Does rehab kill?

“Rehab kills people,” Willenbring said

Dr. Willenbring is right that bad and/or inadequate rehab is dangerous. HOWEVER, this is true of a lot of treatments. For example, an inadequate course of antibiotics is dangerous.

So, what does good treatment look like? He suggests it comes in the form of medication.

Another way to identify what good treatment looks like is to ask one question can cut through a lot of confusion about treatment options—“What kind of treatment do addicted doctors get?” This question avoids arguments about treatment models, evidence-based practices and the effectiveness of 12 step groups. It moves past what physicians recommend for people like you (or your loved one) and what they actually do for people like themselves.

Fortunately, a few days after Dr. Willenbring’s comments were published, the NY Times published an article on a doctor with addiction who was arrested for diverting medication. What kind of treatment did she get?

She was allowed to attend a rehabilitation program while still seeing patients.

Rehab? It doesn’t say what kind of rehab but, rehab?  Really?

She didn’t want to go to the New York Health Committee for Physician Health, a program funded by the American Medical Association to identify and treat doctors with mental health or drug problems, she says, “because I didn’t want anybody to find out.”

Nobody wants to admit defeat or weakness; but only doctors (and airline pilots) thought to have drug problems have such rigorous drug-testing programs, according to Terrance M. Bedient, the director of the Committee for Physician Health. Some lose their livelihoods temporarily, some permanently.

. . .

“I saw people with less privilege, less education, treated the same way I was,” she says. “The judge in my case understood addiction so well. It’s a disease.”

And that is what many in the addiction field think we should remember: not that Dr. Karcher didn’t have advantages — she did — but that she got the kind of treatment that more substance abusers should get. Physicians in New York State have some of the best outcomes in the country, according to Brad Lamm.

“It’s not that they’re better people or better addicts,” he says.

They don’t get specific about the kind of rehab Dr. Karcher got, but what kind of rehab do doctors usually get?

Physicians’ Health Programs (PHPs) do not provide substance abuse treatment. Under authority from state licensing boards, state laws, and contractual agreements, they promote early detection, assessment, evaluation, and referral to abstinence-oriented (usually) residential treatment for 60 to 90 days. This is followed by 12-step-oriented outpatient treatment. Physicians then receive randomly scheduled urine monitoring, with status reports issued to employers, insurers, and state licensing boards for (usually) 5 or more years.

Does this care kill them?

A sample of 904 physicians consecutively admitted to 16 state Physicians’ Health Programs (PHPs) was studied for 5 years or longer to characterize the outcomes of this episode of care and to explore the elements of these programs that could improve the care of other addicted populations. The study consisted of two phases: the first characterized the PHPs and their system of care management, while the second described the outcomes of the study sample as revealed in the PHP records. The programs were abstinence-based, requiring physicians to abstain from any use of alcohol or other drugs of abuse as assessed by frequent random tests typically lasting for 5 years. Tests rapidly identified any return to substance use, leading to swift and significant consequences. Remarkably, 78% of participants had no positive test for either alcohol or drugs over the 5-year period of intensive monitoring. At post-treatment follow-up 72% of the physicians were continuing to practice medicine. The unique PHP care management included close linkages to the 12-step programs of Alcoholics Anonymous and Narcotics Anonymous and the use of residential and outpatient treatment programs that were selected for their excellence.

It’s worth noting that there is other evidence for the use of residential. (See here, here and here.) But, let’s stay focused on the PHP approach.

Is there another approach that rivals the outcomes found in PHPs?

Back to Willenbring:

. . . adding that the model for the 28-day rehab, Minnesota’s Hazelden Foundation, began offering buprenorphine maintenance itself in 2012 after a series of patient deaths immediately after treatment. Hazelden’s medical director, Dr. Marvin Seppala, told me when the rehab announced the change that using these medications is “the responsible thing to do” because of their potential to save lives.

That was 4 years ago. A year in, they were teasing pretty impressive early outcomes and promised more outcomes studies were to come. 4 years is a long time to keep the world waiting. However, they just posted that they expect to publish their outcomes next year. We’ll have to wait and see what they end up reporting.

To be sure, some people have good outcomes with medication assisted treatment. At the same time, it’s not as simple and obvious as the article suggests. First, the evidence doesn’t match the hype. (See here, here, herehere and here.) Second, while the inadequacy of many residential/inpatient treatment programs has gotten a lot of attention, medication assisted treatment has its share of problems. (See this recent photo essay on Boston’s “methadone mile” and this recent article on problems with buprenorphine in northeast Tennessee.)

 

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Update 7/26/2016. FULL 911 Good Samaritan Legislation in Michigan

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Great news!!

Both 911 Good Samaritan Bills have made it out of the Michigan Senate Judiciary Committee.

Now is the time to contact your State Senator and ask her/him to vote yes on these bills.

Find the contact info for your State Senator here.

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(The rest of this post was originally posted 5/12/2016. It is provided here for background.)

Good news!!!

There are 2 bills in the Michigan House of Representatives Criminal Justice Committee that would would provide immunity from criminal charges for people all ages who are seeking emergency medical assistance for themselves or friends as a result of a drug overdose from any illicit drug.

Rep. Pscholka’s bill, House Bill 5649, provides immunity from possession penalties in certain circumstances.

Rep. Singh’s bill, House Bill 5650, provides immunity from use penalties in certain circumstances.

These bills expand upon last years House Bill 4843 by removing limitations based on age and type of drug.

The House Criminal Justice Committee will be taking up these bills on Tuesday, May 17, 2016 at 9:00 AM in Room 327, House Office Building, Lansing, MI.

Contact the House Criminal Justice Committee to let them know you support these bills.

Background

The Facts

Keep these facts in mind:

  • Overdose is now the leading cause of accidental death in the U.S. Most of these overdose deaths are due to opioids.
  • If help arrives in time, overdoses can be safely and quickly reversed with a squirt of naloxone up the patient’s nose.
  • More than half of all overdoses occur in the presence of other people, usually other drug users.
  • Too often, people do not call 911 in a timely manner due to fear of arrest for possession of drugs.

A First Step

At the urging of parents who have lost children to overdose, the Michigan legislature made some good first steps last year. They enacted laws that increased access to naloxone, the drug that reverses overdoses.

On October 13, 2014, Public Acts 311, 312, 313 and 314 of 2014 were signed into law.

These acts will:

  • Allow Narcan to be prescribed to friends and family of heroin addicts, so it’s readily available in the event of an overdose.
  • Protect a person administering Narcan in good faith to be immune from criminal prosecution or professional sanctions.
  • Require emergency medical personnel to carry the drug in their vehicles and be trained in how to administer it.
  • Require the state Department of Community Health to complete annual reports of opioid-related overdose deaths.

Another Step

Last summer, Michigan Rep. Al Pscholka (R-Stevensville) introduced House Bill 4843, a bipartisan measure, that would create Good Samaritan protections for individuals under the age of 21 who seek medical attention for themselves or another person believed to have overdosed. However, the Good Samaritan protections are limited to the illegal possession of prescription drugs (in quantities consistent with personal use) for people under the age of 21.

Last December the Governor signed the Good Samaritan Bill, House Bill 4843, into law.

911 Good Samaritan Laws

NARCAN-KITThe Drug Policy Alliance provides a really good summary of 911 Good Samaritan laws:

Accidental overdose deaths are now the leading cause of accidental death in the United States, exceeding even motor vehicle accidents among people ages 25 to 64. Many of these deaths are preventable if emergency medical assistance is summoned, but people using drugs or alcohol illegally often fear arrest if they call 911,  even in cases where they need emergency medical assistance for a friend or family member at the scene of a suspected overdose.The best way to encourage overdose witnesses to seek medical helpis to exempt them from arrest and prosecution for minor drug and alcohol law violations, an approach often referred to as Good Samaritan 911.

The chance of surviving an overdose, like that of surviving a heart attack, depends greatly on how fast one receives medical assistance. Witnesses to heart attacks rarely think twice about calling 911, but witnesses to an overdose often hesitate to call for help or, in many cases, simply don’t make the call. In fact, research confirms the most common reason people cite for not calling 911 is fear of police involvement.

It’s important to know that this is not a liberal vs. conservative or Republican vs. Democrat issue. Some of the reddest and the bluest states in the country have passed 911 Good Samaritan laws.

Twenty states and the District of Columbia have enacted policies to provide limited immunity from arrest or prosecution for minor drug law violations for people who summon help at the scene of an overdose. New Mexico was the first state to pass such a policy and has been joined in recent years by Alaska, California, ColoradoConnecticut, Delaware, Florida, Georgia, Illinois, LouisianaMaryland, Massachusetts, Minnesota, New Jersey, New York, North Carolina, Rhode Island, Vermont, Washington and Wisconsin.

Further, these laws don’t protect dangerous or predatory criminals.

Good Samaritan laws do not protect people from arrest for other offenses, such as selling or trafficking drugs, or driving while drugged. These policies protect only the caller and overdose victim from arrest and/or prosecution for simple drug possession, possession of paraphernalia, and/or being under the influence.

The Bad News

An overdose is a major medical crisis, right? It’s not unlike a heart attack.

Here’s what happens when someone has a heart attack41KSA2GA12L._SX300_

  1. A person has a heart attack at the grocery store and . . .
  2.  . . . thank goodness, the store has an automatic defibrillator.
  3. Someone has been trained to use the defibrillator and performs the rescue.
  4. Someone else calls 911 to make sure the patient gets all the care they need.
  5. The patient is taken to the emergency department and medically stabilized.
  6. Once stabilized, the patient gets transferred to care that will address the cause of the heart attack and/or care that will prevent future heart attacks.
  7. The patient’s treatment plan will generally include lifestyle changes. (Diet, exercise, etc.)
  8. Then, the patient gets follow-up care that might include:
    • follow up appointments with specialists,
    • periodic tests to monitor for indicators of a recurrence,
    • self-monitoring (blood pressure), and
    • monitoring by the patient’ primary care physician.
  9. If problems recur or there are indications of a potential recurrence, the care plan will be re-evaluated and the patient will get whatever care they need.

Here’s what happens when someone ODs and is rescuednarcan

  1. A person overdoses and . . .
  2.  . . . thank goodness, the someone has naloxone.
  3. The person has been trained to use naloxone and performs the rescue.

Maybe, if they are lucky, these steps happen.

  1. Someone else calls 911 to make sure the patient gets all the care they need.
  2. The patient is taken to the emergency department and medically stabilized.

Naloxone is not enough.

We’d never tolerate cardiac patients being sent home without the proper care. Why should people with an addiction be treated any differently?

The good news

The good news is that there are models that work.

The Gold Standard

A male doctor writes on a patients chart.The best example of what should happen is the the kind of care that opioid addicted doctors, nurses, pilots and lawyers get. They all have low relapse rates and return to work at very high rates.

Here’s what would happen if one of them overdosed at work (or if it was known to their employer):

First, the recovery planning begins with some important assumptions:

  • abstinence is the goal;
  • full recovery with a return to full functioning is the expectation;
  • addiction is a chronic illness and recovery requires long term treatment, support and monitoring; and
  • for recovery to be durable, the addict must be an active participant in treatment and recovery maintenance.

Signpost along the road to recovery.The recovery plan is likely to include the following:

  • Formal treatment. The first phase of formal addiction treatment for most of these professionals is residential care ranging from 30 to 90 days.
  • Supportive services. Supportive services used by these professionals includes AA or NA 12-step groups, aftercare groups from their formal treatment programs, and follow-up from case managers.
  • Long-term support and monitoring. After completion of initial formal addiction treatment, they develop a continuing care contract consisting of support, counseling, and monitoring for usually 2 to 5 years.
  • Drug testing. Regular testing for 2 to 5 years, usually with more frequent testing at the start and reduced testing following periods of stable negative drug test results.
  • Dealing with relapse. Relapses are usually addressed by a combination of increased intensity of care and monitoring and by immediately informing family and colleagues of the physician to enlist their support.

Other options

Buprenorphine (Suboxone) and methadone have been shown to reduce drug use, overdose risk, criminal activity and disease transmission.

Some people are able to stabilize and live normal lives on these medications but, at this point, there is no research demonstrating its effectiveness with quality of life indicators like employment.

Many people hope to use these drugs as an interim step toward abstinence. However, there is no established model for successfully transitioning buprenorphine and methadone patients to abstinence. A large federally-funded study attempting to do this reported, “near universal relapse.”

Another option is an injectable drug called Vivitrol. It is injected once per month and can protect against overdose. Unfortunately, it’s very expensive.

Which to choose?

Hope Traffic SignThe gold standard offers a path to full recovery, but it does demand a lot of structure, effort and lifestyle changes.

Many professionals prefer drug maintenance as a goal. It’s an easier plan to implement and many professionals are not confident that their patients are capable of drug-free recovery. (Look for professionals that are optimistic and believe in you ability to achieve full recovery.)

However, most patients and families, for a wide variety of reasons, prefer abstinence as a goal–the most common reason is that they want their life back the way it was before they became addicted.

Patients not sticking with the treatment plan is the biggest barrier to success with both approaches.

It’s harder than it should be

Getting the gold standard for yourself or a family member is likely to be very difficult. But, there are steps you can take to improve the odds.

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Addiction is disordered learning AND much more.

I’ve had a lot lot requests to respond to this recent piece in the NY Times.

A Personal Narrative or Universal Model?

drug-addictionThe piece is interesting and well written, but it focuses on the experience of one person. I get the impression that she’s frustrated that most people would say that her experience with heroin means she has the disease of opioid addiction. She does not believe she has a disease and doesn’t want to be shoehorned into that model. So, she’s created an alternative narrative to explain her experience.

That’s a fine thing. She may not have had the disease of addiction. In her case, it may have been a result of disordered learning, self-medication and become something akin to a love relationship with the relief that heroin provided. I can imagine it’d  be frustrating to be shoehorned into a model that doesn’t fit one’s experience.

The problem is that she constructs a model of understanding addiction from her personal experience—an experience that seems fairly atypical—and then uses it to try to disprove the disease model and shoehorn people with addiction into her model.

If it was intended to be something memoir-ish, that would be one thing. However, the article also seems to be trying to promulgate this model as the way the addiction should be understood generally.

Addiction as a Category

It’s important to point out that I don’t believe the author uses the same definition of addiction I do. I limit the term addiction to people with chronic and high severity substance use problems characterized by loss of control—not all people with drug problems are addicts.

In a previous post, I took a long look the categorization of substance use problems. In that post, I made the case for addiction as a different kind of problem from less severe substance use problems rather than a more severe version of the same problem.

Dependence was far from perfect. This is not an argument for a return to the abuse/dependence model. (Though I will argue that we should return to conceptualizing as addiction as a different kind of problem from low to moderate SUDs, rather than a different severity.)

Let’s start by stating that addiction/alcoholism is the chronic form of the problem is primary and characterized by functional impairment, craving and loss of control over their use of the substance.

Problems with the categories of abuse and dependence include:

  • Dependence has often been thought of as interchangeable with addiction/alcoholism, but this is not the case.
  • Dependence criteria captured people who are not do not have the chronic form of the problem. We know that relatively large numbers of young adults will meet criteria for alcohol dependence but that something like 60% of them will mature out as they hit milestones like graduating from college, starting a career or starting a family.
  • Dependence criteria captured people who are not experiencing loss of control of their use of the substance.
  • The word dependence leads to overemphasis on physical dependence which, in the case of a pain patient, may not indicate a problem at all.
  • The word abuse is morally laden.
  • For me, there are serious questions about whether abuse should be considered a disorder at all.

Several of these problems are related to doing a poor job in distinguishing which kind of user the patient or subject is.

The abuse/dependence model fell short in distinguishing between kinds of users. Rather than taking a step forward in distinguishing between the kinds of users, the continuum approach implies that there is only one kind with different levels of severity.

In that post, I also pointed out that framing addiction as a more severe version of the same problem would undermine the disease model.

The continuum approach becomes especially troubling when you think about the idea of giving people with low severity SUDs and people with the disease of addiction the same diagnosis, only with different severity ratings.

There’s little doubt that large numbers of young people on college campuses meet diagnostic criteria for an alcohol use disorder under the DSM 5. I doubt anyone would argue that all of these young people have a disease process? Even a mild one?

This seems likely to undermine the acceptance of addiction as a disease. Not just by the public, but also by insurers and policy makers.

So, it’s not surprising that she’s using the broader definition of addiction when questioning the disease model.

Addiction as a Learning Disorder

I don’t at all disagree that addiction involves disordered learning.

However, I would disagree that addiction is only (or primarily) disordered learning. Addiction is disordered learning AND much more.

The idea that learning plays a role in addiction is not new. The American Society of Addiction Medicine definition of addiction includes the following. (Keep in mind that references to memory speak to learning.)

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Addiction affects neurotransmission and interactions within reward structures of the brain, including the nucleus accumbens, anterior cingulate cortex, basal forebrain and amygdala, such that motivational hierarchies are altered and addictive behaviors, which may or may not include alcohol and other drug use, supplant healthy, self-care related behaviors. Addiction also affects neurotransmission and interactions between cortical and hippocampal circuits and brain reward structures, such that the memory of previous exposures to rewards (such as food, sex, alcohol and other drugs) leads to a biological and behavioral response to external cues, in turn triggering craving and/or engagement in addictive behaviors.

The neurobiology of addiction encompasses more than the neurochemistry of reward.1 The frontal cortex of the brain and underlying white matter connections between the frontal cortex and circuits of reward, motivation and memory are fundamental in the manifestations of altered impulse control, altered judgment, and the dysfunctional pursuit of rewards (which is often experienced by the affected person as a desire to “be normal”) seen in addiction–despite cumulative adverse consequences experienced from engagement in substance use and other addictive behaviors. The frontal lobes are important in inhibiting impulsivity and in assisting individuals to appropriately delay gratification. When persons with addiction manifest problems in deferring gratification, there is a neurological locus of these problems in the frontal cortex. Frontal lobe morphology, connectivity and functioning are still in the process of maturation during adolescence and young adulthood, and early exposure to substance use is another significant factor in the development of addiction. Many neuroscientists believe that developmental morphology is the basis that makes early-life exposure to substances such an important factor.

. . .

In addiction there is a significant impairment in executive functioning, which manifests in problems with perception, learning, impulse control, compulsivity, and judgment. People with addiction often manifest a lower readiness to change their dysfunctional behaviors despite mounting concerns expressed by significant others in their lives; and display an apparent lack of appreciation of the magnitude of cumulative problems and complications. The still developing frontal lobes of adolescents may both compound these deficits in executive functioning and predispose youngsters to engage in “high risk” behaviors, including engaging in alcohol or other drug use. The profound drive or craving to use substances or engage in apparently rewarding behaviors, which is seen in many patients with addiction, underscores the compulsive or avolitional aspect of this disease. This is the connection with “powerlessness” over addiction and “unmanageability” of life, as is described in Step 1 of 12 Steps programs.

Is addiction a disorder of learning? Yes. But, it’s also a disorder of genetics, motivation, reward and stress.

 

Dirk Hason has written eloquently on the convergence of thinking of addiction as a learning disorder and muddying the distinctions between problem use and addiction.

For harm reductionists, addiction is sometimes viewed as a learning disorder. This semantic construction seems to hold out the possibility of learning to drink or use drugs moderately after using them addictively. The fact that some non-alcoholics drink too much and ought to cut back, just as some recreational drug users need to ease up, is certainly a public health issue—but one that is distinct in almost every way from the issue of biochemical addiction. By concentrating on the fuzziest part of the spectrum, where problem drinking merges into alcoholism, we’ve introduced fuzzy thinking with regard to at least some of the existing addiction research base. And that doesn’t help anybody find common ground.

Addiction as Love and Self-medication

Addiction as an unhealthy form of attachment or love is also not a new idea. Stanton Peele, a gadfly and long time critic of the disease model wrote the following:

An addiction may involve any attachment or sensation that grows to such proportions that it damages a person’s life. Addictions, no matter to what, follow certain common patterns. We first made clear in Love and Addiction [published in 1975] that addiction— the single-minded grasping of a magic-seeming object or involvement; the loss of control, perspective, and priorities—is not limited to drug and alcohol addictions. When a person becomes addicted, it is not to a chemical but to an experience. Anything that a person finds sufficiently consuming and that seems to remedy deficiencies in the person’s life can serve as an addiction. The addictive potential of a substance or other involvement lies primarily in the meaning it has for a person.

Theories of addiction as a form of self-medication have been about for decades. These theories frame addiction as secondary to another problem which may be social, psychological, environmental or physical in nature.

However, addiction is widely accepted as a primary disease among professional societies.

Further, addiction’s (I’m referring to severe and chronic substance use problems.) onset, course and response to treatment is often affected by social, environmental, psychological and physical problems, but it generally does not fade away when those problems are addressed.

Multiple Mechanisms

The more we learn about addiction, the more we find that there are multiple mechanisms involved. In a 2011 post, I wrote the following (keep in mind that this is abstract speculation rather than a concrete theory):

Or, maybe there are several neurological mechanisms (reward pathway, memory circuits, risk evaluation, self-regulation, stress responses, etc.) and some people may have 2, others may have 6.  Some factors may be associated with a more chronic form, others may be associated with a more severe loss of control and overall severity may be associated with the number of factors the person has. (Some might be primary to addiction, others secondary.)

There are probably a lot more than 6 but, for the sake of argument, let’s stick with 6. So, is it possible that the author had 1, or 2 or 3 of these mechanisms (ones involving memory, attachment and learning) while most people with addiction (chronic and severe) suffer from 5 or 6?

Could this provide a way to view her model as true for her (and some others) and the disease model as true for most people with addiction? I think it might. And, maybe it could also shed some light on a portion of that segment of young, heavy users who mature out.

It’s not that she’s wrong. It’s just that she’s zooming in on one part of a larger story to the exclusion of the rest of what we know.

More reading

 

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Senate sits on opioid investigation report

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The Senate Finance Committee has buried an investigative report on financial ties between drug manufacturers and medical organizations that were setting guidelines for opioid use.

In 2012, the chair and ranking member of the Senate Finance Committee, Max Baucus (D-Mont.) and Chuck Grassley (R-Iowa), launched an investigation into financial ties between drug manufacturers and medical organizations that were setting guidelines for opioid use. When the investigation began, the federal government had already reported that opioid overdoses were killing more people each year than car accidents. Many staffers working for Baucus considered his home state of Montana to be ground zero for the epidemic of opioid addiction.

The committee focused on the American Pain Foundation, the Center for Practical Bioethics, and five other organizations. It also targeted three leading opioid makers: Purdue Pharma (OxyContin), Endo Pharmaceuticals (Percocet), and Johnson & Johnson (Duragesic). The committee demanded to see documents and get answers to its questions.

Over the course of many months, congressional investigators collected and analyzed a mountain of material. These documents, and the report that was drafted from them almost a year later, have never seen the light of day. Instead, they remain sealed in the Senate Finance Committee’s office.

The work is done. Why would they not release it? Read the rest here. Then, contact your senator.

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Pharma’s incentive problem

money-pillsHarvard Business Review examines the ways in which Pharma’s employee and business unit incentives contributes to the opioid crisis. It’s not as piercing as one might home, but it’s interesting food for thought.

Here’s one portion:

It isn’t news that rewarding sales volume rather than public health outcomes is a problem in the pharmaceutical industry. In fact, this is the root of nearly all the mistrust that clouds the industry’s operations, relationships, and reputation. The memory of hefty legal settlements for improper marketing and obfuscation of safety risks lingers, the biggest being GlaxoSmithKline’s 2012 $3 billion penalty over the marketing of antidepressants and a safety issue for a diabetes drug.

But there are ways that employee compensation around outcomes could change that. For one, it could instantly align each sales rep, and other commercial employees, with their customers — and with the patient. Suddenly doctors and pharmaceutical employees could be working to the same defined outcome goal for patients.

So, for example, part of the incentive compensation for the commercial team could be tied to real outcomes in patients in their territories. Certain territories will be more challenging — for instance socio-economic factors, diet, education, and behaviors like smoking could vary from area to area. Adjusting for that, a sales rep could have higher compensation potential for working in such areas and generating results.

Legally, salespeople can only talk about outcomes if they are approved in the drug’s label by the Food and Drug Administration — another reason to have more outcomes data determined in the testing phase. But commercial employees also could work to help improve outcomes through community outreach.

This reimagination of the sales rep as a health outcomes advocate would require some different skills and a new collaboration with health providers and insurers. Strategically, however, it could transform the value of the frontline sales force. Rather fighting for doctor time, the sales force could be a grassroots, public health army working and advocating for optimal health outcome in patients and the community. The opioid story, after all, might have been different if bonuses incentivized value instead of volume.

It’s hard to imagine this kind of transformation of values in this business. I’m not holding my breath. It seems like it would take payer or regulatory intervention.

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Medical management of chronic disease is a mess

Push_vs_Pull_MarketingSenator Ron Wyden, with a focus on seniors, examines the problems Americans face with medical management of chronic diseases.

The struggles that people with chronic illness face are manifold. One problem is coordinating care. It’s hard enough for somebody who’s perfectly healthy to assemble medical records for a new doctor; consider how difficult it must be for an elderly woman who recently suffered a heart attack. Think about her journeying to a doctor appointment across town in the middle of the day. Or filling a hard-to-find prescription and adding it to an already-daunting battery of pills.

America’s health care system tells millions of seniors they’re on their own when it comes to managing their chronic illnesses. The result is a full-time job and far too many chances for dangerous errors and missteps.

Today, Medicare inexplicably charges older Americans a copay just to coordinate care among all their doctors. Doesn’t it defy common sense for seniors to pay extra for care coordination that holds costs down? In my view, this charge should be junked, and care coordination should begin right after seniors receive their free physical provided by the Affordable Care Act. This is one of many commonsense changes to Medicare that could improve the lives and health of seniors with chronic diseases, many of whom have stories all too familiar to every American family.

As Seth Mnookin shared last week, coordination of care is a huge problem. And, as Sen. Wyden’s article suggests, there’s little reason to believe care coordination would be much better if addiction treatment were housed within a doctor’s office.

This is an urgent need in the lives of many people with addiction. There are efforts to improve this inside and outside of traditional medicine. We started a primary care project 5 years ago to get all residential clients connected to recovery-informed primary care and improve coordination of care. It hasn’t been perfect, but there’s a stark difference between today and 2010. If only we could extend that into the rest of their medical care—specialists and emergency medicine.

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A Systems Approach Is The Only Way To Address The Opioid Crisis

wp17a759ca_05_06Health Affairs has a great summary of a recent report on the opioid crisis.

It identifies “six key components to develop a system-wide community solution.”

  1. Recognize That Everyone In Your Community Has A Role To Play
  2. Work Together
  3. Work On Multiple Parts Of The System Simultaneously
  4. Be Unambiguous About The Risks Of Prescription Opioids
  5. Re-Train The Medical Community
  6. Recognize That Addiction Is A Chronic Disease, And Treat It Accordingly

Read the article for details.

The most striking thing is a table that identifies objectives, actions and actors. Nothing groundbreaking, but it does s really nice job of pulling together the multiple needs and systems in one place.

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