Over-medicalization of health?

tumblr_m5l37qV3Ec1qzp5iio1_500A new book, The American Health Care Paradox: Why Spending More Is Getting Us Less, offers an interesting take on why the United States’ huge investments in health care doesn’t translate into better health. Vox did an interview with the book’s authors.

The paradox that we outline is one that a lot of readers will be familiar with: that the United States has very high health-care costs, and in many cases middling — and sometimes lousy — health outcomes when you look at certain metrics. These are metrics — like infant mortality and life expectancy — where, when you look across developed nations, we’re really at or near the bottom.

People cited this paradox before our book, and tried to explain it in any number of different ways. That included rationales like, “Well, U.S. health outcomes are bad because too few people have insurance” or “because prices are just high.”

What our book tries to do is offer another reason that hasn’t been talked about much in health policy: maybe “health spending” isn’t telling us the whole story. Maybe we need to look at a broader summary of what resources nation puts in to support population health.

To do this, we included social services spending in our study, which captures things like housing, food assistance, and job training. The ratio of health to social-service spending was more predictive of several outcomes than health spending alone. This led us to suggest that social-service spending — and, more broadly, attention to the social determinants of health — could be a missing piece in the health reform discourse.

In explaining the concepts in the book, the authors make a very interesting and provocative statement.

To address the problem of over-medicalization of health we need to actually get to the way people relate to their own health, no matter how wealthy they are.

What?!? “Over-medicalization of health”?!?

What do they mean by that?

Think about shoulder pain or back pain. It’s very common in the American public to think “What kind of MRI do I need? What kind of specialist should I go to?” as opposed to thinking “Hm, maybe the briefcase I’ve been carrying around is too heavy. Maybe I’m not sleeping well. Maybe I haven’t hit the gym for the last three weeks.”

It strikes me that this is extremely relevant to the status of addiction treatment, especially as the Affordable Care Act takes effect.

What we have is a chronic disease approach that hasn’t been executed perfectly, but has avoided over-medicalization and it is facing growing pressure to medicalize. It’s also interesting that physicians treat their addicted peers with a model that avoids over-medicalization, but we’re losing support for similar approaches with the general public.

It’s also seems to me that Recovery Management does a good job of seeking to address these social determinants.

I also just saw a very relevant quote on Recovery Review from David Best.

So this question about community recovery capital is partly about stigma and discrimination – whether professionals (in the addictions and related field) believe that people recover and act accordingly. If you are in a system where all the addiction money is spent on substitution therapies, on detox and on counselling, your system does not believe that people recover!

Sentences to ponder

American Society of Addiction Medicine
American Society of Addiction Medicine (Photo credit: Wikipedia)

From the ASAM blog:

…is there any evidence that the general public requires less treatment than do healthcare professionals and pilots? I would further ask, given the excellent outcomes generally obtained by PHPs and pilot recovery programs, why there have been no studies in which members of the lay public go through identical programs to determine what their long term outcome would be. Indeed, what happens when a non-healthcare professional or non-pilot goes through 90 days of rehab, and is then followed regularly by an addiction specialist physician while simultaneously attending twelve-step or similar self-help groups and being subject to random urine drug testing, all as the FAA requires of pilots requesting a special issuance medical, and as state medical boards generally require of physicians wanting to return to practice? Would they too have an 80-90% recovery rate?

[hat tip: Herb]

We’re not alone

Pat Deegan linked to a report on the state of treatment for schizophrenia for medicaid recipients.

Although there was some state-to-state variation in the findings, the study found that, while more than 90 percent of beneficiaries with schizophrenia or bipolar disorder received an evidence-based medication during the year, only 61 percent of those beneficiaries continuously refilled their prescriptions. Medication level monitoring was provided to about half of beneficiaries taking lithium or anticonvulsants, and screening for common side effects of antipsychotics was provided even less frequently. Only 30 percent of beneficiaries received any preventive physical health services. In some states, less than half of beneficiaries received psychosocial services. Overall, only 5 percent received all of the following: a continuous supply of evidence-based medications, medication level monitoring and screenings for medication side effects, and psychosocial services.

It sometimes seems that addiction treatment’s shortcomings get a lot of scrutiny (Our field definitely has a lot of room for improvement.), but I’ve always wondered how other medical treatment systems would fair under similar scrutiny. It’s sad to consider how much despair, stigma and secondary illness is generated by the failure of this system to consistently deliver treatment of the appropriate quality.

Integrated care?

a diagram by fuzzyjay

Pat Deegan bites her nails at the prospect of integrated care for mental health care (The same thing is happening with addiction treatment):

Is recovery going the way of the dinosaur? Is recovery-transformation an old idea that should give way to more enlightened policies of integrated, co-located behavioral and physical healthcare services?

These days, I am hearing a lot about the integration of physical and behavioral health services. I am hearing about the co-location of physical healthcare services in behavioral healthcare centers. I am hearing about federally qualified healthcare centers and their capacity to serve those of us diagnosed with major mental disorders. I am hearing how, in some states, recovery has “fallen off the radar” and has been replaced with initiatives to support access to medical care and physical health services.  A long-time advocate recently told me: “Recovery is old school.  Today we are about integrated care.”  

I don’t know about you, but the last time I was at my annual physical (April 2012), my primary care physician was anything but “integrated” and “whole health”.  I had the standard 20 minute physical exam that never once addressed my psychiatric disability.  After my annual physical, I was in the reception area, getting my referrals for an annual mammogram, bone density and eye exam.  Although a wall separated the medical reception area from the medical exam rooms, I heard a patient yell through the barrier, “And…I’ll need my script for citalopram increased by 10 milligrams.”  To my astonishment I heard the muted physician’s voice answer back through the wall…”OK”.  I found myself wondering, “So this is integrated health and behavioral healthcare?”

What we spend on health

This infographic is from a report on obesity and it’s set off a debate its accuracy. But it gets at a point I’ve made before. And, the more I learn, the clearer it becomes that this general principle applies to medical problems, mental health problems and addiction.

To me, this doesn’t make a case for disengagement from the medical system. Rather it calls for finding some balance between care focused on delivering medications and devices and care that focuses on promoting and supporting health and wellness.

I think addiction recovery has a lot to offer, about maintaining healthy lifestyle changes in particular, but there’s still a lot to learn.

Buprenorphine Maintenance and Health Care Professionals

Mayo Clinic
Mayo Clinic (Photo credit: Wikipedia)

Mayo Clinic Proceedings published a new article entitled, Buprenorphine Maintenance Therapy in Opioid-Addicted Health Care Professionals Returning to Clinical Practice: A Hidden Controversy.

From the article:

When considering all of the aforementioned issues with buprenorphine diversion, it does not seem reasonable to prescribe this medication to an HCP (Health Care Professional) with a history of opioid addiction. After carefully considering the evidence, we believe that opioid-substitution therapy with buprenorphine is not a reasonable choice for this particular patient population. HCPs are engaged in safetysensitive work that requires vigilance and full cognitive function. We therefore recommend abstinence-based recovery until studies with this specific HCP population performed in a simulated health care environment document that highly safety-sensitive tasks can be performed without deterioration in performance.

They also published an editorial that had a couple of complaints about the article but said:

Hamza and Bryson recommend against buprenorphine maintenance for HCPs with opioid dependence. Instead, they support abstinence-based recovery consistent with the current standard utilized by PHPs. With such standards, several PHPs have demonstrated the lowest relapse rate ever reported in the literature.10 Such high success rates among HCPs are related to multiple factors, including the individual’s motivation to maintain licensure and professional practice, the extensive treatment provided to this group, and the long-term monitoring established by state PHPs.11 In fact, one can clearly make the argument that reported success rates are so high that introducing opioid maintenance to this paradigm would not be appropriate. Individual and large collaborative studies of state PHPs have demonstrated that under ideal circumstances, 80% of physicians being monitored for the 5 years after abstinence-based, 12-step treatment do not have a single relapse.12 Will an institutional review board ever approve a study comparing buprenorphine maintenance with this form of treatment? Can buprenorphine maintenance be justified in the face of such data?

We agree wholeheartedly with Hamza and Bryson that caution is needed in decisions associated with the use of buprenorphine maintenance among HCPs returning to the health care workplace. The foundation information required to make good decisions regarding this medication in this population working in safety-sensitive positions is lacking. The use of a medication that has the potential to undermine cognitive function in HCPs working in an emergency or critical patient care setting cannot be supported at this time, given the lack of evidence of efficacy in this population and the absence of adequate national standards for its use.

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Primary care is good for recovery

The doctor's office on Transylvania Project, L...
Image via Wikipedia

Primary care visits are associated with better recovery outcomes:

A yearly primary care visit was also positively associated with remission (OR, 1.39), as was continuing care (OR, 2.34), defined as:

  • having at least 1 yearly primary care visit,
  • completing substance abuse treatment or receiving further treatment,
  • receiving alcohol or drug treatment when the alcohol or drug Addiction Severity Index (ASI) score at last assessment was higher than 0, and
  • receiving psychiatric services when the psychiatric ASI score at last assessment was higher than 0.

Makes our primary care project look pretty smart.