Why Are We Afraid of Universal Health Care?

What does universal health coverage really mean? This is the definition of universal health coverage from the World Health Organization (WHO).

Universal health coverage (UHC) means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.

This definition of UHC embodies three related objectives:

  1. Equity in access to health services – everyone who needs services should get them, not only those who can pay for them;
  2. The quality of health services should be good enough to improve the health of those receiving services; and
  3. People should be protected against financial risk, ensuring that the cost of using services does not put people at risk of financial harm.

In 1948 WHO’s constitution declared health care a universal human right.  The organization works with countries on health care financing to make universal health coverage a reality. The key concept here is the belief that health care is a right, not a privilege. As a physician, this seems like a no-brainer to me. Yet that view is controversial here in the United States.  Many people espouse the view that health care should be available to all, yet believe that it’s too expensive.  The other political issue that hinders universal health care in the US is the philosophy that government involvement in health care is too intrusive into individual privacy and that states should make decisions about healthcare.

Let’s take the first point first. When we say that something is too expensive, what we really mean is that it isn’t a priority. If a member of your family develops a life-threatening illness, health care suddenly becomes first priority, and you rearrange your finances to make sure that your family member gets the necessary care.  We don’t leave funding of the military to states, because it is a priority. We decide, by electing our congress people, what our priorities are.

The Harvard Review published a great article in May of 2015 discussing this issue. The article points out that many poor countries have been able to initiate affordable health care for all citizens at a reasonable cost. Thailand and Rwanda are good examples.  Their infant mortality rate has decreased and life expectancy increased.  The key, according to the article, is that countries have to be committed to the principle that everyone deserves access to health care, and they must have their act together, meaning that everyone is on the same page, to make it happen.  I don’t think we are on the same page about anything at the moment.

Now let’s look at the second issue – the privacy, big Government Issue. How does offering everyone access to health care invade privacy? If you choose not to go to the doctor, that is still your choice.  As far as government involvement in healthcare, we already have it – Medicare. I don’t think most seniors would want to give that up. It’s not completely free, but it is affordable for most seniors.  While the program is not perfect, and not all physicians take Medicare, acceptance by the medical community has improved. Government programs do not have to be fraught with complicated regulations if managed by the right people.

Another prevailing view is that low-income people get health care because doctors won’t turn people away.  Before the ACA, some doctors did see low-income patients on a sliding scale. But many people still couldn’t afford the fees. There were some clinics for low-income people, but they still have to be funded somehow, usually by the state or federal government.  Many low-income people used the emergency room (and still do) for primary care. But who pays for that? We do. It increases the cost of health care because hospitals have to compensate for it.  They key to long-term good health is not acute care – just taking care of the problem at hand. It’s preventive care. That requires visiting a primary care practitioner often enough to head off potential problems.

Universal health coverage can take different forms in different countries. I’ll discuss some of them in the future. No system is perfect. But they all came into being because governments were committed to the idea that health care is a right, not a privilege. If you believe that, you have to conclude that all people deserve access.

Check out the Harvard Public Health Review article “Universal Healthcare: An Affordable Dream,” vol. 4, Global Health, May 2015 (harvardpublichealthreview.org).

 

WHEN DID MEDICINE AND BUSINESS GET MARRIED?

It slipped up on me. I guess I missed the engagement party. I thought I was going about my career taking care of patients as I planned to do when I decided to be a doctor. But today I find myself worrying more about whether I’ve met my billing quota and my RVU (relative value unit) target for the month. The relative value unit measurement tells administrators whether we are seeing enough patients, keeping our schedule full.   I don’t blame administrators. They’re cogs in the wheels of a totally dysfunctional system. They are doing what they can to keep our doors open.

When I interviewed for a position in medical school, I was asked whether I thought that medical care was a right or privilege. It was a common interview question at the time, and I had been forewarned that it might come up. I had no hesitation in answering that question though. I felt then, as I do now, that access to medical care is a right, not a privilege. I wonder if that question is even asked anymore.  Apparently, the correct answer at the time was that medical care is a right. However, I don’t see that organized medicine has ever truly supported that philosophy because if they had, I don’t think we would be in the mess that we are in now.

Somehow, insurance companies got involved in healthcare. I also remember that when I first started working and had to pick an insurance plan, I was advised to look for a plan that had the best catastrophic coverage, because that’s what insurance was really for. The idea then is that you could still pay cash for doctor’s visits and medications. We’ve come a long way from that.

Why have we tied the ability to access health care to a job? Until the Affordable Care Act, if you didn’t work, you didn’t have insurance unless you met fairly restrictive criteria for a state Medicaid plan or you were wealthy enough to buy a private insurance plan or just pay for your healthcare.

At one time, healthcare companies were nonprofit for the most part. But now they don’t claim to be non-profit. Let’s look at the salaries of the CEO’s of the top healthcare insurance companies. This is public knowledge. You can find it at fiercehealthcare.com.

 

Humana CEO Bruce Broussard $10.3 million

United Health CEO Stephen Hemsley $14.5 million

Cigna CEO David Cordani $17.3 million

Anthem CEO Joseph Swedish $13.6 million

Aetna CEO Mark Bertolini $17.3 million

 

So these guys are paid millions of dollars to find ways to deny the medications and procedures that your doctor orders. Of course, that is an oversimplification of what they do – but not much of an over simplification.

I find it interesting that patients are so against a single payer system, yet are willing to have their healthcare essentially dictated by an insurance company with a CEO paid 17 million dollars to rip them off. Go figure. By the way, we already have a single payer system for those over 65 – Medicare.

Doctors and the AMA have some responsibility for the negative view of single payer systems. For many years, the American Medical Association very opposed to any single payer system, also called socialized medicine. That really is not an accurate label for a single payer system. The AMA’s stated mission is “to promote the art and science of medicine and the betterment of public health,” (ama-assn.org). However, in my opinion, the AMA sometimes seems more interested in protecting doctors than in the interests of patients. Don’t get me wrong. We all benefit from organizations that protect our interests, but healthcare is not like any other entity. It’s life and death for patients. Sometimes, what is good for doctors also benefits patients, but not always. I’ve never joined the AMA.

In future blogs I’ll take a look at healthcare systems in other countries. I believe in gathering data before judging something as bad or good. No healthcare system is perfect, not the single payer systems (which are not all the same) and not our insurance-driven system.

I would recommend a book coming out on April 11 by Elisabeth Rosenthal, MD, called An American Sickness: How healthcare became big business and how you can take it back. Dr. Rosenthal has been a practicing physician as well as an author. She has traveled widely, and she is familiar with other healthcare systems. I was able to hear her on a podcast, and I’m looking forward to reading the book as soon as it comes out. One of her messages is that patients can have a role in taking more control of their healthcare and dealing with insurance companies. I have found that insurance companies sometimes listen to patients more than they listen to us. They will often say that they’ve denied something because the doctor didn’t provide enough information, but in reality they are playing the blame game. The doctor probably filled out the confusing, redundant paperwork, but the request still didn’t meet the insurance company’s criteria for approval. I’ve had insurance companies refuse a request 3 times because they sent us the wrong form to fill out 3 times.

Don’t forget Dr. Rosenthal’s book coming out on April 11. It should be a good read if you care about our healthcare system. I found it on amazon.com.

And I still believe that in our country access to food, education, and healthcare are rights. How they are used is up to the individual.

 

 

SOMEONE IN YOUR WORLD IS ADDICTED: OPEN YOUR EYES

In the US Revolutionary War, from 1775-1783 there were 50,000 US casualties.  In the Vietnam War (1955-75), there were 211,454 US casualties, while the Iraqi War, from 2003-2011 resulted in 36,710 deaths and the Afghanistan War, from 2001 to the present resulted in 20,904 deaths (US Military Casualties of War, en.wikipedia.org). Over 40,000 women each year die of breast cancer (Jemal et al. Cancer statistics, 2008. CA Cancer J Clin. 2008 Mar-Apr.).   That’s a lot of mothers, fathers, wives, husbands.   Statistics like that grab us. We’re willing to invest in cancer research and treatment.  We honor our military dead. Yet in 2015 alone, more than 52,000 people died of a drug overdose according to the CDC (Center for Disease Control).  Of those 52.000 deaths, 61%  involved an opiate. Between 2001 and 2014, per the National Center for Health Statistics of the CDC, over 250,000 people have died of prescription drug overdoses. Yet, unless one of them happens to be your son, brother, daughter, best friend, wife, those deaths are largely ignored.

We can distance ourselves from those deaths because “it’s their fault.” After all, “they’re drug addicts.” You don’t see fundraisers for drug addiction treatment or parades to celebrate recovery from drug addiction, at least not very often. Yet, we’ve lost more people to drug deaths (not just heroin, but also prescription drugs) over the last 15 years than we did in the Iraqi and Afghanistan Wars combined, or in the Revolutionary War, and we lost more people in 2015 to drug overdoses than we did to breast cancer. What a tremendous waste.

This is a treatable disease.

 Why aren’t people getting treatment? Only a very small percentage of people with addiction are in treatment. There are several reasons. For one, there aren’t enough treatment resources, and there aren’t enough people who specialize in treating addiction, particularly in rural areas. There is still a lot of stigma and misunderstanding People with addiction are told that they are simply weak-willed, that they could stop if they only wanted to, and they buy into that. They are hopeless and defeated, and they believe that treatment won’t work. Nothing could be further from the truth. Addiction is a disease of the brain, a disordered brain. Once a person is in the throes of an addiction, free will is not operating anymore. As with any disease, people who have been ill for a long time, people who grew up in families rife with addiction, need more intense treatment over a longer period. It’s not easy to find that. It may be expensive.

I listened to an interesting webinar today, presented by the American Society of Addiction Medicine on what the Surgeon General’s Report, Facing Addiction in America, means to clinicians treating addiction. Dr. Thomas McLellan of the Treatment Research Institute was one of the speakers.  He points out that 94% of addictions start between the ages of 12 and 25. So that means that we probably aren’t starting treatment early enough.  Addiction related deaths account for 74% of deaths in the 12-25-year-old age group.

Physicians have a role in this abysmal statistic as well. I can say that because I am one. We have been too quick to prescribe opiates and not good enough at monitoring our patient’s use of them. I think, however, that we are getting a little better at understanding when and how to use opiates, when to not use them, and alternative treatments for pain.  However, what I still find infuriating is the negative attitude that many physicians have towards patients with addiction, even patients who are in medication-assisted treatment. I thought we learned better in medical school. You don’t let your personal biases interfere with your treatment of the patient. I’m afraid we’ve lost that concept in the medical profession.

Unfortunately, addiction is like cancer. If treated early and aggressively, the patient can be saved. But if treated too late, some people won’t make it.  I would be willing to bet that someone in your inner circle is struggling with addiction. Open your eyes. Get them into treatment if possible.

And remember, if people don’t have health insurance, they don’t have access to treatment.

You can read the Surgeon General’s report at addiction.surgeongeneral.gov.

 

 

Listening to People with Cancer

 

Over the last couple of years, I’ve had the privilege of working with patients diagnosed with cancer who were referred to our clinic by local cancer treatment centers. I’ve seen people at all stages of the disease, very early to terminal. They are usually referred to me because they’re very depressed or anxious. Sometimes they are willing participants in treatment, eager to tell their story. Sometimes they are angry and resentful, feeling that their oncologist (cancer specialist) must believe that they are crazy if he or she referred them to a psychiatrist. Hopefully, we can get past that.

At first, I wasn’t sure how I could be helpful to them. After all, most people would be depressed, anxious, angry, and fearful when diagnosed with cancer. Those emotions are normal, though patients sometimes feel that they are being referred because of these strong feelings.  Doctors don’t always handle their patient’s intense feelings well, so sometimes that is true. Often though, doctors just feel that their cancer patients could use some help in dealing with the emotional side of cancer.  Usually, patients just need to ventilate for the first few sessions. They need to tell their story, how they were going along in life just fine and then this- a huge boulder hurtling down the mountainside towards them. Usually they feel blindsided, violated, enraged at the unfairness of it.

I realized that they need for me to be the person who can listen to their fears and not back away. Usually family members are cheerleaders, encouraging them to forge ahead with each new treatment, convinced that they are going to beat this.  That’s what family should do. Cheerleaders are important. But often patients feel that they can’t fully let their guard down and talk about how scared they are, or how they maybe don’t want that next treatment, or how they don’t feel like going on that big family vacation that the kids planned, or put into words the thought that families can’t bear – that maybe they won’t make it. They need a place where they can be gut level honest.

Sometimes I put the brakes on those worst-case scenario thoughts or remind them that the prognosis for cancer treatment is better than ever.  Sometimes we work together to find the words to ask for more information from their oncologist. Patients still feel intimidated by their very busy doctors, and they don’t want to “bother” them with questions, or they forget the questions when they see the doctor.  Occasionally they need to find the words to say “I don’t want to do this anymore.”   I help them find their voice. I remind them that this treatment thing is a two-way street, and they are an equal partner. They may not have the knowledge that the oncologist has, but it is their body.

It’s important to have a place where you don’t have to put on your game face.

Many of my patients won’t die of cancer.  They will be survivors. But I have been impressed with the ways that people process a cancer diagnosis.  One lady said to me recently that she stopped worrying so much about the future. She put more emphasis on today.  She had a blood cancer that was likely to go in and out of remission. She said that she accepted that she probably would not live as long as many people, but she would be more present, more appreciative for each day.   This quiet acceptance seems to benefit patients, but it takes some time to get there. It doesn’t mean that they’ve stopped fighting; it means that they are no longer angry with God and the Universe. They can battle cancer but still savor today.

Our medical profession has advanced unbelievably as far as technology. But I am afraid that we have lost some of our emotional connection with patients. We need to remember that quality of life is just as important as quantity of life.

I would highly recommend a book by Dr. Atul Gwande called Being Mortal: Medicine and What Matters in the End.  Dr. Gwande addresses the issue of quality of life and how that concept may run counter to what the doctor recommends. He discusses some creative and humane ways to bring more quality of life to the end of life.

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YOUR SMART PHONE AND RECOVERY

Technology has come to the world of mental health and addiction. Cell phones figure prominently in our lives now. They can also figure, positively or negatively, in mental health and addiction recovery.

The cell phone can be a gateway to positive help or an avenue to people who perpetuate illness. Patients starting treatment for recovery need to eliminate phone numbers of dealers and “friends” who use. They know that quick access to these people during a tough time can be disastrous. People experiencing depression and suicidal feelings may not use their phone often enough to call for help and support. They tend to isolate. Communicating with dysfunctional family members can exacerbate addiction and depression, anxiety, and suicidal feelings.

Why not use the phone in a positive way that supports recovery? There are many cell phone apps available now that can be helpful to people experiencing depression, anxiety, mood swings, difficulty with sleep, and/or addiction. Some are better than others. There is little objective research at this point to determine how effective these apps are from a statistical standpoint. However, as with all treatment, you get out of it what you put in. These apps are not replacements for therapy with a professional, but they can aid recovery. You have to find what works for you.

I am going to highlight some apps that have been reviewed online. There are many others, but these are recommended by several mental health sites such as Psych Central and Healthline. Most are free.

One of the most interesting is called Reach Out. It was originally developed for use by military personnel but is available to anyone.  This app is geared toward preventing suicide. It can be used by people who have suicidal thoughts and by family members or friends who are concerned about someone who may be suicidal.   For people contemplating suicide, it has several videos that suggest alternatives, give tips on stopping suicidal thoughts and combating the negative, all or nothing thinking that suicidal people have. It suggests activities that can distract from suicidal thinking. The app lists resources for more information about preventing suicide.  It has a Help Center that lists a suicide hotline number and allows the user to list phone numbers of contacts who can be helpful. Of course, people with suicidal thoughts have to be willing to use it. It’s probably most helpful for people who have recurrent thoughts rather than an immediate impulse, and who are willing to consider alternatives.

For those concerned about someone who may be suicidal, the app lists signs of suicidal thinking, makes suggestions about how to approach the person and what to ask. It also lists resources for more information about suicide.

There are several apps that are useful for persons suffering from severe anxiety and panic attacks. One of them is Breathe2Relax. It illustrates the proper technique for breathing during a panic attack. It gives step by step suggestions on how to deal with a panic attack. Another app for anxiety is SAM, Self-help for Anxiety Management. It also provides suggestions which can be used during a panic attack. These apps work best if you take some time to understand them. There are features that are simple and can be used immediately, but with some work on personalizing the settings, they can be more effective on an individual basis.

Depression CBT (CBT stands for cognitive behavior therapy) is only available for Android at this time. It was recommended by Healthline (healthline.com) as one of the 10 best mental health apps of the year. It offers an assessment tool that allows you to follow the severity of depression and offers audio programs that help with anxiety and depression. It directs the user to resources that help pinpoint negative thought patterns that underlie depression. Pacifica, which is available for IPhone, is similar to Depression CBT.

MoodKit was rated highly on several sites. It has a mood tracking feature and suggestions to improve mood as well as a thought checker to monitor mood.  However, it isn’t free.  It costs $4.99 to download.

None of these apps are appropriate for use alone when you are suffering from severe depression and suicidal thoughts.  You need to be in a formal, face-to face treatment, but the reality is that your therapist can’t be with you 24 hours per day. These apps can be helpful between sessions.

One of the better apps for addiction is Addicaid. It’s free. It has a check-in where you can disclose whether or not you used that day. Either way, you can post and get support from others. It has 12 educational sessions on various recovery topics. You can track your progress, get information on location of meetings and communicate with friends. There is a resource section with hotline numbers.

As I said before, you have to spend some time exploring these apps and getting to know how they work in order to really be able to use them quickly and efficiently.  There are others available. If you google mental health apps or addiction apps, you will come up with more.

So if you have a smart phone, utilize it as an aide in your recovery.

It’s National Recovery Month

2016-recovery-month-logo

 

September is National Recovery Month.   It’s sponsored annually by the government agency SAMHSA (Substance Abuse Mental Health Services Administration).  National Recovery Month celebrates recovery from mental illness and addiction.

How do we define Recovery? SAMHSA has identified four dimensions of Recovery: 1. Health, 2. Home, 3. Purpose, 4. Community.  The ability to manage one’s disease symptoms by making healthy choices with regard to diet, taking medications as prescribed, and abstaining from substances and activities that do not promote well- being fall within the health dimension.

The home dimension emphasizes the importance of a safe and healthy place to live for recovery to take place. SAMSHA defines purpose as “Meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income and resources to participate in society.”1  

Last of all, the community dimension speaks to the importance of having a support system consisting of family and friends that provide love and hope.

Notice that the SAMHSA definition of recovery doesn’t say anything about being “normal.” We can’t define normal. People who recover from a serious mental illness or addiction are usually changed in significant ways.  Recovery doesn’t require the person to be exactly as they were. You can’t go through the experience of dealing with a mental illness or addiction without becoming an emotionally deeper, stronger person. It also doesn’t require that the person be totally free of the illness.   People with mental illness and/or addiction (you can have both) are always vulnerable. I particularly like the SAMHSA definition of the health dimension – the ability to manage symptoms by making good choices, not necessarily to be totally without symptoms.

Many people, with and without serious illness, struggle with finding meaning and purpose in life. I like the SAMHSA examples of purpose – having meaningful daily activities such as a job, caretaking, volunteering, being creative.  Living life as best you can meets the definition of purpose in my opinion.

People with mental illness and/or addiction can recover.  If you know someone working to recover, the most important thing you can give them is hope.

 

Check out the resources on recoverymonth.gov

 

http://www.facebook.com/RecoveryMonth

http://www.youtube.com/RecoveryMonth

http://www.twitter.com/RecoveryMont

 

1 SAMHSA’s Working Definition of Recovery, download PDF at store.samhsa.gov.

 

 

So You Don’t Like Obamacare?

So you don’t like Obamacare?  Too expensive, you say. We just can’t afford it. Too much like socialized medicine.  Your co-pays are higher. Why should your insurance be more expensive just to help pay for others to have medical care?  After all, in our country, we expect people to take care of themselves. If they can’t, it’s their fault. Right?

Let’s think about the implications of that philosophy. If an adult fails to provide for his or her family adequately and is unable to afford health insurance, who pays the price? The children pay the immediate price, and we, society, pay the long-term price.  What happens when children don’t get adequate medical care? It impairs their ability to perform in school. Where does that lead? To dropping out of school, having fewer opportunities as far as jobs, decreased ability to support their own families, etc. You can see the consequences of that.  The extreme outcome is alienation from society and perhaps criminal activity. That definitely affects society as a whole.

What happens if parents of children don’t’ get adequate medical care? They can’t focus on the job of being good parents. That affects society as a whole.

We pride ourselves on our technical advances in medicine. We tend to think that leads to good medical care. But consider this.  Christopher Ingraham wrote an excellent article for the workblog of the online Washington Post in September of 2014 titled “Our infant mortality rate is a national embarrassment.”  The CDC (Center for Disease Control) had issued a recent report indicating that the infant mortality rate for the US was 6.1. This means that for every 1000 live births, there are 6.1 deaths.  Compare that with the infant mortality rates of Finland and Japan at 2.3, of Korea (yes Korea) and Spain at 3.2 and Switzerland, Netherlands, Ireland, and Greece at 3.8. We are # 27 in the rankings, definitely not #1. So that suggests that all of our technology is not benefitting certain segments of society.

Ingraham quotes from a draft paper by Chen, Oster, and Williams, which was later published in 2016 in the American Economics Association Journal of Economic Policy. There may be some differences in how pre-terms births are classified in other countries, for example whether a pre-term birth before 20 weeks is considered a miscarriage rather than a stillbirth. That may account for some of what seems like a surprisingly high infant mortality rate, but it doesn’t account for the entire picture.

The most interesting point of the Chen paper is that the infant mortality rate actually increases when you consider the post neonatal period, the time between birth and 12 months.  The infant mortality rate gap actually widens between the US and other wealthy countries during this period. The authors conclude that this is due to socioeconomic disparities in our country, in other words the higher post neonatal mortality rates are coming from disadvantaged groups.   Certain states actually have an infant mortality rate higher than some 3rd world countries, for example Alabama with an infant mortality rate of 8.7 per 1000 live births and Mississippi with a rate of 9.6.

So does Obamacare fix this? Will the post neonatal infant mortality rate go down now that more people have access to medical care? Possibly, but it’s too early to tell.  The Affordable Care Act has not been in place long enough to measure the impact on infant mortality, but it is a start.  The infant mortality rate certainly won’t go down without some intervention, and there had not been any significant move to make medical care available to those without insurance before the ACA was passed. There was Medicaid, but many people below the poverty line did not qualify for Medicaid particularly in states with very stringent requirements.

Do we care about the infant mortality rate? It probably doesn’t directly affect our day-to-day lives. But what are our values and ideals as individuals and as a country? Do we leave the disadvantaged behind and suffer the consequences as a society?  I just don’t think that’s compatible with who we are.

I’m glad to see that medical care is more accessible.  However, having access to care is not enough. It has to be good care equal to the care that the rest of us have. If it means that my insurance is more expensive or the co-pays are higher, then so be it.

We are one of the wealthiest societies in the world. Does that benefit trickle down to people who are poor? Are we isolationists in our own society, not caring about the welfare of others, or do we try to elevate the living standard of society as a whole? Certainly having access to affordable medical care doesn’t guarantee that people will take advantage of it. People still have the opportunity to make good or bad choices in life, choices that affect their lives, their children’s lives and our lives as members of society.  But healthy people generally think more clearly and are more likely to make good choices. That can make life better for all of us.

 

Patienthood vs. Personhood

For too long in the medical profession, we have referred to patients as “the diabetic” or “the schizophrenic” or “the addict” or “the bipolar.” Most physicians would say that this is just shorthand; we know that our patients are people. However, I believe that we need to apologize to all patients for this terminology. It dehumanizes. People are not defined by their illness. You are a person with diabetes or a person with schizophrenia, or a person struggling with addiction or bipolar disorder. Sometimes I think you, the patient, actually come to believe that the diagnostic label defines you. You begin to think of yourself as a schizophrenic before you think of yourself as a wife, husband, mother, teacher, friend, sister.  We in the medical profession need to stop this pigeonholing of our patients and you, patients, need to stop buying into it.

I sometimes wonder if this is primarily occurring because of the push to see more patients. As busy physicians, we have to focus on the problem at hand. Those of us who are employed usually have a target amount that we are supposed to bill each month.  That means seeing a certain number of patients each day. Those in private practice have overhead and malpractice premiums.  Some physicians see the electronic medical record as a barrier between patient and doctor. Patients may feel that the doctor spends more time looking at the computer than at them.  We are very focused on technology. Even in psychiatry, this is happening to some extent. But is that really an excuse?

My grandfather was a country doctor in a small town in Kentucky. I didn’t know him. He died before I was born. I grew up in the same small town. Many people told me how much my grandfather meant to them. He made house calls. He delivered babies at home. He saw his patients on their turf, not necessarily on his. I’m not saying that modern technology is bad, because the survival rate for babies and all patients is so much better now. But you can be sure that he knew his patients as people. He visited their homes, he saw them at their worst and at their best.  He treated their grandparents, parents, and children. There is something good about that. I don’t know how we can replicate that today.

When I wrote the required essay on my application for medical school, I remember writing that I thought medicine was the perfect bridge between science and art. We’ve tilted toward the science side, and that certainly has its benefits. We are saving more lives. We have a better understanding of why and how our treatments work. But I hope we don’t lose the art side of medicine.

So stand up for your personhood. Remind us, when we forget, that you are a person with a life above and beyond your diagnosis.  Remind yourselves that there is more to life than your illness, that you are members of a community, country, world and universe bigger than your illness.   Don’t get me wrong, I love the science of medicine.  We have made huge strides in the treatment of cancer, heart disease, mental illness and so many other diseases.  I love the black and whiteness of science. I love the certainty of science, though I sometimes wonder if that really exists. But I feel that we may have lost some creativity and humanity in the face of the explosion of technology.   When I end my career as a psychiatrist, I hope that I can say that I practiced the ART of medicine.

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Suboxone: Just Another Addiction?

I heard recently from a friend who attended a continuing education update on suboxone for non-physicians that the addiction counsellors who were there spent the entire session trashing suboxone.  I’m guessing they didn’t learn much. I’m not sure what role the moderator played, but apparently the trashing went on without anyone speaking up for the other side.  So, as a prescriber of suboxone, I’m going to speak up for the other side.

When I hear people criticize suboxone, it is usually based on opinion.  I see addiction, especially opiate addiction, as a medical illness that affects the brain.  I see many of the choices that addicts make as a result of this brain dysfunction.  What often appears to be a choice, is not really a free-will choice. It’s fueled by craving, fear of withdrawal, and for people who have failed many treatments, a sense of hopelessness. We don’t treat other medical illnesses based on opinion. We look at the research.

These are the most common criticisms that I hear about suboxone.

  1. It’s just as bad as the heroin. It’s just another opiate, replacing one opiate with another. You’ve got to be kidding me. You really think that suboxone, an FDA approved medication, is just as bad as heroin? Honestly, I have heard people, even addiction therapists, say this. Suboxone is a partial–opiate agonist, meaning that it binds to opiate receptors, but does not have the full effect of an opiate such as morphine or heroin. People who take suboxone don’t crave opiates because their opiate receptors are occupied, but they don’t feel high.  My patients tell me that they feel “normal.” They feel clear cognitively.
  2. It can be abused just like heroin.  Yes, it can be abused. So can gabapentin, amitriptyline, tramadol, Wellbutrin, Prozac, and many other legally prescribed medications. Oh, and let’s not forget the opiates that are legally prescribed for pain. Because suboxone is a partial–opiate agonist, you have to work hard to abuse it. Most true opiate addicts don’t’ want to bother abusing suboxone because they don’t get the kind of high that they get with the stronger stuff. It’s too much trouble. Plus, the effect of suboxone plateaus after a certain amount. In other words, you can take more but you won’t get any more benefit. This is in contrast to pure opiates which continue to exert effect (mainly getting high) as the dose goes up. This is why addicts take so much of the pure opiates that respiratory suppression occurs and death ensues. Most people who have overdosed on suboxone have other drugs in their system as well, usually benzodiazepines (valium, xanax, ativan). It’s hard to overdose on suboxone alone, but not impossible.  If people are determined to overdose, they will find a way to do it, whether it’s suboxone or something else.
  3. That doctor kept my family member on it for 7 years. Yep, that’s another common complaint. Family members or anti-suboxone therapists feel that patients should be off of suboxone in a few months. It’s the should word again. When suboxone first came out, the thinking was that people could be tapered off in 6-12 months. However, studies have shown that some of those people who were tapered off quickly, relapsed. It seems that people who stayed on it longer, did better. The dose can and should be decreased over time, but it may be that some people manage better with a small amount long-term.  So I would say that if your family member or client is doing well, working, managing family life, contributing in a positive way to society, why are you worried about whether or not they take a pill to treat their addiction? So they’ve been on it for 7 years, or 8 years or 10 years.  We need to accept that this is a chronic, serious, tough to beat illness.
  4. The withdrawal from suboxone is worse than heroin. That’s why you work with a physician who understands suboxone.  It has to be tapered slowly. Some people can taper faster than others. Withdrawal symptoms can be treated. Why rush?   If the client just stops suddenly (which sometimes happens when friends, family, or therapists hassle them about being on suboxone), there will be withdrawal symptoms.
  5. Addicts can do it without medication if they are really motivated. This one really gets me. So that means that if someone fails a treatment, it’s their fault?? That’s called blame the patient when the treatment doesn’t work. Yes, many people can do it without using medication and more power to them. But what about the ones who can’t? Are we to just chalk it up to their lack of commitment? In medicine, if someone fails treatment, we change the treatment, we don’t’ just wave them off as unmotivated. People who have been able to conquer their addiction without medication tend to be the loudest proponents of the “my way is the only correct way to do this” approach. So is there really only one way to achieve sobriety? I just don’t think so.  One belief that underlies this idea that all addicts should be able to get sober on their own without medication is that addiction is just the product of a weak will. PEOPLE, it’s not that simple. READ the studies, look at the science of addiction. If it were really that simple, I think we would have more sober people and fewer deaths from opiate addiction.
  6. If they are taking medication, they aren’t really sober. This is often the AA/NA stance. That’s why many patients on suboxone either don’t go to self-help groups, or they go but don’t reveal that they are on suboxone. That’s too bad. AA and NA have a lot to offer opiate addicts on suboxone. They still need contact with people who are sober, people who have been through what they have. Sometimes they have more than one addiction.  Too bad these groups can’t get past the idea that some people benefit from taking medication for their illness. I often want to ask people who complain about suboxone if they would advise people with diabetes or hypertension to go off their meds because they should be able to control their blood sugar or blood pressure on their own.  By the way, I don’t hear a lot of complaints about people taking the approved medications for alcohol dependence – disulfiram, ReVia, acamprosate.

People who are on suboxone are struggling to get their lives back together. They don’t need to be sabotaged by others who feel that there is only one right way to get clean, their way.  Suboxone is not magic.  Most people on suboxone are also in therapy.  Before you criticize somebody on suboxone, think about whether you would rather have them on a medication that helps them maintain sobriety or at risk of relapse because they have failed other treatments. Would you rather have them alive or dead?

This is one study looking at suboxone versus methadone versus placebo. There are many others published. Go to PubMed (The National Library of Medicine) and search suboxone or buprenorphine. Base your recommendations about suboxone on research rather than opinion.

 

Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014;(2):CD002207.

Drunkorexia – Is Your Child At Risk?

There is a new trend on college campuses.  While college students are known for risky behaviors, this one is very hazardous to health. It’s called drunkorexia. Dr. Dipali Rinker, a research assistant in the department of neurology at the University of Houston, reported on a study that she conducted at the Research Society on Alcoholism meeting in New Orleans on June 30, 2016. The phenomenon of intoxication on an empty stomach is not new, but the extreme to which some college students are taking it is very concerning.   According to the findings from Rinker’s study, these students engage in one or more of the following behaviors before or after drinking: excessive exercise, binging and /or purging, or extreme calorie restriction. The main purpose of the behaviors is to enhance the euphoria from drinking, though some students reported that they also wanted to decrease calories from the alcohol. Rinker reports that in her study, both men and women were equally likely to engage in drunkorexic behaviors to reduce calories from alcohol.  She noted that college women who drank more had more bulimic behaviors and more problems with alcohol as a result of those behaviors.

 

A similar study was reported by Science News (sciencedaily.com) in October of 2011. That study was conducted at the University of Missouri and was reported by Victoria Osborne, assistant professor of social work and public health. She and her colleagues found that 16% of students surveyed had restricted calories in order to save them for drinking alcohol.  In her study, three times more women than men reported these behaviors.  The motivation for drunkorexia in this study included getting drunk more quickly, preventing weight gain and saving money for purchase of alcohol rather than food.

 

Combining excessive drinking with lack of nutrition can lead to both short-term and long –term consequences.  Drinking alcohol on an empty stomach leads to intoxication much more quickly. College students are particularly vulnerable to making bad decisions when very intoxicated. They may be new to college, seeking social approval, feeling both insecure and exhilarated at new-found freedom. The impairment that comes from alcohol intoxication can lead to sexual victimization, violence (as victim or perpetrator), difficulty academically, or life-threatening alcohol poisoning.  For students who came to college with a history of eating disorder issues or substance abuse problems, this combines the two and adds another layer of dangerousness.

 

Chronic alcohol use can result in nutritional deficiencies, especially deficits in folate and thiamine. Though the study subjects were not specifically tested for nutritional deficiencies, it stands to reason that this could be an issue when you combine poor nutrition with excessive drinking, even if it’s binge drinking. Thiamine is important in memory, cognition and muscle coordination. Folate is important in the development of new cells. It is extremely important during pregnancy because low folate can cause neurological birth deficits, especially spina bifida. Of course, college women are definitely of child bearing age, and may not always recognize that they are pregnant immediately. College students are not immune from other chronic diseases such as diabetes, hypertension, and seizures. Excessive drinking can increase the likelihood of seizures especially in someone who already has a seizure disorder. Of course calorie restriction and poor eating habits resulting in poorly controlled blood sugar increase the chances of diabetic complications such as neuropathy and vision problems.

 

So, as a parent, you may be wondering what the take-home message is here. Can anything be done to prevent your child from participating in this behavior?  Your input as a parent can make a difference. Here are some suggestions for the pre-college discussion.

 

  1. Know your child. Has your child had social anxiety, some self esteem-issues? Allow your child to discuss anxiety about adjusting at college. Help your child come up with some ideas for meeting people.  If your child is shy, practice some conversational techniques that may work for them.
  2. Ask your child directly how her friends feel about alcohol and drugs. Sometimes kids are more willing to tell you how their friends feel than how they feel. But chances are, they feel the same way.
  3. Talk with your child about how she might handle some specific scenarios when alcohol is offered. Help her come up with some responses and actions that will work for her when she needs them.
  4. Work on problem solving. If he does find himself in a bad situation, what can he do? Keep communication open. If he is being pressured to drink or is drinking, he needs to be able to talk to you about it without fear.
  5. Don’t be complacent if your child has tried alcohol or drugs during high school and seemingly “learned their lesson.” You may think that the novelty has worn off, and they are not as likely to go overboard, but that isn’t true. These kids are more likely to increase their use of drugs and alcohol in college.
  6. Be aware of how things are going once they get to college. Call and visit. If grades start to deteriorate, they seem distant, they seem tired or speech seems slurred, ask questions.
  7. Be honest with yourself about your own drinking and drug use. You are the role model. If you have a problem, your kids are more vulnerable because of genetic and environmental influences.

 

If you think you may have a problem yourself, start there. You really can’t have the kind of open communication that you desire with your pre-college child if you have not dealt with your own substance use.   If you aren’t sure whether you have a problem, get an assessment from an addiction professional. If you know you have a problem, get treatment. Check out the American Society of Addiction Medicine website (asam.org). Click on Resources and then Find a Doctor.

University of Missouri-Columbia. (2011, October 17). ‘Drunkorexia:’ A recipe for disaster. ScienceDaily. Retrieved July 4, 2016 from www.sciencedaily.com/releases/2011/10/111017171506.htm.

Research Society on Alcoholism. (2016, June 27). Drunkorexia 101: Increasing Alcohol’s Effects Through Diet and Exercise Behaviors. ScienceDaily. Retrieved July 4, 2016 from www.sciencedaily.com/releases/2016/06/160627100223.htm