Showing posts with label addiction. Show all posts
Showing posts with label addiction. Show all posts

Tuesday, July 31, 2012

Diane Rehm Show: Mental Health Under the Affordable Care Act

I was a guest on today's Diane Rehm Show on National Public Radio, along with Rachel Garfield from the Kaiser Family Foundation, Pamela Hyde from SAMHSA, and Richard Frank, the Harvard health economist.

The topic was about the Accountable Care Act (ACA) and its potential impact on mental health and addiction services.

They already have the recording up, as well as a transcript.

Saturday, October 29, 2011

What I Learned Part III

  • More on social media and medicine today. One survey of a surgery department showed half of residents and faculty had public Facebook accounts and a third posted professional information.
  • People are using "mindfulness" therapy to treat sex offenders. No studies on efficacy.
  • Offenders with bipolar and psychotic disorders are twice as likely to have more than two additional arrests than non- SMI offenders.
  • Some criminal defendants try to claim that the government is a corporation, and that they should be tried under contract law rather than criminal law. This is sometimes called a "straw man defense" and may prompt judges to request a competency assessment.
  • Defendants who graduate from mental health courts demonstrate improved life circumstnaces with regard to housing, quality of life, symptoms and compliance. Some studies have shown mental health courts to result in improvement for as many as 78% of defendants.
  • Court ordered custody evaluators are more likely to recommend paternal custody if the mother is poor or has a history of psychiatric admissions. They are more likely to recommend maternal custody if the father has a history of arrests.
  • No suicide prediction tool has a predictive validity greater than 3%.
  • Forty percent of patients given opioids for non-cancer pain misuse their meds, 5% become addicted.
  • In the UK people with ASPD may be subject to multiagency public protection agreements, sharing information between government agencies.
Coming up tomorrow:
      Correctional risk management and the forensic sciences sampler. Good luck to everyone without power in the snow!

Sunday, July 24, 2011

Cocaine: Running all Around Their Brains

First, a quick shout out to Dr. Doug Perednia over on Road to Hellth (paved with mixed intentions) who wrote a glowing review of our Shrink Rap book!  

We think of addictions as conditions that destroy lives.  With some addictions-- like crack, or cocaine, or heroin-- it seems inevitable.  In the New York Times, there are two recent articles about addiction that are worth looking at.  Sherwin Nuland has a book review of

Sigmund Freud, William Halsted, and the Miracle Drug Cocaine
By Howard Markel
Illustrated. 314 pp. Pantheon. $28.95.

Dr. Nuland writes:

That song of praise was “Über Coca,” a monograph published in July 1884 in a highly regarded journal. In his perceptive new book, “An Anatomy of Addiction,” Howard Markel points out that this landmark essay — Freud’s first major scientific publication — was in fact a turning point for the young scientist. “The most striking feature of ‘Über Coca’ is how Sigmund incorporates his own feelings, sensations and experiences into his scientific observations,” Markel writes. “When comparing this study with his previous works, a reader cannot help but be struck by the vast transition he makes from recording reproducible, quantitatively measurable, controlled laboratory observations to exploring thoughts and feelings.
Nuland goes on to say:

“Most recovering addicts,” he writes, “insist that two touchstones of a successful recovery are daily routines and rigorous accountability.” Around 1896, Freud began to follow a constant pattern of awakening before 7 each morning and filling every moment until the very late evening hours with the demands of his ever enlarging practice (he was soon seeing 12 or more patients per day), writing, lecturing, meeting with colleagues and ruminating over the theories he enunciated in such articulate literary style. Markel concludes: “It appears unlikely that Sigmund used cocaine after 1896, during the years when he mapped out and composed his best-known and most influential works, significantly enriched and revised the techniques of psychoanalysis and . . . attempted to ‘explain some of the great riddles of human existence.’ ”

 We're a psychiatry blog, so I'll let you read the book review (or the book) yourself if you want to read about the Dr. Halstead, the famous surgeon, and his cocaine use.

In a separate opinion piece, "Addictive Personality?  You May be a Leader"  neuroscientist David Linden talks about how similarities between addictive personalities and leadership characteristics:

The risk-taking, novelty-seeking and obsessive personality traits often found in addicts can be harnessed to make them very effective in the workplace. For many leaders, it’s not the case that they succeed in spite of their addiction; rather, the same brain wiring and chemistry that make them addicts also confer on them behavioral traits that serve them well.
So, when searching for your organization’s next leader, look for someone with an attenuated dopamine function: someone who is never satisfied with the status quo, someone who wants the feeling of success more than others — but likes it less.

I'll leave the rest to you.

Tuesday, April 26, 2011

National Strategy to Reduce Prescription Drug Abuse

Nearly 500 people have taken our Attitudes about Psychiatry survey so far. If you haven't yet, [please do.]

The White House released its plan last week entitled "Epidemic: Responding to America's Prescription Drug Abuse Crisis" [LINK to pdf of this 10-page plan]. Below are some of the elements in this plan that is part of the National Drug Control Strategy (like that has worked so well :-/).

The areas of this plan involve education of prescribers and users, monitoring programs, making it easy to dispose of controlled dangerous substances (CDS for short), and enhancing enforcement. The plan establishes thirteen goals for the next five years, and also creates a coordinating body, the Federal Council on Prescription Drug Abuse, to oversee and coordinate it all.

If any of our readers have comments on specific items (I've numbered them for ease of reference), including unintended (or even intended) consequences, please chime in.

    1. require training on responsible opiate prescribing
    2. require Pharma to develop education materials for providers and patients
    3. require professional schools and organizations to include instruction on balancing use of opiates for pain while reducing abuse
    4. require state licensing boards to include relevant ongoing education in their licensure requirements
    5. help ACEP develop guidelines for opiate prescribing in the Emergency Department [this should be a big help]
    6. increased use of written patient-provider agreements
    7. facilitate public education campaigns, especially targeting parents
    8. encourage research on low-abuse potential treatments, epidemiology of substance abuse, and abuse-deterrent formulations
    1. encourage effective PDMP (Prescription Drug Monitoring Programs) in every state, including use of HIEs and connecting with federal health care systems (VA, DOD, IHS, DOJ), and expanding interstate operability of PDMPs
    2. support reauthorization of NASPER, which funds PDMPs
    3. explore provider insurance reimbursement for checking the PDMP database before writing CDS prescriptions [interesting...might work]
    4. reduce "doctor shopping"
    5. issue Final Rule on electronic CDS prescribing [finally!]
    6. increase use of SBIRT programs, including via EHRs (Electronic Health Records)
    1. expand on "take-back" programs (eg, allowing pharmacies to accept unwanted pills for disposal)
    2. develop DEA regs on CDS disposal and educate public on it
    3. get Pharma involved
    1. increase training for law enforcement personnel and prosecutors
    2. aggressive action against "pill mills" and inappropriate prescribers
    3. establish a Model Pain Clinic Regulation Law for states to use
    4. increase surveillance of prescription drug trafficking
    5. use PDMP data to identify "doctor shoppers" and do something about it
This is long enough, so I won't list the plan's thirteen goals; these begin on page 9.

While I am concerned that the enforcement aspects will continue to criminalize actions against people with addictions (which should be viewed more as a health problem rather than a criminal problem, IMO), the increased use of Prescription Drug Monitoring Programs to increase identification of and assistance for people with prescription drug abuse problems should be helpful. Recent articles about the diversion of opiates, even by elderly folks who are supplementing their fixed income by selling their Percocets to neighbors, make it clear how deep this problem is. Some of these interventions have a decidedly Big Brother feel to them. But people are dying, so something must be done.

Monday, December 27, 2010

The Angry Birds

You always think it can't happen to you. Addiction is something that happens to other people, other families.

Let me first talk about anger, because it's an emotion we commonly address in psychotherapy. Anger is a normal human emotion, but it's gotten a bad rap, and the inappropriate expression of anger can make life very difficult. When anger is recognized and used wisely, it can help us to solve problems, to stand up for what we believe in, and to change the world. It's never a terribly comfortable emotion, and often people strive to decrease their comfort by discharging anger.

So tonight I downloaded the Angry Birds app to my iTouch. Oh, I'm not so sure about this. I've catapulting these little animated critters at piggys in pens all night. I spent over an hour on level twelve. I can't stop. I posted on my Facebook about it, and an old high school friend--who's now a physicist at Stanford-- told me not to do it..."It's like crack." It's late and I want to go to bed. But what about the piggys in the stone pens on Level 15? Doesn't some angry bird need to smash them? If you know any shortcuts, please do share. Not sure I'll ever blog again....

Wednesday, June 24, 2009

Not-so-lucky 13

One of the things psychiatrists try to assess during the mental exam is judgment. Mostly we guess, be we're not bad guessers, and we usually can tell how someone's judgment is by listening to the stories they tell about their lives.

What makes for bad judgment? Children often don't have the best judgment, an issue of maturity and experience to help form it. Teenagers, particularly boys, aren't noted for their great judgment, either. Substance abuse lead to bad decision in realms beyond those that can simply be attributed to the pursuit of a substance. Mental illnesses, particularly mania, are marked by poor judgment, and certainly brain tumors, delirium, intoxication.....

Okay, so I'm pasting an article from the Associated Press about a mom who was denied custody of her children when she came to court after 13 beers. If she was hoping to get the children back, I think it's safe to say she might have impaired judgment ("might"....oy I've never seen her, who knows if AP is reporting this accurately, and so I'm hedging...)...found it in my local paper under "Weird news"...

FORT SMITH, Ark. (AP) — A mother who drank 13 beers before a psychological evaluation failed to recover custody of her three young children despite claiming she wasn't drunk because she "can drink like a fish." The woman wanted to get the children back from her husband's stepmother. The Arkansas Court of Appeals rejected her Wednesday, citing addictions, frequent absences and criminal activity to support her habits. It said the woman made no meaningful efforts to restructure her life. The children are ages 6, 4 and 4. The state took custody in 2007 when the woman's mother said she could no longer care for the children. Human Services workers later won an order declaring the children's mother unfit and want to see the children adopted.

Tuesday, June 23, 2009

38 Cents per Cancer Stick

When I was growing up, cigarettes were something people bought from vending machines. I've never been a smoker, but I want to say they cost about a dollar? I'm not so sure, and it's not something I pay much attention to. Today, I learned that a carton of cigarettes cost $75! $7.50 a pack, or 38 cents a cigarette. So someone who smokes 2 packs/day, pays about $450 a month.

The funny thing is, I didn't know this because people never complain to me about the cost of cigarettes. They complain about the cost of medicines (this sometimes includes patients with medicaid who have a $1 co-pay for their meds), the cost of health insurance, and the cost of medical treatment. At times, I've suggested that patients with heavy habits cut down by one pack a month (so less than a cigarette a day) to be able to afford their medicines and I've been met with groans.

Do I think cigarettes should cost this much? Yes. The health problems they cause and the cost they inflict on society is so huge, that I believe they should be heavily taxed-- and the monies should go to medical expenses incurred by smokers and research on how to better prevent addictions (my personal rant, added at no additional cost). But I think it speaks to power of their addiction that people are willing to put out this huge sum of money on cigarettes-- people who don't have it, people who really can't afford it, people who would go without necessary medical insurance or medical care, meals at nice restaurants, vacations, and many other things that $5,000 a year would buy.

So why is this a Shrink Rap post? Patients with severe and persistent mental illnesses have higher rates of smoking than the population as a whole, and they also die a lot younger, often from cardiovascular disease. Check out this post on Psych Central.

Monday, March 09, 2009


I heard a talk today on CBT4CBT: Computer Based Training for Cognitive Behavior Therapy where substance abuse treatment is supplemented with On-line real-time psychotherapy groups. I hope I'm saying this right.

The patients go to regular appointments, but in addition, there is an on-line group. The patients and a therapist all 'meet' at a pre-arranged time. There is a camera on the therapist, so his image pops up in the corner of the screen. He can write on the main part of the screen. The participants call in over their computers (each is given a microphone). They're aren't seen, but they have screen names, and they talk one at a time: they press a button to speak and release it when they are done, assuring that people don't talk over one another (I could use one of these buttons in real life). All the patients liked it and they did as well as the controls who had real-life treatment without the supplemental on-line group.

Here's a link if you want to read about this stuff.

And the talk I heard used a platform designed by eGetgoing, an online substance abuse treatment service. I learned something new today.

Monday, January 05, 2009

When Love is Not Enough.

In my post on Changes.... Novalis writes:

"And what do we mean when we say that someone "could" change if they only "would?" In some alternative universe? If they were us? It may be more reasonable to think that someone can change when they, in fact, do change, and not before then. In that sense we only know reality after the fact."

So, in yet another NY Times piece:
Modern Love Facing My Obsession, in the Flesh By BENOIT DENIZET-LEWIS
Published: January 2, 2009, Denizet-Lewis writes in a poignant way about his struggles to resist sexual impulses to connect with strangers:
But pride is no match for addiction. This morning I’d resolved to break my habit, to make the day different. I knew I needed to get some work done before heading to a childhood friend’s wedding later in the day. No time for sex! But as I sat at my desk, a thought occurred: “If I am not going to have sex today, I should take care of business now.” I decided to look at pornography online for 15 minutes (20 minutes max). An hour into that, I got an e-mail message from Mike saying he wanted to meet. I decided to skip the wedding.
Denizet-Louis goes on to write:
As I sped home, I wanted to cry. What was happening to me? Why couldn’t I stop chasing sex, no matter the consequences? To make myself feel better, I called Mike. He answered, offered a convoluted excuse involving flat tires and dead cellphone batteries, and then we had phone sex. When we were done, I considered driving my car off a cliff.

TO much of the general public, sex addiction is a punch line, a pop-psychology diagnosis or an attempt to explain away recklessness and perversion. But my sex addiction is unfortunately very real; it has cost me a job, romantic relationships, friendships and, on many days, my sanity and self-respect. I have checked myself into inpatient sex-addiction treatment centers twice. I have set up Internet blocking software — the kind designed for children — on my computer, only to buy another computer when the urge to go into chat rooms became too strong.

Sometimes it seems easy enough to say "if you don't like your life, change it." Sometimes it's hard to appreciate just how difficult that can be.

Wednesday, September 03, 2008

Should Doctors Scold?

Okay, first I was scrolling through KevinMD's blog, and this caught my attention:
In Whoa! an Er Doc talks about psychiatric, pain, and obese patients in his ER. Regarding the obese patient in the ER, he writes:

However, many, many people are obese because they simply eat too much unhealthy food and do not exercise enough. Many of these people live in subcultures within America where obesity is not only tolerated (mostly in women), but is praised, despite the well known health hazards. Obese patients are treated with respect in my ER - however, if they are disrespectful to the staff, demanding, and make a nuisance in my shop, they will get rebuked,just like any one else. Additionally, just like with smoking, I feel it is a doctor’s duty to reprimand patients for unhealthy behaviour - and this includes unhealthy eating and subsequent obesity.

I'll refrain from rambling about people who blame overweight folks for their condition. Another post, another day. What grabbed my attention was this doctor's use of the word Reprimand. It's not just that he reprimands, oh my gosh, no, he feels a duty to reprimand. I think I missed that part of medical school.

Perhaps it's just the harsh terminology. He's talking about behaviors here: over-eating, under-exercising, smoking. Can I add drinking alcohol and using illicit drugs to the list? I do, however, sometimes feel a need to remind people that smoking is bad for your health (it seems to be one of the few behavioral issues we're fairly certain of) and it may well be that using illicit drugs makes it harder to stabilize one's mood. So far, very few people have changed their behavior simply because I've suggested it would be healthier. And fortunately, so far, very few people have left treatment when I've repeatedly suggested they change their behavior. Sometimes I add that if they don't do so, I may be limited in my ability to help them.

I do feel kind of obligated to state the obvious from time to time. I don't think I scold, and sometimes I wonder if I was firmer, more insistent, or more threatening, might I be more successful in getting people to change their behavior? The fact is, I don't have that in me, I don't really believe it would make a difference in anyone's motivation to give up their addictions, and I believe a physician's role is to treat illness and be compassionate, not to reprimand.

ClinkShrink, of course, just puts them in Lock Down.

Sunday, June 08, 2008

Street Value of Psychiatric Medications

StevebMD asked: "Is there a way to find out the "street value" of various psych meds in different cities? We know that benzos and opioids are highly valued, but I'm curious about other things like antipsychotics and sleep meds."

So I did some googling and did not find much. I even went on, but couldn't find much there, either. So, I thought I'd set up a little database for people to enter what they know about the street value of, say, a 100mg pill of Seroquel.

Now, I am NOT trying to encourage these sorts of illicit transactions (you do know that it is a federal offense to sell a controlled prescription drug, right?). Indeed, the more we become aware of the potential for diversion of the drugs we prescribe, the more we can guard against it.

So, please complete the following form for any medications you may have knowledge of (either from asking your patients or from your own personal knowledge). Include your zip code so that I can set up a Google Map of all the entries. Once we have a number of datapoints, I will add the map to this post.

[View Database]

Thursday, June 05, 2008

Online Access to Prescription Medication History

I saw a headline this morning that the California attorney general is moving to provide instant access to a patient's prescription history for doctors and pharmacists (regulatory boards and law enforcement organizations currently have ready access to this info).  

State Atty. Gen. Jerry Brown unveiled a plan Wednesday to provide doctors and pharmacists with almost instant Internet
 access to patient prescription drug histories to help prevent so-called doctor shopping and other abuses of pharmaceuticals.

Brown told a Los Angeles news conference that the state's prescription monitoring is a "horse-and-buggy" system that needs significant improvements because it now can take healthcare professionals weeks to obtain information on drug use by patients. That delay can allow some patients to get large quantities of drugs from multiple doctors for personal use or sale.

"If California puts this on real-time access, it will give doctors and pharmacies the technology they need to fight prescription drug abuse, which is burdening our healthcare system," Brown said.

The database, known as the Controlled Substance Utilization Review and Evaluation System, contains 86 million entries for prescription drugs dispensed in California.
I have mixed feelings about this issue.  Maryland passed a similar bill this past session to study such a program.  There is a very serious problem with abuse and diversion of controlled medications, such as Percocet, OxyContin, Lortab, and Xanax.  It is indeed very easy to get scripts from duped physicians and nurse practitioners and PAs, get it filled, and then sell it on the street for a 1000-5000% profit.  We need methods to control this.

The flip side is the risk of privacy violation.  Patients could have their privacy breached.  So, how much are we as a society willing to give up to combat this problem?

My suggestion:  Build in banking-level protections, provide patients access to their own histories, provide patients the ability to permit or deny access on an individual basis (so that they have control over access), and permit patients to see who has accessed their records.  Also, provide protections to prescribers and pharmacists which allow them to not prescribe or fill a medication if the patient refuses access to their history.

This provides a greater amount of control over access to personal info, while still providing the ability of prescribers and pharmacists to exercise careful judgment about the medications they write or fill.

I'm not totally sold on this solution, but it does seem to be a better compromise than the big brother approach.  I'd like to hear your thoughts on this difficult problem.  Please add your comment below.

Thursday, February 28, 2008

For The Sake Of Argument

[Subtitle: Clink Takes The Bait]

But first, Good News for those following the HBO In Treatment Sub-Blog: Post on Sophie below this: Click Here.

If I were a trout I'd be three feet out of the water by now. Dinah's post "When A Shrink Picks A Benzodiazepine" is like a bright colorful feathered fly with a tantalizing spin. I tried resisting, but I just had to leap for it.

In my clinic today two patients had benzodiazepine issues. Patient One had been taking his mother's Xanax. Patient Two had his parole violated for a dirty urine. He said he had been getting his psychiatric care through a local program, but that they had only prescribed Xanax "to help me with my marijuana problem". I asked him what they were giving him for his bipolar disorder, and he said, "Oh nothing. Between the marijuana and the Xanax I was alright." Right.

I'd like to think the outpatient doctors for both Patient One and Patient Two were both as careful as Dinah. Hopefully they both took good substance abuse histories and knew their patients well. I'm sure they were well-intentioned. Right. The problem with the approach Dinah suggests is that people with active addictions aren't going to tell you about them. They're going to conceal their substance abuse histories and lie about the pharmacies they go to. Taking a history isn't going to help too much.

So for the sake of argument (and we do like to argue here at Shrink Rap!) let's say Patient One's mother has, as Dinah suggests, a fear of flying that necessitates occasional benzodiazepine use. So nervous flying mom also has a pot-smoking son who also drinks a bit (but is smart enough to hide the empties), a son who also snorts his Ritalin. Patient One's doctor takes a history and learns nervous flying mom has never abused alcohol or been dependent on drugs. He doesn't find out about snorting, pot-smoking son because nervous flying mom is clueless. He writes a prescription for a benzodiazepine and now pot-smoking son mentally blesses him whenever he opens his mom's medicine cabinet. And I have a new parole-violating patient. And mom's doctor never has a clue this is going on.

So when I hear about free society docs who never have a problem with patients on benzodiazepines, I can't help but wonder if the problems are truly that rare or if they just never find out about them. The patients disappear when the med gets tapered (or they get arrested) and the doc never hears the end of the story.

And I wonder why, when working in a public clinic, it is "very rare" that Dinah will start benzodiazepines in that setting. I suspect it's because with those patient the substance abuse issues are a little harder to conceal, especially when they come to her freshly released from jail. Thus, addicts from low socioeconomic classes are pretty much stuck buying their stuff off the street.

So I agree with Dinah that prescribing involves a risk-benefit assessment. I just don't get the part where the risk of temporary nervousness while flying outweighs the risk of diversion, misuse, abuse and dependence. I'm still working on that part.

(Dinah and I could keep this up until people beg for more In Treatment posts. I'll try to contain myself.)

Wednesday, February 27, 2008

When A Shrink Picks A Benzodiazepine

I'm still talking about our not-so-favorite shrink medications, those calming, addictive benzodiazepines: valium, librium, ativan, klonopin, and everyone's favorite: Xanax.

If you listened to our podcast The Benzo Wars, you know this is a heated topic among the three Shrink Rappers, and then ClinkShrink had to go post again in Sober Thoughts. Okay, it finally happened, I finally agreed with something Clink said about benzos. She writes:

Doctors aren't soothsayers or mind readers, and taking a good history or talking to relatives won't always turn up the problem prior to writing a prescription. We want to care for people and relieve distress and a prescription is one way to do that. Unfortunately, it is also possible to create a new addiction in a person who never had one before and we have no way of knowing ahead of time which patient this will happen to.
ClinkShrink is right here: some patients take a medicine and it gathers a life of it's own, an addiction forms. And there's not a way of knowing if that post-operative Percocet will start an addiction or make the patient vomit or simply relieve the pain. Clink has made the point that it's never worth the risk in the case of benzodiazepines: take them and your life could dissolve and you could end up being her inmate.

While she's right about the unknown risk, I'll make the point that life is full of uncertainties. With her thinking, one should never try a drink-- it could (oh, and it often does) lead to alcoholism. I don't know when I prescribe any medication who will get diabetes from it, who will have a bad side effect, whose kidneys and thyroid will be compromised, who will become suicidal from that SSRI, or who will have a horrible time with withdrawal symptoms when they decide to stop it. I don't know who will become addicted, I do my best to take a guess.

I do prescribe benzodiazepines for short-term use for acute anxiety. I don't see a problem with giving someone a tablet of Ativan for an MRI or a few to deal with post-9/11 flying anxiety. And if someone is having panic attacks, they are a good temporary measure until a prophylactic agent kicks in. I've seen plenty of patients on benzodiazepines (yes, even Xanax) where I tell them to stop the medicine, and they do so without arguing, bargaining, complaining, or insisting it's the only thing that helps. I only prescribe them in my private practice where I follow the patients very closely and know them well. In the clinics where I've worked, very few doctors have used these medications, and it is very rare that I'll start them in that setting.

So what helps me feel a little more comfortable prescribing a benzodiazepine?

1) If a patient has been on them in the past and stopped them without difficulty. I don't hesitate to check with old docs and pharmacies.
2) If the patient has never had a problem with alcohol-- benzodiazepines bind to the same receptors and there is cross-tolerance.
3) If there is no personal history of substance abuse or addiction
4) If there is no family history of substance abuse or addiction
5) If the patient understands that it's a short-term solution, not a permanent thing.
6) And yes, I've had patients come to me already on these medications where I just can't get them to taper off and I can't really pinpoint how exactly the medication is hurting them. I will continue such a patient on a low dose. It's been just a handful of people over the years, most people don't seem to need or want chronic benzodiazepines.

Funny, but ClinkShink writes:
I say: "Respect your gut." If you think it may be a problem for you, it could be. If your loved ones or doctor is encouraging you to take more and you're not comfortable with that, say so. Repeatedly if necessary.
My experience-- and I have no data to support this, it's just my "gut"-- is that when I tell patients that the medication can be addictive, the people who express concern are the ones I worry least about-- you're supposed to worry about getting addicted, you're supposed to watch out for a craving for the drug. It's the people who immediately say, "Oh, I won't get addicted," that I worry about the most.

Life is full of risks-- I'll give you a list if you'd like, but they'll include the heart attack you can have when you get on the treadmill and the concussion you can get when you fly off your bicycle.

At this point, I feel a little anxious when I write a new prescription for almost any medication.

Friday, February 22, 2008

Sober Thoughts

[I'd like to thank Clinking By Proxy for helping me post while my Comcast was down. I owe you chocolate. And yes, Dinah, I'll babysit Max. He's adorable.]

I used to think that I wouldn't write about substance abuse because I wasn't an "official" substance abuse expert, at least not on paper. I didn't do an addictions fellowship and addiction per se was not usually the primary focus of treatment in my outpatient clinic. Then came my Dose Dependent post and the Benzo Wars podcast and all the subsequent comments, positive and negative, about the issue. I discovered I had a lot to say, mainly as a result of several years of direct practical experience.

Many doctors, as a rule, do not like patients with substance abuse problems. They fill up the emergency room, they suck down psychiatric resources, they fill up the psychiatric inpatient beds looking for detox or housing, they fill up the inpatient medical wards with conditions resulting from their lifestyles. They take a lot of time and work and they're not always nice people to deal with.

Those are the folks with the severe addictions, the ones that result in arrest and incarceration or homelessness and poverty. There are lots of other addicts out there whom I never see, the middle-class non-criminal addicts whose addiction touches the lives of their families and loved ones but never quite sinks to the level of the streets. These addictions are no less serious. I think I get vocal about these folks (and about things like prescription controlled substances) because I can see where things are headed. I know how bad they can get and the human wreckage that will be left along the way. I can tell you story after story about people who have never done a thing wrong in their lives until that on-the-job accident and the first opiate prescription, or that first hit of cocaine (or the first benzo prescription) and the next thing you know the wife is gone, the job is gone, the house is gone, and they're in prison. It does happen, more often than you think.

Doctors can't always tell who is or isn't an addict among these nice, educated, relatively well-heeled genteel non-criminal folks. Addiction is a hidden disease, a disease of denial, a thing that's carried in secret and buried away even from the addict. Addicts can hide their problems even from people living in the same household. Shame is a powerful motivation for secrecy. Doctors aren't soothsayers or mind readers, and taking a good history or talking to relatives won't always turn up the problem prior to writing a prescription. We want to care for people and relieve distress and a prescription is one way to do that. Unfortunately, it is also possible to create a new addiction in a person who never had one before and we have no way of knowing ahead of time which patient this will happen to. Giving a warning about addiction potential or cautions about continuous use is one way of approaching this problem, thus leaving the responsibility for the addiction back with the patient ("I warned you this could happen, I have it documented in the informed consent section of my progress note.") but this would be little comfort to me when I see these folks in prison.

When I read comments from people who say they're reluctant to take more of their prescribed controlled substance, I say: "Respect your gut." If you think it may be a problem for you, it could be. If your loved ones or doctor is encouraging you to take more and you're not comfortable with that, say so. Repeatedly if necessary. You're the one carrying both the symptoms and the addiction risk. As one of our anonymous commenters said:

"We didn't wake up one day addicted. It was one or more of your colleagues with an MD after their name who started all of this for the vast majority of us so as someone else said, why don't you take it up with them at your conferences or in professional writings or wherever it is that you all gather to talk down about us and the problem your crew created?"
That's exactly why we're blogging and podcasting about this. Thank you.

Thursday, January 10, 2008

Dose Dependent

Sometimes I wonder how much free society doctors know about what their patients are doing. Without going into detail about specific patients, I can tell you I see guys coming in to prison on Valium, Xanax, Klonopin and other medications (or claiming to be on them) from their family doctor or their neurologist or their surgeon. They get the meds for chronic pain, back spasms, anxiety, PTSD, sleeplessness and now (the latest trend) restless leg syndrome. Occasionally the meds get prescribed for panic disorder, but I'm amazed that these folks also seem to be able to tolerate daily amounts of cocaine while suffering from panic disorder.

I don't doubt each of these doctors is acting in good faith, with reasonable care and consideration, in the best interest of the patient. I'm sure each doctor has their own particular 'red flags' to watch for which would trigger concern about addiction or abuse. I would be surprised if they all knew about each other.

Good doctors can be deceived and manipulated just like any other human being. Manipulation and deception go hand-in-hand with addiction. (Just look at the number of times people find Shrink Rap by googling 'how to manipulate my psychiatrist' and 'how to get a shrink to prescribe Xanax'!) Sometimes the doctor only finds out about the substance abuse problem after the arrest. I imagine the hard part then is not getting really pissed off at the patient when you find out you've been deceived. Sometimes when I hear free society docs talk about their cases I suspect substance abuse and suggest that perhaps the patient may not be telling the entire story. Those docs get offended. "You just say that because you work with criminals," they say, "My patient isn't a criminal." Well, a lot of addicts have problems without getting caught.

So what can I do about substance abuse in prison? The key element is education. When I have a patient lobbying for benzodiazepines (Xanax, Valium, Klonopin or something like that), I teach them about the effects of substance abuse on mood or other psychiatric disorders. I teach them about the physical effects of controlled substances, the potential for dependence and addiction, and the legal consequences of using illicit drugs. Finally, I encourage abstinence.

To which the patient usually replies: "I know all that, doc. Stop bullshitting me. The only thing that works is Xanax."

At least I try.

Sunday, June 10, 2007

My Three Shrinks Podcast 24: Dr Phil on Skype

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Okay, folks, this one's a bit on the long side, but well worth it. Around the 28-minute mark is an "interview" with talk-show psychologist Dr. Phil. See below for my notes about it, but let's just say that Dinah has vowed to get even with Clink and me. Or, click here to listen to just the prank and the mash-up song.

Also, listen in to us next week in Podcast #32 as Doctor Anonymous joins us as a guest blogger (this one's for real).

June 10, 2007: #24 Dr. Phil on Skype

Topics include:

  • Genetics of Cocaine-Induced Paranoia. Roy talks about a recent article in Biological Psychiatry by Kalayasiri which suggests that a particular mutation (C1021T) in the dopamine beta-hydroxylase (DBH) gene was associated with significantly increased paranoia in a small group of cocaine abusers. Genetics is playing an increasing role in understanding how we respond to drugs AND to our environment.
  • Dinah wins an award for her writing.
  • Expectation Vs. Evidence-based Medicine. We get into a detailed discussion about how patients' perceptions and expectations get in the way of evidence-based medicine (with examples from Flea's post on admitting children and direct-to-consumer advertising). "Doc, my friend got better with DrugX so I want to try it." "It goes back to 'who deserves care'."
  • Dr. Phil visits My Three Shrinks. THIS IS A MUST-LISTEN SEGMENT! Clink and I play a trick on Dinah by "calling" Dr. Phil on Skype and he "interviews" us. This is a riot!! Dinah is such a good sport. [link to DrPhil Soundboard]
  • Dark Tourism. After reading a NYT piece on touring prisons, Clink discusses the concept of dark tourism, where people seek out notorious sites to see (like cemeteries and prisons). She sent us a humongous scholarly piece on the subject (see Clink's Travelogue for more fun). Dinah talked about visiting catacombs in Paris where the walls are made of human bones, and here's a pic of those. (Note from Dinah, I wanted to put the picture and the link in, but I didn't listen to the podcast to hear if I was editted out. They do those things, you know).

  • Special DrPhil/MTS mashup treat at the end. Credit KLF (aka The Timelords aka The JAMs) for the song, Doctorin' the Tardis, which you can find on emusic for 25 cents, or on iTunes for 99 cents.

Find show notes with links at: The address to send us your Q&A's is there, as well.
This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from

Thank you for listening.

Saturday, June 09, 2007

DBH Gene in Cocaine-Induced Paranoia

So I thought I'd make another post about how more is being learned about our genetic makeup and how that may relate to medication side effects. In this instance, the "medication" is cocaine, which causes a huge release of dopamine. Some folks get really paranoid after using cocaine. This study asked the question "Is reduced breakdown of dopamine associated with paranoia symptoms in cocaine users?"

First some background. The above graphic shows that the neurotransmitter dopamine (or DA) is converted into norepinephrine (or NE, sometimes also called noradrenaline, or NA) by the enzyme dopamine beta-hydroxylase (DBH). You can see that all this enzyme does is add the little -OH (or hydroxy) part to the dopamine molecule to make norepinephrine.

Kalayasiri 2007 showed that a particular mutation (C1021T) in the dopamine beta-hydroxylase (DBH) gene was associated with significantly increased paranoia in a small group of cocaine abusers (see top graph). Cocaine users were blindly provided with different doses of cocaine (bet it was easy to find subjects) and their level of paranoia was rated every few minutes using a Visual Analog Scale (VAS). Users with the TT variant of the gene rated their paranoia level consistently higher than those with the CC or CT gene variant. It has elsewhere been shown that the TT form of the DBH gene is broken, and so is much weaker at converting DA to NE. The resulting higher levels of dopamine in the TT people may be why they get more paranoia.

[Genetics 101 Note: when you see this type of notation, "C1021T", all it means is that at position 1021 along the double-stranded DNA for that particular gene, there is either a C or a T nucleotide at this single point on either DNA strand... if each of your two DNA strands (one from Mom, one from Dad) contain one or the other, then you are homozygous for either one (CC or TT)... if Mom gave you a C and Dad gave you a T, then you are a CT (called heterozygous). Thus there are 3 genetic variants (in this case, CC, CT, or TT) which can exist at this single nucleotide position. These single nucleotide variants, or "polymorphisms", are referred to as SNPs, or Single Nucleotide Polymorphisms. Different SNPs can result in that particular gene's product or function to be enhanced or diminished, resulting in functional variations which may contribute to individual variations in one's response to disease, drugs, or the environment.]

Because this paranoia and related symptoms are uncomfortable to most people, it may serve as a deterrent to using cocaine. In fact, folks with the TT genotype might be at reduced risk of becoming addicted to cocaine because their DBH gene does not work as well. In fact, the alcohol deterrent drug, disulfiram (Antabuse), also happens to block the DBH enzyme (remember, the DBH gene contains the instructions to make the DBH enzyme). This would result in someone with a normally functioning enzyme (from a CC or a CT SNP) to have an enzyme that works like someone with a TT SNP. Antabuse has been shown to be helpful in treating cocaine addiction.

As further evidence of this connection, Schank 2006 used DBH knockout mice to demonstrate hypersensitivity to cocaine in these animals, suggesting that low DBH activity in some cocaine abusers may increase the drug-related dysphoria and aversion, making them less likely to become addicted to the drug.

We hypothesize that the ratio of dopamine (DA) to norepinephrine within noradrenergic vesicles is elevated in TT [homozygous] subjects, so that during cocaine intoxication, DA-mediated neurotransmission is relatively elevated in regions richly innervated by noradrenergic and dopaminergic fibers (e.g., prefrontal cortex). Alternatively, given observations of up-regulated high affinity DA receptor binding sites in DBH knockout mice, TT homozygotes may be hypersensitive to DA, and thereby [may] be more vulnerable to cocaine-induced paranoia.

Pretty cool.

Friday, February 23, 2007

Why Docs Don't Like Xanax (some of us)

[BTW, you might also be interested in checking out our related podcast, #19: Xanax Blues.]

This is in response to JW's question below about the "rules" docs use about prescribing Xanax/alprazolam. Not all docs feel this way, but here's how I think about it. Of course, I am not suggesting that, if you are taking this anti-anxiety drug, you should stop it. I'M NOT. Talk to your doctor if you have concerns.

The half-life for Xanax is short... on the order of 6-20 hours. Halcion is the only similar sedative that has a shorter half-life (and that one has even more problems). Thus, it doesn't stick around long. It is also quite lipophilic, meaning that it quickly gets into the brain. So, it has a quick on, quick off way of working. Sounds great, right?

The quicker a drug works, especially one which makes you feel good in some way, the more addicting it is, as the cause (taking it) and effect (feeling it) are close in time, making it very reinforcing. This is fine if you just take it on those rare anxious moments where you need something to get through it. However, since it works so quickly, many folks start taking it more and more often, until it gets to the point that they are taking it daily. Then they start taking it as soon as they feel it wear off. Before you know it, you are taking it 3-4 times per day. Now, that's not the big problem.

The big problem is all because of your brain's laziness. See, your brain makes it's own natural Xanax-like substance, called GABA. GABA works by inhibiting the brain's natural tendency to speed up. It's like a brake pedal, where the accelerator is stuck in the pedal-to-the-metal mode. GABA keeps your brain from over-working. Xanax (and other sedatives, and alcohol) works by acting like GABA in the brain (sort of). If you start taking it daily, your brain starts thinking "I guess I don't need to make so much GABA because this Xanax stuff is here, so I'll only make 20% of what I usually make." It takes a week or more for your brain to stop making the GABA (which is why just a few days on Xanax won't lead to much trouble), and a week or more for it to start making it again when you stop taking the Xanax.

Here's where the trouble begins. If Xanax wears off in just a few hours, but it takes a week for your brain's natural Xanax to kick back in, what happens in the interim? Withdrawal. What does that feel like? It feels like a panic attack, but worse. High blood pressure, rapid heart beat, tremors, confusion, delirium, hallucinations, seizures. What do folks do when they feel a panic attack coming on? Take another Xanax.

As a hospital-based physician, I see lots of folks, often older, who wind up with severe withdrawal problems from Xanax. It's usually because they run out of the drug, decide to cut back or stop taking it, or something else happens (eg, stroke, get sick) and they forget to take it. Or they don't tell their surgeon they are on it, and 2 days after their hip surgery I get called because they are hallucinating.

Some prescribers think it is a good antidepressant (it's not). Or that, because of the short half-life, it's not as addictive (it is).

So, here are my rules of thumb about Xanax:

  1. Avoid it.
  2. Keep the doses small.
  3. Do not use in older folks or forgetful folks (more likely to forget it, thus more likely to have problems).
  4. Do not use in anyone with a history of alcoholism or addiction (yes, that means you have to ask).
  5. Tell folks to avoid from daily use.
  6. If they are on it, warn them that stopping it suddenly, even for a day or two, can result in confusion, hallucinations, seizures, and even death.

Sunday, December 10, 2006

My Three Shrinks Podcast 2: Roots

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We'd like to thank our readers and listeners for your kind comments and suggestions about our first podcast. This one's a bit longer, at about 33 minutes. I think we'll get better about the time. About 20 minutes seems to be a good balance.

This is actually the second half of the original podcast, which went long so we sliced it into two podcasts. Don't expect to get a podcast every other day... if we do one every other week, I'll be pleasantly surprised (though I'm striving for every Sunday). Maybe we can be like Digg's Kevin Rose and Alex Albrecht and drink alcohol at the beginning of each podcast... that would be interesting.
Here are the show notes for the podcast:

December 10, 2006: Roots

Topics include:
  • Dr Anonymous is again not mentioned in this podcast (but we do thank him for the idea about the musical bumpers between topics)
  • Thorazine Immunity: Clink reviews a 1992 case in which a prisoner sued the on-call psychiatrist for involuntarily medicating him with chlorpromazine due to violent, self-injurious behavior... but without going through any hearing panels for forced meds [Federal Code: Civil action for deprivation of rights]
  • Dinah brings a duck to the "Shrink Rap Studio" (my kitchen table)
  • FDA hearing on December 13 about adding a black boxed warning on antidepressant labels about the possibility of increased suicidality in adults: Will this reduce access to these drugs, causing undertreatment of depression and actually INCREASE suicide rates? (Check here for background materials)
  • Recent PubMed articles and Corpus Callosum post about this whole antidepressants and suicide issue. Also, Dinah mentioned this, hot-off-the-press, Finnish article, showing an increase risk of attempts and a decreased risk of deaths.
  • Treatment of social phobia [PubMed]
  • Social phobia and alcohol [PubMed]
  • Paxil- and other SSRI-related withdrawal symptoms [PubMed]
  • Sexual dysfunction and SSRIs [PubMed]
  • Putting roots on someone
  • Psilocybin mushrooms for Monk's OCD
  • Maryland psychologists discuss adoptions in gay marriages
  • NYT: Gender dysphoric children

This podcast is available on iTunes. You can also download the .mp3 or the MPEG-4 file from
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