February 11, 2014
By Kim Johnson
Deputy Director, NIATx
Co-Director, ATTC Network Coordinating Office
The blogosphere has been full of reflections and opinions
on the tragic death of actor Phillip Seymour Hoffman from an apparent heroin overdose. I am amazed at how much of the discussion is hateful. We still have
a long way to go in addressing stigma and teaching people about addiction.
We were actually taken with one blogger’s commentary on his
physician’s paying more attention to cholesterol levels than to
maintaining
recovery. If you’re in recovery and your doctor doesn’t ask about it, then
you should find another doctor. Of course, being of the engineering ilk, we (at
NIATx) don’t
blame the doctors. We think about how the system is designed to produce this
result. And at least for me, the ruminations on system design and how to
improve it bring me back to the issue of integration.
While I don’t want to
debate the fact that the origins of our separate system lie in stigma and the
lack of a decent medical response to addiction, we are now 40 or 60 years into
a system design that doesn’t work for most people. Doctors don’t treat
addiction, at least in part, because we define treatment as counseling, which
they are not qualified to do.
Ask your friends or family who are not involved in addiction
treatment. What do they think treatment is? Any perceptions they have are likely to come from a
TV show like Celebrity
Rehab. In this image, treatment happens in a residential program
where people sit around and talk a lot. Somehow, after they talk enough about
how awful everything has been, they come out cured. I have this picture in my
head of a big black box that people enter as a versions the Gollum--the Lord of the Rings character who is torn between his lust for the Ring and his desire to be free of it--and exit magically transformed into the good elf Legolas. Um, right.
Doctors definitely don’t do that.
What do doctors do? They screen, diagnose, and treat with
medications and procedures. They also monitor symptoms and change treatment recommendations
based on a patient’s response to the treatment prescribed. Think about how that
fits in a system that adequately treats addiction. In an integrated system, we
treat the brain as an organ in the body, and the mind as a function of the
organ called the brain. We treat diseases of the brain with the whole panoply
of options available to us, which include medications as well as counseling,
and we treat addiction as the chronic condition that it is. Treatment of
chronic conditions starts with screening and early intervention. Once a person
is diagnosed, treatment includes medications to address symptoms, counseling to
help people learn to manage symptoms, and ongoing follow up to monitor symptoms.
Physicians know this process. They don’t do counseling (other than advice
giving, which is what they think of as providing council). They refer people to counseling as an
ancillary service.
PCSS-O “
is a
collaborative effort led by the American Academy of Addiction Psychiatry with
the American Medical Association, the American Psychiatric Association, the
American Osteopathic Academy of Addiction Medicine, the American Dental
Association, the American Society for Pain Management Nursing and the
International Nurses Society on Addictions,” explains Kevin Sevarino MD, of the
American Academy of Addiction Psychiatry and Medical Director for PCSS-O. “The
coalition recognizes the critical role for an interdisciplinary approach to
managing the complex needs of pain management.”
PCSS-O has trained more than 15,000 people on safe and effective
use of opioid medications since its launch in 2011. With online modules, live
and archived webinars, links to the latest news on opioid prescribing,
and a provider mentoring program, this initiative seeks to reach and educate a
broad audience about safe opioid prescribing.
PCSS-MAT is a three-year
grant that was awarded in September 2013. Adam Bisaga, MD, Columbia University,
also with the American Academy of Addiction Psychiatry, serves as chair for the
PCSS-MAT Mentoring Panel.
Says Bisaga,
"The
goal of the PCSS-MAT training program is to enhance prescribers' and other
health professionals’ knowledge, skills, and attitudes regarding the safe and
effective use of medication-assisted treatment of opioid dependence by providing access to a wide range of
web-based educational materials and individualized expert mentoring. This free
training program is specifically designed for providers, primarily those in the
primary care specialties, who may be new to working with this population."
These two training options may go along way toward
changing office visits like the one described by the blogger mentioned earlier whose doctor monitors his cholesterol levels more carefully than his recovery.
My personal experience with a primary care provider addressing
substance use has been different: I have had three providers in the past 25
years, and all three have asked about my alcohol, tobacco, and drug use. I’m
kind of a boring patient, so I don’t know how well they would respond had I
exceeded any thresholds indicating that they should ask more questions. But
they at least are doing the first step. I think the tide has turned and that
screening, at a minimum, is becoming a norm. Tools like PCSS-MAT and PCSS-O can
support physicians as they learn how to treat the people who they identify as
needing treatment.
And those of us who have spent 40 years defining treatment
as counseling need to embrace the fact that treatment is more than counseling. We
also probably have to embrace the idea of a physician rather than a counselor
leading a treatment team. You can hear more views on this topic during
The Bridge Video Talk Show, this Thursday, February 13, at 1pm EST (12noon CST, 11am MST, 10am PST.)
It is heartbreaking to see people, famous or not, die of a
treatable disease. Let’s stop protecting our turf and redesign this system in a
way that gets us different results.
Kimberly
Johnson served for seven years as the director of the Office of Substance Abuse
in Maine. She has also served as an executive director for a treatment agency,
managed intervention and prevention programs, and has worked as a child and
family therapist. She joined NIATx in 2007 to lead the ACTION Campaign, a
national initiative to increase access to and retention in treatment. She is
currently involved in projects with the ATTC Network and NIATx that focus on
increasing implementation of evidence-based practices, testing mobile health
applications, and developing distance learning programs for behavioral health
