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!

Less effective and focused on only one problem

Some friends shared this video about the benefits of exercise:

At about 7:00, he says:

So a German researcher named Rainer Hambrecht looked at this with about 100 cardiac patients He got the group to exercise, and by that I mean 20 minutes a day in an exercise bicycle and once a week a 60 minute aerobics class, and the other half got the high tech stent and just did their normal activity, and after one year 88% of the exercise group were event free, compared to 70% of the people who got a Stent. So both worked, but I find it sort of incredible that the low tech made a bigger difference and you have to remember that the Stent just fixes one part of the heart.

Earlier, he outlined the diverse benefits of physical activity in various populations, including:

  • [in knee arthritis patients, it] reduced rates of pain and disability by 47%
  • reduced progression to dementia and Alzheimer’s by around 50%
  • reduced progression to frank diabetes by 58%
  • 41% reduction on the risk of hip fracture
  • reduced anxiety by 48%
  • 23% lower risk of death
  • number one treatment of fatigue
  • shown again and again to improve qualty of life

This got me thinking about whether12 step recovery is to addiction what exercise is to heart disease.

Preventing heart attacks is a very good thing. That stents exist and are readily available is a very good thing. This sounds like a very strange thing to wonder, but would we be better off it cardiac care was a little less medicalized? If there was a little more parity in research and resources invested in helping people be more physically active? I know that there are some efforts in this direction, but is the medical system missing the boat?

In the same way we have interventions (like medications) that can prevent overdose and reduce drug use. But, these offer none of the other benefits. Further, the damage done by addiction is often pretty global—physical, emotional, social, familial, spiritual, occupational, educational, etc. So…an intervention narrowly focused on drug use is, at best, a start on the path to wellness and recovery.

Of course we can’t make cardiac patients exercise and we shouldn’t withhold care to patients who do not exercise or give them second class care. But, maybe, the medical system should be more focused on “recovery” rather than just harm reduction?

The addiction treatment system did a lousy with people who didn’t engage in our version of exercise, we didn’t do a good job supporting it beyond a period of a few weeks or months, we sometimes used some dubious and even harmful methods to get people to do it. (We’re not alone in this. Medical history is full of dubious and harmful methods.) But…there’s been a lot of improvement, a lot of success and it offers global benefits that go well beyond abstinence or reduced drug use. So…why are so many people in a hurry to abandon and dismantle this system?

“real addiction treatment”

pills galore by Boots McKenzie

I’ve previously expressed concern about the medicalization of addiction treatment as health care reform takes effect. Here’s an ASAM member’s complaint that addiction medicine physicians have not sufficiently medicalized their treatment services:

I also respect those individuals who have suffered from the disease of addiction and have found help with 12-Step based programs. I understand their desire to recommend the treatment that worked for them to others, but enough is enough. Peer support groups and the 12-Step philosophy are fine, but they are not medical treatments and they are not counseling.

If ASAM wants to move forward as a professional organization, and become the voice of real addiction treatment, we must move past this never-ending discussion about, and homage to, 12-Step programs. Evidence-based treatment is medically managed withdrawal (not “detox”), and, if available, medication-based stabilization for as long as necessary. This needs to be combined with appropriate, evidence-based psychosocial interventions such as cognitive-behavioral therapy and motivational enhancement techniques that can be brief, mostly carried out on an outpatient basis, and focused on relapse prevention.

Notice the exclusion of twelve step facilitation in the list of evidence-based practices. (In spite of the fact that it has been found to be just as effective as CBT and MET, and more effective than either with the heaviest drinkers.)

Doctors against medicalization

“If the only tool you have is a hammer, you tend to see every problem as a nail.” — Abraham Maslow

An addiction physician says:

Over the past two years, I’ve witnessed a worrisome trend: the medicalization of addictions. Some of this makes no sense to me. Let me explain.

He describes the emerging norm of discharging patients with up to 7 medications, often including drugs that have potential for misuse, and finishes with this thought:

Message to substance providers: We have a problem. Although addiction experts may justify these “treatments” because education and solace is provided to the patients, I believe that this mocks the purpose of (the very important and necessary) addiction treatment. There is little, if any, harm reduction, because the clients are prescribed the same or other addictive compounds during and after rehab. The clients are also prescribed new drugs, particular in the latter case of the alcoholic woman, whose potential for drug-drug interactions and future adverse events cannot be accurately predicted.

The clients are receiving expensive inpatient care [$40,000+ per month] for services and treatment that could easily be managed in cheaper and less-acute-care outpatient settings, like intensive outpatient or partial hospital programs. And, most importantly, the clients are continuing to rely heavily on pills to combat their anxieties, mood changes and addiction.

Problem? Relying on pills got them to rehab in the first place. So what’s the point of attending and paying for — or charging a commercial insurance carrier, Medicare or Medicaid, or any other third-party payer — for an expensive retreat that leaves you in virtually the same mental place, or worse, than you started? Not that much.

I’m even more worried about what health care reform will mean for this. I fear primary care physicians are going to be the front lines, armed only with a prescription pad.