Precision Medicine Focuses on Addiction

By Dr. Richard Juman 05/12/16

New tools in medicine and psychiatry assist in tailoring specific treatments to patients.

Precision Medicine Focuses on Addiction
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Medicine continues to become more sophisticated in the implementation of precise diagnostic tools and targeted interventions for a wide spectrum of illnesses and conditions. For example, when selecting a particular antidepressant for a patient, in the past, the choice of medication would be based on the medication’s general efficacy and side effects; now, we can also factor in the patient’s genetic and other highly specific lab data. Michael Genovese, MD, an expert on pharmacology, neuromodulation and pharmacogenomics, explains some of the critical developments…Richard Juman, PsyD.

Richard Juman: Clearly there are tools for precise diagnostic evaluation and treatment planning that weren't even dreamed of just a few years ago. Can you describe a few of the tools that you are most impressed by, and give me a few examples of situations in which your decision-making about clients was radically informed by these new approaches? 

Michael Genovese: Rapidly, we are developing tools in psychiatry to optimize the care of individual patients. Hallmarks of Integrative Medicine include accounting for the whole person as well as the individuality of the patient, and being open to all appropriate modalities.

We’ve made advances both diagnostically and therapeutically. I regularly request personalized psychoneurophysiological stress evaluation and EEG brain mapping for my clients. Combined with more traditional psychological testing, the information from these evaluations provides valuable information about areas of the brain that could benefit from neuromodulatory interventions such as neurofeedback or Transcranial Magnetic Stimulation.

In terms of pharmacology, pharmacogenomic testing has become a useful tool in formulating an appropriate treatment plan. Pharmacogenomics is the study of genetic variations that influence individual response to drugs. Knowing whether a patient carries any of these genetic variations can help prescribers individualize drug therapy, decrease the chance of experiencing adverse drug events, and increase the effectiveness of drugs. Pharmacogenomic testing is now available clinically to physicians and can be used as an adjunct to inform our clinical judgment.

Can you give our readers a couple of examples of situations in which these kinds of assessments made a significant difference in the way that you treated clients you were working with? 

The first step in the bio/neurofeedback process is to evaluate patients’ current psychophysiological and psychoneurophysiological status. This evaluation comprises a brief self-report of patients’ overall perceived resiliency, a comprehensive psychophysiological stress evaluation, and an abbreviated quantitative electroencephalogram (QEEG).

These data provide an informative snapshot of the degree of patient physiological resiliency along with current psychoneurophysiological status. For instance, it is often the case that patients will evince a typical psychophysiological pattern which parallels their emotional condition(s). Through heart rate variability analyses, it is not uncommon to observe that depressed patients will typically respond to demands with increased high frequency activity (which we may interpret as a state of overwhelm) while anxious patients typically respond to post-stress recovery periods with increased very-low frequency activity (which we may interpret as “holding on” to stress). As for the abbreviated QEEG, findings from this assessment provide a general overview of cortical-electrical ratios, brainwave power, and stability from various structures of the brain (i.e., frontal lobe, anterior cingulate, etc), which are interpreted to represent various behaviors associated with these regions (e.g., frontal slow-wave dominance may indicate various conditions of attentional challenges, memory, impulsivity, etc.).

Each evaluation is methodically interpreted into an integrative profile, and when discussed with patients, they are often struck by the accuracy with which biorhythmic and EEG data can “reveal” their temperament and condition(s). From there, bio/neurofeedback protocols are chosen collaboratively with the patient and expectations for training are discussed.

As you are examining all of this data, is it possible to tease apart the patient's premorbid brain functioning and personality from the effects of their chronic and recent substance use? And how do you determine what the goals of the bio/neurofeedback interventions should be? 

The entire team endeavors to do just that, to account for what is the premorbid baseline versus the presentation on admission. Having the extended time in Residential allows for an ongoing investigation. I work closely with Dr. Antoinette Giedzinska-Simons, who runs our neuromodulation program. 

The clinical applied sciences of psychophysiology and psychoneurophysiology are, by every account, true mind-body medicine. The very essence of an individual’s ability to attend to the over-activation of his or her peripheral nervous system, and regulate these systems in the direction of his or her intention is—in itself—an act of integration.

When you include neurofeedback into this model, while coaching the individual toward an enhanced awareness of conscious state and mind-body integration, it becomes a profound multidimensional experience.

Obviously each client is different, but overall, how would you describe your views with respect to the optimal use of psychotropics in recovery? Do you find that most clients benefit from the sustained use of prescribed medications when their inpatient treatment is over and they return to the community? 

MG: That certainly depends on the patient. Many people would rather avoid long-term medication, and generally I'll try to support that, especially if the medication in question is potentially addictive or poses a significant risk to the patient.  

In the context of a major comorbid disorder, such as Bipolar Disorder, long-term medication administration may be necessary and it is the physician's responsibility to explain why. Chronic illnesses sometimes require long-term management, not unlike hypertension.

Since you clearly believe in a fully biopsychosocial approach to treatment, what do you consider the most helpful non-pharmacological interventions for patients to participate in during rehab? 

MG: It’s difficult to single out one aspect of treatment as the most important. We are a family-centered program, and certainly the family involvement is key. Often, we are treating the “identified patient,” but some of the most important work happens during family week. The various psychotherapeutic approaches (Individual, Group, EMDR, Somatic Experiencing) probably confer greater or lesser degrees of benefit depending on the individual patient, but their collective benefit is paramount. I frequently tell the medical students that some of the most important change we can effectuate are the epigenetic changes associated with psychotherapy. We can work with the patient to augment gene expression, which is truly profound.

I tuned in to your recent webinar on Adverse Childhood Events and their etiological role with respect to developing later addiction. So I know that you are well-persuaded by the link between trauma and addiction. But, given that your work with patients tends to be limited to 30 days, is that enough time to begin to address some of those issues, or does it make more sense to wait until recovery is stable and those issues can receive attention in continuing care?

Thirty days is enough time to take a pause and start to introduce some concepts to people. Some are so deep in their addiction that they're in no way ready to start addressing the underlying trauma. We have some patents who spend the first 30 days working on their addiction, then extend their stay with us to start the very difficult trauma work that they will have to continue in PHP, IOP and continuing outpatient therapy. 

Either way, we make it clear to patients that 30 days, 45 days, even 60 days, is only a small part of the lifelong continuum of their care.  

There has been an unprecedented amount of movement lately on various fronts with respect to substance use. The CDC's recommendations around prescribing opioids, the FDA's relabeling of certain pain medications, Congress's movement towards passing the Comprehensive Addiction and Recovery Act. What do you make of it all, and do you think that these developments will make a difference?

First of all, I’m hopeful that this surge of activity fuels our ability to counter what everyone agrees is an epidemic. I’m particularly interested in two sections of CARA:

Title I Section 102 provides for a national education campaign. Clinicians have long said that we can’t adequately confront a problem until we fully understand it. Surprisingly, some still view addiction as a lack of willpower or a character defect. The general public requires education about addiction, but so too does the medical community. I speak with doctors frequently who admit they would like to know more about the pathogenesis of addiction. If they understood the disease process better, they would be in a better position to treat it more effectively. The confluence of public acknowledgement that addiction is a disease state, and the enhancement of knowledge of those treating the disease, should result in better outcomes.

Dovetailing with that idea, Title III Section 301 contemplates expansion of evidence-based treatment, including medication-assisted treatment, through government grants. Greater availability of currently available treatment will not only help those in need now, but I imagine it will foster interest in research to improve on our current capabilities. For example, oral and injectable naltrexone have been helpful for a subset of patients; now physicians are looking to longer-term implants to remove medication compliance as an obstacle. Neuromodulatory techniques such as Transcranial Magnetic Stimulation are being studied in addiction treatment, and papers are being published around the world regarding safety and efficacy. Common sense would dictate that the urgency of the crisis will hasten adaptation of newer approaches. 

The FDA, CDC and Congress have a common goal with their actions, one that harmonizes perfectly with ours as healthcare providers—healing. It is incumbent upon all of us to maintain the current energy aimed at achieving this goal. 

Michael Genovese is the Chief Medical Officer of Sierra Tucson, a world leader in integrative health. He is Assistant Clinical Professor of Medicine at the University of Arizona, a Diplomate of the American Board of Psychiatry and Neurology, and a member of the American Psychiatric Association and of the American Academy of Addiction Psychiatry. Dr. Genovese writes, speaks, teaches and consults widely in the disciplines of pharmacology, neuromodulation and pharmacogenomics.

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Dr. Richard Juman is a licensed clinical psychologist who has worked in the field of addiction for over 25 years. He has treated hundreds of patients as a clinician and also provided supervision, program development and administration in a variety of settings including acute care hospitals, long term care facilities and outpatient chemical dependency centers. Find him on LinkedIn and Twitter.