place for the use of that medication. For a person in recovery, a lot of communication is needed as well. Other people should know about it—family members, friends, and sponsors should be made aware of what is going on with this person in recovery in regards to the pain medications. The last thing you want is for the person in recovery to suddenly have this kind of secret and not know how to discuss it with the people closest to you. It needs to be an open discussion.
We tend to tell people to avoid opioid pain medications for chronic pain. A real risk is present and not just for people in recovery, but for anyone who uses opioid medication on a continuing basis. The research data doesn’t support the use of opioid medications for chronic pain. They simply do not work over long periods of time. You get initial relief and this fools you into thinking that you are getting long-term relief. Unfortunately, that’s not often the case.
At Hazelden Betty Ford Foundation, we believe in providing opioid pain medications only when people absolutely need them. We only provide them in high-risk situations where there is moderate-to-severe pain due to a specific reason like, "I just had surgery" or "I broke a bone in my leg." In such cases, when it comes to relieving the pain, there are not a lot of choices. You have to go with opioids but you have to do it in a way that makes sense. We suggest that people in recovery make no decisions on their own about their pain medications. When it comes to any p.r.n medication (Interviewer’s note—p.r.n. is an abbreviation meaning "when necessary," for an occasion that has arisen, as circumstances require), the patient in recovery should not be making any decisions on how much is needed or when it is needed. This burden should never be placed on them.
There should not be directions on the opioid pain medication bottles that say something like “Use 1 to 2 tablets every 4 to 6 hours” because such directions open the door for manipulation and abuse. We talk to the physicians about this all the time, yet it remains a standard practice. That’s a bad position to put anyone in recovery in because then they’re making the decision about how much and how often. If you are still in pain after using the specific dose that was prescribed, then call your doctor and talk it over. For someone in recovery, the decision should always come back to a discussion with the prescriber, taking the person in recovery out of the equation as much as possible.
Here at Hazelden Betty Ford Foundation, we use a holistic approach towards the treatment of pain. If someone has acute pain, like they broke their leg, we understand if the opioid pain medications are temporarily needed. We will keep a client on those opioid pain medications as long as their doctor thinks it is necessary. As the patients respond, we will then help them get off those drugs in a safe manner. When it comes to chronic pain, however, the opioids tend to do a lot more harm than good. As a result, we are taking people off of those drugs, and we are using group and individual psychotherapies to address pain. A lot of chronic pain issues are caught up in long-term emotional issues that have never been addressed. Pain can improve by addressing those issues. We use Qigong, Tai Chi, yoga, massage, and acupuncture as well as neurocognitive enhancements to address how the brain responds to pain itself. We want to help people alter their own neurochemistry to change the way they respond to chronic pain.
Chronic pain basically takes on a life of its own. Some of the new brain-scanning studies show structural changes in the brain that are directly associated with chronic pain. If we can help someone respond differently to the pain, the possibility exists to restructure the brain and restore a more normal function. Chronic use of opioids for many people actually results in more pain. Opioid-induced hyperalgesia can develop as a result of long-term opioid use in the treatment of chronic pain. Other strategies are needed beyond opioids to deal with the issue of chronic pain, and we are developing and then implementing such strategies at Hazelden Betty Ford Foundation.
In Prescription Painkillers: History, Pharmacology, And Treatment, you wrote with Mark E. Rose a comprehensive account of the history, social impact, pharmacology, and addiction treatment for commonly abused, highly addictive prescription opioid painkillers. Since the book was published, the prescription painkiller plague that began with OxyContin and has been tearing through the United States ever since has continued unabated and even intensified. How can the prescription painkiller epidemic be effectively addressed? What role could an esteemed institution like the Hazelden Betty Ford Foundation play in this process?
I mentioned earlier that the number one reason that people go to doctors is because of pain so this problem is really inherent to the practice of medicine. Unfortunately, there’s little medical education around the treatment of pain. In terms of change, it has to be at the top of the list; more educational opportunities basically for anyone involved in the medical system. When it comes to the prescribing of scheduled substances, the prescription drug monitoring programs that have been installed in many states across the country have been extremely helpful. A doctor should be able to know and should want to know whether or not a patient has been doctor shopping. Doctors have information available to them that they’ve never had before, and they should be taking advantage of this resource.
Unfortunately, a lot of states that have installed these programs have not mandated the actual use of prescription drug monitoring by physicians when they are prescribing scheduled substances. Without such a legal mandate, only about a third of physicians actually check before prescribing these truly dangerous drugs. They should know what else has been prescribed to the patient in front of them and not knowing is just inadequate. Until they are mandated, I imagine the use rate will stay about the same, undermining the efficacy of the prescription drug monitoring programs.
Overall, when you treat chronic pain with opioid pain medication, you are using a highly addictive substance to treat a condition that is not going away. It is bound to fail and lead to the problems that we presently are seeing across the country. When the medicine fails to keep pace with the condition, prescription painkiller dosages are increased to address the lack of efficacy. Such increases only end up worsening the problem. We need to improve the treatment of chronic pain by other means and support that research. Right now, the Mayo Clinic has a chronic pain treatment program that takes all patients off opioid pain medication and uses a real strict cognitive behavioral approach. At Hazelden Betty Ford Foundation, we are doing that as well while also focusing on education and advocacy on both a state and national level, bringing attention to this problem.
As the medical director, you were instrumental in redefining opioid addiction care at Hazelden. Informed by your own work with recovery medications, you instituted several new treatment practices, from offering maintenance doses of the medication buprenorphine for the first time to breaking new ground in incorporating opioid-specific counseling groups in the therapy schedule. Do you believe that the universal application of such practices is just around the corner? Have you encountered resistance from the 12-step groups that do not believe in treating one drug addiction with another drug?
I would say that I hope that universal application is just around the corner, but I think it’s going to take time. A problem is a lack of trust on both sides of the aisle when it comes to people who support the use of these medications and the people against it. I have colleagues that tell me that every single patient who comes into their practice with opioid addiction problems should be put on buprenorphine. Unfortunately, that’s often all they do without any psychotherapy or group support or referral to outpatient treatment or 12-step programs. It’s like, “Just take this medicine and you’ll be fine.” Such an approach is completely inadequate.
Then there’s the other side of the aisle where I have colleagues that won’t prescribe buprenorphine to anyone. As a result, they only suggest the other methods for people needing to enter into recovery. The problem is we are in a public health crisis. The Centers for Disease Control (CDC) has stated that we are in an epidemic defined by overdose from opioids. It’s starting to shift again from prescription opioids back to heroin, but the actual type of opioid is not as important as what we are doing to address the problem. It requires everything that we can do to help stop it.
We have had resistance within the 12-step communities. Not necessarily from the groups, but from individuals within those groups. No 12-step groups have resisted specifically what we are talking about or even spoke against it in any public forum. In keeping with their traditions that hasn’t happened. Individuals, however, certainly have come forward and said things like, “You’re ruining AA” and “We don’t want your patients on medicine in our meetings.” They refuse to sponsor people on those medications. It’s been troublesome from that perspective.
We’ve actually developed an approach called Stigma Management for our patients. If they’re placed on a medication and they’re attending 12-step meetings, we help them find meetings that are amendable to these medications and don’t mind if people are on these medications. We help the patients figure out ways to discuss being on the medication in those environments. We don’t want them to have to feel like they're hiding something and keeping a secret because they are taking those medications. Some people at some meetings won’t let people talk about this. They’ll really give them a hard time and tell them to get off the medications even though a doctor at one of our facilities has prescribed them. Our goal is to get people off these medicines ultimately, but we need to be sure that they are in a safe position before they go about making that change. By using stigma management, we are helping them figure out ways to interact with people positively around the use of these medications while addressing any questions or issues that might arise.
How do you think the Affordable Care Act (PPACA) will affect the treatment industry, and do you believe it will provide more access to addiction treatment for people across the country?
It’s already playing a role in the treatment industry because there’s a great deal of venture capital pouring into the treatment of addiction. I think that’s good and bad: It’s going to give a lot more people access to treatment, but the question is: What will the quality of that treatment be like? We’re a not-for-profit company and for-profit companies tend to have much different motivations. Not that for-profit companies don’t provide very good treatment because many of them do, but the possibility exists for very bad treatment as well.
Most of the money from these venture capitalists is pouring into residential treatment in the form of facilities and plans for residential treatment systems, and I don’t think that was the original intent of the Affordable Care Act. In general, they wanted to make sure that all levels of care—residential, outpatient and day treatment alike— ould be available to people that needed it, but under fairly well-defined circumstances with an emphasis on outpatient care to reduce the costs associated with the treatment of addiction. Outpatient care obviously doesn’t work for everyone, but it does work for the vast majority. Yet, all of this new money is going into residential care, which represents a small group of people with this disease that actually need and respond well to that level of care.
At the same time, I do think it’s fantastic for people suffering from the disease of addiction that they will have access to care in ways that they did not have before. Certainly, people with insurance and people who didn’t have insurance before will now have access to addiction treatment. I think it’s great because it will help so many people get what they really need. But there are still a lot of hoops to be navigated as well and difficulties remain, before we can say we’ve significantly improved access to addiction treatment.
On August 18, 2013, you tweeted, “A complex brain disease requires many approaches, the addiction field needs to bring the best of these together, not fight over who's right.” Do you see a lot of territorialization and compartmentalization in the addiction field in terms of clinicians wanting their specialties at the treatment forefront? Can you give a couple of examples of these fights between disciplines and how you think such problems can be addressed?
Currently, the main territorialization and compartmentalization in the treatment industry really comes down to the issue that we’ve already discussed—the use of medications, particularly buprenorphine for opioid dependence. There’s also been a real backlash against 12-step programs in the last couple of years. Such a backlash seems to be a cyclic event that occurs every five to ten years where newer programs come along and negativity arises about 12-step programs. Most of this negativity is not adequately researched. There appears to be a real lack of knowledge by such critics about the actual programs and how they work. Even though there is a lot of research supporting 12-step programs, people seem to like the new shiny object, the new therapy. Somehow, a spiritual approach continues to scare people and turn people off. They have difficulty with an approach that came out of a lay understanding of recovery. It’s not for everyone, but it’s the best thing going for a long-term approach to abstinence.
The use of medications and the use of 12-step programs are the areas where many of these fights seem to take place. I have worked with psychiatrists firmly against the 12 steps because they thought spirituality necessarily implied religion. I think it comes out of a misunderstanding of what the spiritual approach in the 12 steps actually means and how it is used in that context. Nonetheless, such a misunderstanding can prove to be a real stumbling block.
One of my favorite unofficial sayings that I learned in a 12-step program is, “Religion is for people who want to go to heaven; spirituality is for people who have been to hell.”
That’s right! I’ve heard that saying as well and I love it.
You have said in an interview with The Addiction Professional, “The outcomes for addiction are not that good, so we need to do anything we can do.” Although you were speaking specifically about opioid drug therapy, couldn’t the same sentiment be applied to the treatment industry as a whole? With an average one-year sobriety success rate post-treatment of less than 10%, isn’t the treatment industry at the point of bankruptcy? Such a success rate would be considered a gross failure in almost any other industry. How can the treatment industry be reformed to improve the effectiveness of its outcomes? What needs to be changed for drug and alcohol treatment to be more effective in the long run?
I have to start with the 10% statistic. In a fairly famous paper, Dr. Thomas McLellan compared addiction treatment to the treatment of other chronic illnesses like hypertension and diabetes. They found 40 to 60% relapse rates during the first year post-treatment as opposed to that much lower rate. The 10% number is based on a specific inner city population with homeless and jobless individuals. That tends to be where you get those really low numbers, and it’s also based on old data about alcoholism that suggests such low one-year recovery rates. One-year recovery rates also are not the only way to measure treatment outcomes, although it is one way to do so.
Still, older data shows that among alcoholics the recovery rates for one year are about 60 to 80% if you have both intact family and intact job. If you were missing one of those, it dropped in half to 30 to 40% after one year. If you were missing both, it drops in half again to 15 to 20%. I always keep that in mind; there are different ways of measuring how we are doing as treatment providers and as treatment centers, and that is only one way of measuring it. I do, however, agree with the premise of the question because I don’t think that we are doing an adequate job. I believe we can do a lot better.
First of all, we have to standardize how we measure treatment outcomes because there is no specific standard in the treatment industry. At Hazelden Betty Ford Foundation, we’re actually working on that. We want to have a standard established. Right now, you can go online and look up a treatment center and they can say anything they want about their outcomes: “We got 80% people still sober after one year” or “Everybody who comes here gets cured of addiction,” and it can’t be accurate when they state such things.
We need to move where the competition in terms of treatment options is based on outcome and not on location, food or thread count. If I’m picking a surgeon, I’m picking him based on his outcomes. My wife had to have both her knees replaced last summer because of an inherited family problem with arthritis. We got a doctor at the Mayo Clinic to do it and he did a great job and she’s had a very positive recovery, but we picked him based on his outcomes. We didn’t go to Mayo because of the weather or the thread count or the gourmet food, but because that physician had a proven track record of successful outcomes with this particular surgical procedure.
We have to get there in this field in regards to treatment and recovery choices made by our patients. That’s the single most important change we can make because competing based on effectiveness always has a real impact. Once you’re competing based on outcomes, everybody will want to get better outcomes and thus provide better treatment. With such a change, all the treatment centers will have to improve their standards of care. Over time, they will use evidence-based practices in order to achieve the better outcomes. They will have to keep up with the literature and research to incorporate those things into their treatment programs.
Finally, we need to treat addiction as the chronic illness that it is. A one-month course of treatment or a six-week course of outpatient treatment simply is not adequate. Like any other chronic illness, it needs a long-term approach towards treatment that hopefully moves from highly structured professional treatment to self-management strategies over time that promote sustainable sobriety. During the first few years of recovery, there should be more involvement and follow-up that we haven’t figured out in order to support patients. Too much time and energy and money is being spent on that initial period of time when what is really needed is figuring out a way to spread it out and provide more support over an extended period of time.
The last thing that comes to mind would be more oversight of the actual practice of how addiction treatment is provided. Hazelden Betty Ford just opened a treatment program in West Los Angeles. In doing so, we found out that non-licensed individuals can offer outpatient treatment for addiction in the state of California. You don’t have to have a licensure of any kind and that’s a very unusual situation where the local plumber could decide to run a treatment program on his off days because he happened to be in recovery and knew a thing or two. He legally could provide therapy in California on an outpatient basis and that’s completely inadequate and needs to be changed. Such a system certainly is not going to result in great quality treatment, great outcomes while being able to incorporate the advances that keep with the latest research.
You have specialized in providing effective addiction treatment options for healthcare professionals who are addicted. Why is addiction an “occupational hazard” for healthcare professionals as you have said in the past and what kind of specialized treatment is needed for healthcare professionals facing such a crisis?
The primary reason I described addiction as an occupational hazard was mostly in regards to anesthesiologists, ER doctors, nurse anesthetists and those people that have the highest access to the most powerful drugs on the planet. If you’re a nurse anesthetist, you’re the one handling the fentanyl, the sufentanil, and these other powerful drugs and providing them to the patient. In the handling of it, you have the highest access to the possibility of diverting some of that medication.
We know that children growing up in areas where there’s a lot of drug dealing going on, the drug dealing becomes normalized and the risk for taking those drugs becomes much higher. As a result, there’s a higher percentage of people using and a higher rate of addiction in those areas. I think the same can be said for medical professionals and physicians. If you have access, the likelihood of trying something increases and the potential for addiction increases. Then you combine those risk factors with the fact that healthcare professionals have high stress jobs. Stress is a risk factor for both addiction and relapse once people are addicted. That’s why I talk about it as an occupational hazard. The research shows physicians have about the same percentage of addiction as the general population, although the research isn’t great because it’s hard to accurately get these numbers. There are, however, different types of addiction among physicians. Very few physicians smoke their drugs or use illegal substances while many use prescription opioids and benzodiazepines. You would think such use would be safer, but that’s simply not true. After all, fentanyl is 50 times more powerful than heroin. When they are using, they’re really using remarkably dangerous and addicting substances.
As for specialized treatment for physicians, the reason for such a specialized approach to their treatment is several fold, but the first thing is that physicians tend to be fairly bright people. If you don’t have an adequate understanding of that and enough brainpower to contend with it, they can just run you around in circles and not get adequate treatment. That’s a problem for some counselors. Of course, there are many counselors absolutely up to the task, yet experience with physicians and other healthcare professionals can really be beneficial. You don’t want a doctor going to an outpatient program where nobody has ever treated a physician before. They’ll end up doing whatever they want and be right back to work in no time.
The challenge of physicians going back to work brings up other regulatory problems that need to be considered in such specialized treatment. Physicians in treatment often are involved with a state board or a state physicians' health program or even the Drug Enforcement Administration. When licensing issues come up, you need a staff that knows about these issues for a couple of reasons. One, if the physician is doing well and fostering good recovery, you want to advocate for them, in regard to return to working and the ability to continue their practice. If they are not doing well in treatment, however, you want to contact those programs and readily describe the lack of progress in order to make sure that someone who is going to be a danger to patients doesn’t return to the workplace.
The prescription painkiller plague has been so highlighted in the media and beyond that other prescription drug problems tend to be pushed under the proverbial rug. There are many reports, however, that prescription drugs like Adderall and Xanax are being abused to the same extent as the prescription painkillers. What do you see as the biggest prescription abuse problems in the country beyond the painkillers and how do these problems need to be addressed?
Beyond the painkillers, the benzodiazepines—Librium, Valium, Xanax, Klonopin and the others—traditionally have been very close to the opioids in regards to emergency room admissions and overdoses. Deaths are very high as well, although they usually tend to be combined with opioids in a deadly prescription cocktail. Benzodiazepines as a category of medication are really problematic, particularly in regards to the elderly. Medications are being provided that cause a lot of falls and accidents, particularly when combined with other sedatives and alcohol. The result is a bevy of additional healthcare problems caused by providing these medications.
In terms of addiction, the benzodiazepines are a problem, but, as you mentioned, the amphetamines are a problem as well. We are seeing a resurgence of the use of prescribed amphetamines. In fact, the amphetamine Vyvance was just approved as a treatment for binge eating disorders. When addictive substances are being prescribed to treat ongoing issues or even chronic problems, I find it really problematic as a physician. We went through that in the 1950s with "mother’s little helpers" when women were using amphetamines for weight loss, and they’re not effective treatments long-term. Although they certainly can reduce appetite and cause weight loss, the downside is huge. If people aren’t altering their eating behaviors and approaches to exercise, it’s not a good long-term solution.
With any drug of abuse, increasing access leads to increasing the problems of abuse and addiction.
On May 20, 2013, you tweeted, “It is essential that physicians recognize that we contribute to the opioid epidemic by overprescribing.” Given the prescription painkiller epidemic, is more training for clinicians about addiction and addict behaviors like doctor shopping needed? How can the Hazelden Betty Ford Foundation become a trailblazer in the institutionalization of such training nationwide?
Yes, we really do need more information and training for physicians and all other healthcare providers around the country. There’s just such little attention paid to addiction in the formal training that exists in medical school, nursing school, psychology programs and the like. Although there has been a stabilization in the prescribing of opioids, and doctors are changing, such educational opportunities are absolutely needed, and we are doing that on a regular basis at the Hazelden Betty Ford Foundation. Recently, there has been a recommendation by the American Academy of Neurology that opioids not be used for chronic pain so the landscape is changing. What we are seeing is that well-intentioned physicians are recognizing that the research does not support the use of opioids for the treatment of chronic pain. The problems clearly outweigh any benefits.
Yet, a lot more needs to be done, both for physicians and the public. We do an annual conference on addiction medicine for primary care doctors. We partnered with the Mayo Clinic’s annual pain conference this year. Prior to the pain conference, Hazelden Betty Ford Foundation offered half a day on addiction medicine for any of the attendees that were interested. It’s a great opportunity to partner with the Mayo Clinic and address this issue. We have a one week professional in residence program at multiple sites for physicians and other healthcare professionals interested in learning more about addiction. The program is divided between didactic education about addiction treatment and actual experience in a residential treatment setting.
The funniest thing about these programs is that so many physicians who come into that program have had little or no training in addiction medicine. They also claim to never have dealt with people in early recovery. They meet people ranging from their first few days in our program to a couple of months, and they realize that these are really good people. They are surprised how different they are from the people they remember during those long nights in the ER that were really just a major pain in the ass. These are good people with a bad disease, and they start to see what that really means.
There’s a program at the Betty Ford Center—the summer institute for medical students—that’s a completely charitable driven program where students come from med schools across the country and spend a week learning about addiction. We have multiple internships and residencies for healthcare professionals at our programs to address this challenge. A major part of our mission is to improve education for healthcare professionals about addiction and its treatment. If this opioid crisis, and the next drug crisis, is going to be addressed, such education is necessary.
John Lavitt is a regular contributor to The Fix.