Do you do much as an addiction psychiatrist?

[ExcaliburPrime1]

I write this not to be disparaging, but just because I am a clueless intern with little experience.

A little background: One of our rotations as interns (probably the best, in terms of hours certainly, but also cool attendings) is at the VA substance abuse program. It's basically an intensive outpatient program that meets within the hospital. Anyway, besides prescribing some naltrexone or methadone, I didn't really see us doing much. I mean, sure, we'll talk to the patients and see them every few weeks, and I got to know my people pretty well, but it seemed like the heavy lifting was done by the patient and the rest of the program (going to the daily groups).

Maybe I'm missing something?

Anyway, it was a great experience and I am now seriously considering addiction psychiatry, particularly for opiate use disorder patients.

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[wolfvgang22]

I work at the VA and I spend 1/3 of my time treating patients in the IOP program. I was sort of volunteered for it at first, and like many psychiatrists I did not want to get a Suboxone waiver or treat substance abuse much. But I have found in many ways it is a little easier than the rest of my practice here, and a nice change of pace.

It is satisfying to prescribe buprenorphine/naloxone and not at all difficult, and these patients recover very well.

Alcohol Use Disorder is the most challenging among the patients we treat for substance abuse. For a variety of reasons these patients are less adherent to their treatment plans.

The support patients in the IOP program get is so helpful. I think over all it is more healthy that the patient is required to have more investment and responsibility for his or her own recovery, and at the same time the more robust counseling, group therapy, and social support the VA here offers these patients results in better outcomes. I think we would have more success with other patients ( like a lot of chronically depressed and chronic PTSD patients) if we did more of this IOP style treatment for other non substance abuse disorders here on campus.

No, it is not boring.

 

[dl2dp2]

I think as a general psychiatrist you should be able to handle garden variety addiction issues. However, as an addiction psychiatrist you often see people who are quite ill. People with an opiate use disorder and a benzo use disorder, plus BPD, plus multiple prior suicide attempts, plus multiple prior hospitalizations, now newly hooked on K2, and presents with depression. That's actually not an atypical case in an outpatient addiction practice--something like 10%. There *is* a learning curve to get comfortable with cases of this sort, and it's not simply medication. Mostly about things like triaging, treatment context selection, family work, etc.

 

[OldPsychDoc]

....Mostly about things like triaging, treatment context selection, family work, etc.

...and the administration...

Oh, Lord, the administration...

 

[MacDonaldTriad]

...and the administration...

Oh, Lord, the administration...

Isn't it wonderful now that we have e-mail and computers so we can accomplish an order of magnitude more regulatory volume?

 

[F0nzie]

General psychiatry has no shortage of substance use disorders. Approximately 50% of the psychiatric population has a substance use disorder. The problem is most of the individuals in this group are precontemplative.
Specializing in addiction may increase your exposure to a population with a higher level of motivation.

I enjoy the challenge of treating dual diagnosis but I also find it gratifying to treat addictions in the absence of interference from other psychiatric disorders.


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[Candidate2017]

I rotated with an IM attending who does suboxone in a nice area. Healthy, younger, working patients. Most eschewed therapy (too busy working, bad therapists/cost or not wanting to associate with addicts) but were highly motivated and took responsibility for their recovery. Exact opposite of most IM or psych patients. Seemed professionally and economically rewarding if you can put up with constant tobacco odor.

 

[hamstergang]

Most eschewed therapy (too busy working, bad therapists/cost or not wanting to associate with addicts) but were highly motivated and took responsibility for their recovery.

I feel this sentence is a contradiction.

 

[HarryMTieboutMD]

A few things to keep in mind

1) Treating addiction in the VA (from which most fellowships are incidentally based) is MUCH different than treating it in the general population. There is a lot more structure and support in the VA (overbearing at times), and contingency management is basically built in.

2) Any doctor can learn how to prescribe buprenorphine by reading about it. After your rotation the 8 hour certification course will seem like a huge waste of time (it was for me; online and a lot of midlevels trying to get cert'd asking dumb questions). Still, midlevels are likely to f it up somehow, so you may be forced into damage control. Methadone takes more skill and an understanding of its (chaotic) pharmacology

3) There are a lot of addiction psychiatry jobs (vs addiction medicine), but it is actually very difficult in practice because though we have (some) effective treatments what is really the crux is motivating the patient to take responsibility for himself or herself. Thankfully people are realizing that the 1-3 month rehab then "DC to a church basement" is an untenable solution, so long term care may be more widely accepted (like in the physician PHP model)

4) I think the future for neuromodulatory treatments in addiction is huge, especially based on some of the optogentics work done and network mapping using rs-fMRI. I think TMS has a lot of potential- and could be a game changer- in this respect. The MUSC groups are working on this, but I think there will be a lot more to come

 

[Candidate2017]

I feel this sentence is a contradiction.

This was a functional population (working or going to school), not the VA, IOP or inpatient. Many said the free groups didn't work and they didn't like how people would sell or trade meds in the parking lot after groups. I can see how it's a bad idea for former prescription painkiller abusers to associate with heroin addicts. It's not like they didn't try but quality affordable therapy is a unicorn.

 

[Jules A]

This was a functional population (working or going to school), not the VA, IOP or inpatient. Many said the free groups didn't work and they didn't like how people would sell or trade meds in the parking lot after groups. I can see how it's a bad idea for former prescription painkiller abusers to associate with heroin addicts. It's not like they didn't try but quality affordable therapy is a unicorn.

I have a problem accepting this and wonder why a practice with so many "functional" patients isn't able to offer and require high quality therapy. Isn't therapy a stipulation for bup reimbursement? It reminds me of my patients who are housewives munching on percs like they are Skittles but are resistant to therapy or groups because they aren't like "those people". My purpose when prescribing is geared toward functional improvement and the therapy component is where my patients get actual growth.

Although I am aware of the research that we accept methadone or suboxone long term, without an end point as a successful recovery is doing the majority of patients a huge disservice in my opinion.

 

[HarryMTieboutMD]

I have a problem accepting this and wonder why a practice with so many "functional" patients isn't able to offer and require high quality therapy. Isn't therapy a stipulation for bup reimbursement? It reminds me of my patients who are housewives munching on percs like they are Skittles but are resistant to therapy or groups because they aren't like "those people". My purpose when prescribing is geared toward functional improvement and the therapy component is where my patients get actual growth.

Although I am aware of the research that we accept methadone or suboxone long term, without an end point as a successful recovery is doing the majority of patients a huge disservice in my opinion.

Exactly. MAT has been around for a long time, and of course you are going to see robust effects across most outcome measures in RCTs. Obviously MAT has significant public health implications and can be a lifesaver but to think that affecting one neurotransmitter system (and making a huge deal abt kappa OR antagonism) is a miracle drug and panacea for an illness as complex as addiction is to live in a fantasy world.

I think some of the most compelling data are from the impaired physician studies measuring 5 year outcomes (granted numbers are a little inflated and they have different incentives but some of it could be generalizable) where OST is not allowed. The abstinence rates across the board (including opioid use disorder) are about the same. Outcomes for Physicians With Opioid Dependence Treated Without Agonist Pharmacotherapy in Physician Health Programs. - PubMed - NCBI

 

[NickNaylor]

I think some of the most compelling data are from the impaired physician studies measuring 5 year outcomes (granted numbers are a little inflated and they have different incentives but some of it could be generalizable) where OST is not allowed. The abstinence rates across the board (including opioid use disorder) are about the same. Outcomes for Physicians With Opioid Dependence Treated Without Agonist Pharmacotherapy in Physician Health Programs. - PubMed - NCBI

I don't think the outcomes in treating physicians are generalizable, just like I wouldn't think finding similar results in groups like airline pilots, lawyers, etc. also aren't generalizable. There are huge incentives - largely professional - to be successful in treatment. As was said elsewhere in this thread, no amount of substance treatment is going to be successful if there is no buy-in by the person getting treatment. In these cases, the buy-in for these folks is gigantic.

 

[HarryMTieboutMD]

I don't think the outcomes in treating physicians are generalizable, just like I wouldn't think finding similar results in groups like airline pilots, lawyers, etc. also aren't generalizable. There are huge incentives - largely professional - to be successful in treatment. As was said elsewhere in this thread, no amount of substance treatment is going to be successful if there is no buy-in by the person getting treatment. In these cases, the buy-in for these folks is gigantic.

This sentiment misses the point. The question is not "are these outcomes generalizable?; it's "what about these 5 year abstinence rates may be generalizable?"

Yes, physicians have their licenses at stake but keep in mind there is a lot of data showing that the license is the last thing to go- meaning that impaired physicians regularly give up families, homes, health, etc but it's not until the threat of license suspension/revocation to people commit to treatment (anyone who as done work with impaired physicians knows this). And one of the ideas of the 5 year contract is to exhort the physician from making Recovery externally motivated to internally motivated).

The point is our current model of 30-90 day rehab then discharge to a church basement (+/- pharmacotherapy) is not sustainable and that long term, interdisciplinary care with monitoring, support groups, etc might be more ideal. And it is our (meaning people of all disciplines who treat addiction) to work with the pre contemplative patient.

 

[Armadillos]

My purpose when prescribing is geared toward functional improvement

Although I am aware of the research that we accept methadone or suboxone long term, without an end point as a successful recovery is doing the majority of patients a huge disservice in my opinion.

Above you mention you primarily want to see functional improvement with your treatment, but then later it seems your thoughts towards long term agonist treatment is more guided by a moral/philosophical evaluation of what you consider to be a successful recovery. These two thoughts seem somewhat at odds.

 

[NickNaylor]

This sentiment misses the point. The question is not "are these outcomes generalizable?; it's "what about these 5 year abstinence rates may be generalizable?"

Yes, physicians have their licenses at stake but keep in mind there is a lot of data showing that the license is the last thing to go- meaning that impaired physicians regularly give up families, homes, health, etc but it's not until the threat of license suspension/revocation to people commit to treatment (anyone who as done work with impaired physicians knows this). And one of the ideas of the 5 year contract is to exhort the physician from making Recovery externally motivated to internally motivated).

The point is our current model of 30-90 day rehab then discharge to a church basement (+/- pharmacotherapy) is not sustainable and that long term, interdisciplinary care with monitoring, support groups, etc might be more ideal. And it is our (meaning people of all disciplines who treat addiction) to work with the pre contemplative patient.

Completely agree with you on the final point.

I guess my question is - apart from the somewhat obvious, which is that an acute or subacute intervention without any significant long-term treatment is unlikely to be successful - how does this shape treatment for the handful of homeless, jobless patients with genuine axis I disorders +/- significant axis II pathology drinking themselves to death that come in through the psychiatric ED at our county hospital? Not sure I really see the connection. And in terms of dollars spent - both on physical/mental health and in terms of not being a productive in life - it's that latter population that is ultimately going to have a larger impact, not the former (i.e., the high-achieving, professional population).

 

[clausewitz2]

This sentiment misses the point. The question is not "are these outcomes generalizable?; it's "what about these 5 year abstinence rates may be generalizable?"

Yes, physicians have their licenses at stake but keep in mind there is a lot of data showing that the license is the last thing to go- meaning that impaired physicians regularly give up families, homes, health, etc but it's not until the threat of license suspension/revocation to people commit to treatment (anyone who as done work with impaired physicians knows this). And one of the ideas of the 5 year contract is to exhort the physician from making Recovery externally motivated to internally motivated).

The point is our current model of 30-90 day rehab then discharge to a church basement (+/- pharmacotherapy) is not sustainable and that long term, interdisciplinary care with monitoring, support groups, etc might be more ideal. And it is our (meaning people of all disciplines who treat addiction) to work with the pre contemplative patient.

While I have no beef whatsoever with your assessment of the massive failings of the current treatment model, it's also worth bearing in mind that physicians are not just going to differ from gen pop based on the fact that they have a license that is at stake. This is a group of people who whatever else may be true about them went through a selection process that stressed a certain degree of doing what one is told and putting up with quite a lot of unpleasantness in pursuit of an objective that only really exists in the distant future. They are probably on average going to be a tad different in their cognitive styles and certainly their formative experiences and beliefs about their own abilities than your average 12 stepper.


And of course they are going to be most motivated in defense of their license, it's clearly a fundamental part of their identity. Why is this surprising?

 

[Armadillos]

Reminds me of the old marshmallow test from undergrad psych. Nobody is better at delaying gratification than someone who made it through medschool and residency. I would imagine being able to delay gratification is a massive asset in recovery.

 

[Jules A]

Above you mention you primarily want to see functional improvement with your treatment, but then later it seems your thoughts towards long term agonist treatment is more guided by a moral/philosophical evaluation of what you consider to be a successful recovery. These two thoughts seem somewhat at odds.

I do understand how it sounds but don't necessarily believe they are at odds because a majority of my patients' function and physical health improve significantly if they are able to stay sober with an eventual discontinuation of agonist therapy.

 

[HarryMTieboutMD]

Completely agree with you on the final point.

I guess my question is - apart from the somewhat obvious, which is that an acute or subacute intervention without any significant long-term treatment is unlikely to be successful - how does this shape treatment for the handful of homeless, jobless patients with genuine axis I disorders +/- significant axis II pathology drinking themselves to death that come in through the psychiatric ED at our county hospital? Not sure I really see the connection. And in terms of dollars spent - both on physical/mental health and in terms of not being a productive in life - it's that latter population that is ultimately going to have a larger impact, not the former (i.e., the high-achieving, professional population).

Right, and this is a structural problem and part of the emerging focus across medicine now on dissemination and implementation, which in itself is another task, and a large reason why this is currently a "call to arms". If the election turned out differently this *might* have been tenable in the near future. Just fyi drug courts, though heterogeneous, generally have better outcomes than the general population. Its really easy to be cynical about this and point out the obvious flaws but this is such an enormous public health problem that we have to throw everything we have at it

While I have no beef whatsoever with your assessment of the massive failings of the current treatment model, it's also worth bearing in mind that physicians are not just going to differ from gen pop based on the fact that they have a license that is at stake. This is a group of people who whatever else may be true about them went through a selection process that stressed a certain degree of doing what one is told and putting up with quite a lot of unpleasantness in pursuit of an objective that only really exists in the distant future. They are probably on average going to be a tad different in their cognitive styles and certainly their formative experiences and beliefs about their own abilities than your average 12 stepper.


And of course they are going to be most motivated in defense of their license, it's clearly a fundamental part of their identity. Why is this surprising?

Your post is shortsighted.

First, it is well established that the prevalence of SUDs among physicians approximates that of the population (higher in some cases; eg benzos and for a while IV legal narcotics). Yes, physicians have both internal (motivation, persistence, tolerating delayed gratification) and external differences (namely, financial resources and access) from the general population that may portend favorable outcomes, but this doesn't make treating them any easier; in fact they are often much more difficult to treat. In fact, largely because they often require intervention to get to treatment in the first place (because of denial, enabling staff, being able to hide problem, easy access, lack of self reporting, etc), the literature suggests they are under-treated. However, once in treatment, their denial systems are so complex and entrenched that it breaking through requires a concerted effort (particularly for psychiatrists; though I've seen my fair share of anesthesiologists who really were convinced that shooting up in the OR was totally normal). Of course this is a person centered issue but in general it can present difficulties. Anyone who has treated impaired physicians (my med school had one of the biggest impaired physicians programs in the country so I did a number of these evals as an MS4) will attest to this.

Either way, despite their differences from the general population things like contingency management (this of course requires creativity on part of the physician), drug testing, longitudinal care, relapse management, mutual support groups, focus on lifelong recovery, etc should be extended to the general population.

That the threat of a revoked license is a motivating factor isn't that surprising- it's what some MDs will go through BEFORE that happens (that might make non physicians inclined to get help)- family, money, health etc etc etc is what's pretty remarkable when you see it. I remember thinking "yeah now you're here because the board of medicine is threatening you, but you have you're on the verge of decompensated cirrhosis, your kids hate you, your wife left you" and similar repeatedly.

Here is the best paper on the subject showing 5 year outcomes. FYI the original data were published in BMJ, but this paper (using the same data) is much more comprehensive and better. I'm not sure why the same thing was published multiple times (I asked Mark Gold, and he gave me a vague answer), but either way it's one of my favorites: Setting the standard for recovery: Physicians' Health Programs. - PubMed - NCBI

 

[Jules A]

Just fyi drug courts, though heterogeneous, generally have better outcomes than the general population. Its really easy to be cynical about this and point out the obvious flaws but this is such an enormous public health problem that we have to throw everything we have at it

Here is the best paper on the subject showing 5 year outcomes. FYI the original data were published in BMJ, but this paper (using the same data) is much more comprehensive and better. I'm not sure why the same thing was published multiple times (I asked Mark Gold, and he gave me a vague answer), but either way it's one of my favorites: Setting the standard for recovery: Physicians' Health Programs. - PubMed - NCBI

Anecdotally I have seen good results with more than a few patients who were enrolled in drug court. In addition to avoiding the return to jail there is accountability and a long term, comprehensive support system in place which is crucial.

Cool that you know Mark Gold. I have heard him speak multiple times and always enjoyed it although I found myself wishing he was still in the heyday of his career rather than winding down.

 

[clausewitz2]

Your post is shortsighted.

First, it is well established that the prevalence of SUDs among physicians approximates that of the population (higher in some cases; eg benzos and for a while IV legal narcotics). Yes, physicians have both internal (motivation, persistence, tolerating delayed gratification) and external differences (namely, financial resources and access) from the general population that may portend favorable outcomes, but this doesn't make treating them any easier; in fact they are often much more difficult to treat. In fact, largely because they often require intervention to get to treatment in the first place (because of denial, enabling staff, being able to hide problem, easy access, lack of self reporting, etc), the literature suggests they are under-treated. However, once in treatment, their denial systems are so complex and entrenched that it breaking through requires a concerted effort (particularly for psychiatrists; though I've seen my fair share of anesthesiologists who really were convinced that shooting up in the OR was totally normal). Of course this is a person centered issue but in general it can present difficulties. Anyone who has treated impaired physicians (my med school had one of the biggest impaired physicians programs in the country so I did a number of these evals as an MS4) will attest to this.

Either way, despite their differences from the general population things like contingency management (this of course requires creativity on part of the physician), drug testing, longitudinal care, relapse management, mutual support groups, focus on lifelong recovery, etc should be extended to the general population.

That the threat of a revoked license is a motivating factor isn't that surprising- it's what some MDs will go through BEFORE that happens (that might make non physicians inclined to get help)- family, money, health etc etc etc is what's pretty remarkable when you see it. I remember thinking "yeah now you're here because the board of medicine is threatening you, but you have you're on the verge of decompensated cirrhosis, your kids hate you, your wife left you" and similar repeatedly.

Here is the best paper on the subject showing 5 year outcomes. FYI the original data were published in BMJ, but this paper (using the same data) is much more comprehensive and better. I'm not sure why the same thing was published multiple times (I asked Mark Gold, and he gave me a vague answer), but either way it's one of my favorites: Setting the standard for recovery: Physicians' Health Programs. - PubMed - NCBI

Please show me the part of my post where I said that they were going to be easier to treat. Not at all what I was saying. More along the lines of "this is a population that is probably highly divergent from a random selection of people with substance abuse problems."

You are rightly proud of having specific training in treating these physicians and emphasize why things are so different for them. Fair enough! Only, when you have identified a really very distinct sub-population with a number of structural, cognitive, psychological, and legal factors at play that just do not apply on average to garden variety substance using patients, this just maybe should suggest that attempting to generalize from studies focusing exclusively on this highly constrained and markedly different group should be done with a healthy abundance of caution, regardless of what Mark Gold may have said to you about it or anything else.

 

[HarryMTieboutMD]

Please show me the part of my post where I said that they were going to be easier to treat. Not at all what I was saying. More along the lines of "this is a population that is probably highly divergent from a random selection of people with substance abuse problems."

You are rightly proud of having specific training in treating these physicians and emphasize why things are so different for them. Fair enough! Only, when you have identified a really very distinct sub-population with a number of structural, cognitive, psychological, and legal factors at play that just do not apply on average to garden variety substance using patients, this just maybe should suggest that attempting to generalize from studies focusing exclusively on this highly constrained and markedly different group should be done with a healthy abundance of caution, regardless of what Mark Gold may have said to you about it or anything else.

The discussion was centered on generalizing some aspects of treating impaired physicians to the general population, with an obvious limitation (and possible barrier to successful treatment) being having a license at stake. You implied that physicians' 5 year success rates (again the topic of the discussion) are not solely attributable to the license but an innate ability to delay gratification and other intrinsic factors (with which I don't disagree btw- but again it's too parsimonious of an explanation).

Given that we don't have much better right now I don't see any harm in piloting these interventions in the general population, and there is no such thing as "garden variety substance using patients"- it affects everyone We create environments like state run detoxes, VAs, private rehabs etc that attract certain demographics, but in my experience things like contingency management, follow up, drug testing, etc all improve chances of recovery (see drug court example above, where the enforcement is naturally more draconian) It's easy to be cynical and come up with reasons for why they may not work (which is nonetheless important) but to just sit idly is unacceptable.

Oh, and I'll pay attention to what Mark Gold- who has done more work and made more contributions to this field than almost anyone else alive today- says 10 times out of 10