Addiction Psychiatry: Laws, Guidelines, and Suggestions

Clinical traditions are important, but they can become ossified as the “right way to treat addiction.” So, we need to turn a sharp, skeptical eye on treatment models.

FROM THE AMERICAN ACADEMY OF ADDICTION PSYCHIATRY

[[{"type":"media","view_mode":"media_crop","fid":"43418","attributes":{"alt":"prescription_Burlingham/shutterstock.com","class":"media-image media-image-right","id":"media_crop_9894157225487","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5704","media_crop_rotate":"0","media_crop_scale_h":"80","media_crop_scale_w":"120","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":"Burlingham/shutterstock.com","typeof":"foaf:Image"}}]]Although boundaries are essential in the treatment of addiction, drug policy, and life in general, an unthinking devotion to rules and protocols produces disastrously rigid addiction treatment and public policy. In the simple case of medication dosages, clinicians are well aware that a small minority of patients who are rapid metabolizers, or who have developed tolerance to a medication, may well need dosages far above the published guidelines. In the more complex scenarios of treatment selection, some patients may benefit from referral to a peer-led support group; others may benefit from professional therapy, and still others succeed with the simple prescription of an anti-addiction medication-but most require multiple such interventions.

Addiction treatment is not a one-size-fits-all endeavor.

Boundaries in addiction psychiatry run the gamut from mandatory legal obligations, to well-accepted clinical guidelines, to the mere suggestions of clinicians. And although even laws are open to interpretation, written standards of any sort become part of the national standard of care that physicians are expected to meet or exceed-even if they do not carry the force of law. There is a vast range of legitimate approaches to addiction and substance misuse, although clinicians rightly fear official censure, legal action, or malpractice litigation if rules are not followed.

Given the potential for complications with the treatment of addicted patients-and their penchant for getting caught up with the law-boundaries are important, not least because psychiatrists must put on the mantle of authority and reassure and guide patients, perhaps more than in other specialties. Treatment modalities that are not only effective but also demonstrably well accepted in the field help the clinician convince the patient and his or her family to take the leap toward sobriety.

 

Laws and regulations

Clinicians who specialize in treating addiction are constrained by a variety of laws and regulations designed to protect patient confidentiality, avoid the diversion of dangerous medications, and ensure the provision of excellent care. Some of these rules are hard-and-fast: buprenorphine prescribers must have the Drug Addiction Treatment Act of 2000 (DATA-2000) waiver, patient confidentiality under the Health Insurance Portability and Accountability Act and the Code of Federal Regulations Title 42 is sacrosanct, and current medical licensure is obligatory for physicians. With our ability to prescribe powerful and potentially addictive medications, we can endanger our patients, the public, and ourselves if we ignore the applicable regulations.

However, in all but the most obvious of scenarios, conflicting obligations complicate our adherence to laws and regulations. When should confidentiality be breached for the addicted person who is harming himself with drugs or alcohol? Different clinicians, quite naturally, have different thresholds for what is enough of an emergency to warrant a no-permission call to the patient’s family or to the 911 dispatcher. And while medication dosages should usually adhere to published guidelines, most clinicians prescribe unusual dosages sometimes, thereby stepping outside of the usual standard of care in hopes of helping their patient.

Clinical traditions

Clinical traditions and lore are important, but they can become ossified as the “right way to treat addiction.” So, we need to turn a sharp, skeptical eye on treatment models handed down from our teachers, methods popular among the general public, and media-driven paradigms such as the Intervention model. The Intervention model is unique for being both an accepted if poorly researched paradigm and a wildly popular media sensation.1,2

Peer-led support groups such as Alcoholics Anonymous don’t claim to be treatments but are widely misperceived as the most, if not the only, effective model for the treatment of addiction. A notorious failed model of addiction treatment was Synanon, whose cult-like beginnings engendered more mainstream and effective treatments such as the Therapeutic Community model in use today by Phoenix House, Daytop Village, and others. Groundbreaking books (eg, The Disease Concept of Alcoholism3) and catchy slogans such as “addiction is a brain disease”4 can mislead by simplifying complex phenomena.

Although efforts to destigmatize addiction by pointing out its biological aspects are certainly laudable, those attempts ignore some of the less-quantifiable aspects of addiction that also need to be addressed for most people with substance-use disorders. This is not to say that people who suffer from addiction are spineless or immoral, only that their condition usually needs more than a pharmacological solution! So, there is little value in relying on unproven or simplistic notions about addiction therapy, whether they are pharmaceutical or psychosocial treatments.

 

Evidence-based medicine

By the same token, of course, evidence-based medicine can engender its own tyranny and cadre of true believers, whose reliance on data-driven models fails many patients with addiction. A recent book5 about the prevalence of “medical reversals”-the abandonment of a treatment because clinical experience demonstrates what good studies should have shown long before the treatment entered the market-outlines the strengths and weaknesses of medical research. The authors opine that these sorts of embarrassing and dangerous reversals could be avoided by rigorous and unbiased randomized, controlled studies, but they also lay out the multiple ways in which clinicians are misled by what appears to be definitive evidence of a treatment’s effect or lack thereof. Among these are bias introduced by the sponsors of a study, the use of surrogate endpoints that have little clinical meaning, and blind acceptance of single studies that, however convincing, cannot be replicated.

In the world of addiction, for instance, while the use of anti-craving medications such as naltrexone and acamprosate is well-supported by research, these medications are hardly a panacea for addiction, despite the contention by some that failing to prescribe them constitutes medical malpractice. More than that, the real-world effects of these medications are not entirely clear. Although data show a measurable effect size in decreasing the time to first drink and total amount of alcohol used, these surrogate measures do not tell us what we really care about: were the patient’s morbidity, mortality, and overall functioning improved?

Well-designed clinical studies often disprove previously hard-and-fast rules in medicine. And in any case, the data rarely define what to recommend to a certain patient, with a certain set of values, at a particular time. An unthinking fealty to the evidence base of our addiction practice can lead to missteps every bit as dangerous as reliance on unproven treatments or the pronouncements of senior clinicians.

 

Treatment guidelines

Recent treatment guidelines from the American Society of Addiction Medicine6 (ASAM) exemplify the sort of carefully constructed industry standard that must be a part of our clinical knowledge base but cannot and should not form a cookbook for treating addiction. For instance, the guidelines define those with comorbid psychiatric disorders as a “special population,” despite a consensus in the literature that about half of those who present for treatment of opioid addiction have a comorbid psychiatric disorder, making dual diagnosis more the rule rather than a “special” exception.7-9 Given the enormous variability of those who present with an addiction to opioids and a co-occurring psychiatric condition-ranging from schizophrenia to anxiety-no standard approach can apply. The ASAM guidelines inevitably, and correctly, contain recommendations for off-label medications, gut-level practical recommendations without clear scientific support, and some inadequately studied treatment regimens.

Buprenorphine regulations

One conspicuous boundary in addiction treatment today is the legally dictated cap on the number of patients to whom a physician may prescribe buprenorphine. The regulations allow for physicians with a DATA-2000 waiver to prescribe for 30 patients and, after a year with the waiver in place, allow prescriptions for up to 100 patients. Some have argued that this cap denies treatment to patients in areas underserved by physicians with waivers, most commonly rural populations. There is no doubt that too few physicians prescribe buprenorphine, but simply eliminating the limit is an obvious and easy answer that is almost certainly also the wrong answer. Most physicians who now hold the waiver do not prescribe up to the limit, and it is a bit difficult to imagine comprehensive treatment of more than 100 patients by one clinician.

Rather than summarily abolishing the cap on the number of buprenorphine patients that one physician can treat, the American Academy of Addiction Psychiatry, along with the American Psychiatric Association and the American Osteopathic Academy of Addiction Medicine, advocates for a more measured change in the present regulations. This would involve:

• The abolition of the Drug Enforcement Administration inspections that many potential prescribers blame for their reluctance to prescribe buprenorphine

• The use of physician assistants and nurse practitioners in those practices that prescribe buprenorphine to large numbers of patients

• An exploration of telemedicine for buprenorphine prescriptions

• The expansion of federal funding for buprenorphine training

These nuanced modifications to the buprenorphine regulations are designed to expand the availability of buprenorphine while minimizing the risks of substandard treatment and diversion.

A healthy respect for boundaries

Although there are plenty of shrill and simplistic advocates on both sides of these sorts of debates, most realize that the truth usually lies somewhere between the poles of the simplistic (and simplifying) dichotomies we fashion for ourselves. In addition to obtaining the right education and experience for treating addicted people, clinicians must remain more cognizant than most of the rules and regulations that form the boundaries for our clinical interactions. Our patients are inveterate rule-breakers, and we should therefore promote a healthy respect for boundaries, while avoiding the slavishly rigid thinking that results in flawed public policy and clinical disaster. Keeping the well-being of the individual patient paramount will protect that patient from the foolish inconsistency of mechanistic medicine, and the concomitant danger of tradition-based superstition.

Acknowledgment-The author acknowledges the American Academy of Addiction Psychiatry (AAAP) for help with this article. AAAP is the premier organization for learning and sharing about the science of addiction psychiatry research and clinical treatment.

Disclosures:

Dr Westreich is Associate Professor of Clinical Psychiatry in the division of alcoholism and drug abuse, department of psychiatry, New York University School of Medicine in New York and serves as the consultant on behavioral health to the Commissioner of Major League Baseball. He is Immediate Past President of the American Academy of Addiction Psychiatry. He reports no conflicts concerning the subject matter of this article.

References:

1. Johnson V. Intervention: How to Help Someone Who Doesn’t Want Help. Center City, MN: Hazelden Press; 1986.

2. A&E Network. Intervention; 2005-2015. http://www.aetv.com/shows/intervention. Accessed February 24, 2016.

3. Jellinek EM. The Disease Concept of Alcoholism. Melrose, MA: Hillside Press; 1960.

4. National Institute on Drug Abuse. Principles of Drug Abuse Treatment for Criminal Justice Populations: A Research-Based Guide. www.drugabuse.gov. Accessed February 24, 2016.

5. Prasad VK, Cifu AS. Ending Medical Reversal/Improving Outcomes, Saving Lives. Baltimore, MD: Johns Hopkins University Press; 2015.

6. American Society of Addiction Medicine. The National Practice Guideline, for the Use of Medications in the Treatment of Addiction Involving Opioid Use; 2015. http://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/national-practice-guideline.pdf. Accessed February 24, 2016.

7. Brooner RK, King VL, Kidorf M, et al. Psychiatric and substance use comorbidity among treatment-seeking opioid abusers. Arch Gen Psychiatry. 1997;54:71-80.

8. Krausz M, Degkwitz P, Kuhne A, Verthein U. Comorbidity of opiate dependence and mental disorders. Addictive Behav. 1998;23:767-783.

9. Rounsaville BJ, Weissman MM, Crits-Christoph K, et al. Diagnosis and symptoms of depression in opiate addicts, course and relationship to treatment outcome. Arch Gen Psychiatry. 1982;39:151-156.