The health care debate continues in Washington, D.C. and across the nation. What impressed me this week was the Republican assertion that Americans were by and large happy with their health insurance. I don't know anyone who is happy with their health insurance, and, as a physician, I know many people who have health insurance and use it. Advocates for President Obama's plan point out that people will have much better coverage of services under their plan even though individuals will pay 10 to 13% more. Republicans argue that people would rather keep the plans they have and save the 10 to 13% increase in premiums.
I'd like to weigh in on what people don't get with today's health insurance, because I know what I don't get paid by insurance to do. If I see anyone more than once per week, I don't get paid. I remember my surprise when I saw an 86 year old woman with heart failure daily in order to keep her out of the hospital (her wishes) and as able to do so. Medicare, however, paid me only for the first visit of the week and denied all the others as medically unnecessary. Had I admitted her to the hospital (she certainly would have qualified), presumably Medicare would have paid the hospital, though they might have scrimped on my daily visits to her. Heart failure is the number one cause of geriatric admissions to hospital. Imagine the savings that might accrue if we had geriatric home teams who could manage such patients outside the hospital. However, contemporary health coverage will not permit that.
Here's another example. I work with many seriously mentally ill people. The most common diagnosis they receive is schizophrenia. I work with a small subset of these patients intensively, for no charge (since no one will pay me). The patients I see once or more per week use much less medication and have many fewer hospitalizations than the patients I see once per month (what insurance will allow). I like to work with these people in a group format because they learn from each other. Insurance will not allow that either. The cost of the medication that the insurance does cover ranges between $500 and $1000 per month. I can usually keep the patients with whom I work more intensively below $200 per month in medication costs.
What's also important, but rarely considered by today's insurance companies, is the level of suffering. I imagine insurance executives sitting in board rooms thinking that we doctors would see patients daily for hours if we could and that nothing would come of it besides our income. I don't even think that happened in the heyday of psychoanalysis when people were seen daily (that's been rare since 1970). I've submitted a paper for publication on the outcomes of 51 people diagnosed with schizophrenia whom I saw for more than four hours per month over several years. Over 80% of these people were doing well and were off medication at seven year follow-up. Imagine the cost savings if we were actually paid to help such patients. People with schizophrenia die, on average, 25 years before age-matched controls without that diagnosis and the last year of their life is quite expensive.
In fact, 70 to 80% of the total amount spent during a person's life is spent in their last year of life. That could be reduced if doctors spent more time talking to families, which is also not currently often reimbursed. In fact, the patient must be present in order for insurance to be billed, and that is sometimes not in the patient's best interest. Sometimes it is very important to have conversations with family members that the patient may not want to hear.
I remember a 104 year old man for whom the family wanted full resuscitation efforts were his heart to stop. The insanity of this was that chest compressions would have probably killed him by breaking all his ribs and bruising his heart. We were able to spend several hours discussing this with family members over two weeks and eventually consensus was reached for a "do not resuscitate" order. My bill for these meetings was denied by Medicare as medically unnecessary. Imagine the cost of transporting him from the nursing home with ambulance sirens blasting, paramedics working, and then the ensuing chaos that would have ensued. I did see this happen once and watched the code team half-heartedly pursue resuscitation of a 108 year old man. Not a single person thought it would work, but the family insisted, and at least a $20,000 hospital bill was generated.
Another example comes from a chronic pain patient. People with chronic pain are largely failed by the medical profession. Within the medical model of a pill for every woe, the pill offered is often a narcotic. Narcotics lead to tolerance and tolerance is a sign of addiction.
Once people are addicted, physicians will often then refuse to treat them. What now! Chronic pain, however, is largely a central nervous system phenomenon. The brain learns about acute pain from a sudden injury and then changes and adapts to continue to feel that pain long after the injury has stopped transmitting pain signals. This fact is part of virtually every continuing education course for physicians in chronic pain, but largely ignored in practice because the ways of approaching central nervous system change are largely not covered by health insurance. Cognitive behavior therapy, hypnosis, narrative therapy, neurofeedback, biofeedback, and many others have shown useful in studies, but are not covered. Only visits to physicians for medications and sometimes the medications themselves are covered. I have worked with many patients to reduce chronic pain using these tools, and insurance has paid me less than 10% of the time.
Success is irrelevant to the insurance industry because what matters is short term (quarterly) profit and loss, not people's health in the long-term or even long-term cost-savings. Take my patient Mary as an example. Mary was referred by a mutual friend to work with me to reduce pain and restore functioning. I worked with Mary for eight sessions and we started making progress toward reducing medication and reducing pain. Then Mary heard from her insurance company that they would not pay any more than 8 sessions. Because we were making progress, I offered to work with Mary for whatever she could afford, even if it was only $5 a session. She declined saying she only wanted to do what her insurance would cover.
Why do I see select patients for little or nothing? Because I need to feel effective. Within the constraints imposed by contemporary health insurance, rarely can I help people with chronic disease and suffering in a meaningful, transformative way. I have invented ways to circumvent this healing circles that are peer-led or relatively leaderless in which everyone helps everyone else and no fee is charged. It is the patients whom I see for next to nothing who are improving and reducing costs to the health care system. The ones insurance cover are not getting well very fast.
We should consider this in the health care debate. Data is available for discussion. Numerous studies have shown that 80% of primary care visits to health care practitioners involve the ordinary suffering of daily life and not diseases that need treatment, yet we throw pills and potions at these woes as if that is their solution.
Health care reform will never work unless we find cost-effective ways to address the ordinary woes of daily life and stop attempting to medicate them away. This will not happen until insurance coverage is expanded to include coverage of prevention and non-pharmacological therapies. I would be thrilled if we moved toward a system that rewards good outcomes.
If I were paid in accordance with people's getting better instead of compliance with a list of covered services, I would be much better off finacially and might find more effectiveness and sense of satisfaction from within insurance reimbursed services. That would be a novel experience I would welcome.
Wednesday, March 23, 2011
The Narrative Interview: Day 3 of the Australian Journey
Of course, the bigger news than our Australian adventure is the tragedy of the earthquake in Japan and the accompanying tsunami, which remind us of our relative insignificance relative to the forces of Nature. We suffer with the rest of the world for those who were harmed in this natural disaster.
However, our trip continues and today we are in Warburton, Victoria, and met some members of the local community who work with children. I gave a lecture at the Warburton Town Hall and, of all people, the Governor of Nambe Pueblo in New Mexico, attended. We were able to chat afterwards and I learned about "The Gathering of Eagles", which will take place at Nambe Pueblo in New Mexico during the last week of July. We were staying at Sancta Sophia Meditation Center in Warburton, a center started by a Carmelite, Sister Kathleen, and a Benedectine, Father Ken. Their mission was inter-religious dialogue, of which we were having much.
Next we focused upon how we would interview within a storied paradigm as compared to diagnostic interviews based upon conventional diagnostic categories. I had the opportunity to interview an aboriginal woman who had defied diagnosis for 12 years except for her asthma and back pain. Her main symptom was severe fatigue, for which her doctors had just prescribed an antidepressant. We quickly reviewed her laboratory studies which were largely unremarkable as is so often the case. There were some signs of chronic, low grade inflammation like a slightly elevated erythrocyte sedimentation rate, a slightly increased platelet count, a slightly low level of triiodothyronine, a slightly reduced estradiol level, a slightly reduced blood hematocrit, and a slightly elevated evening cortisol level, none of which were diagnostic of anything. Her symptoms consisted of some menstrual irregularities, some extra ovarian follicles, moderately severe asthma, back pain, and stomach pain from duodenitis. She had seen conventional doctors and natural healers, including a traditional Chinese doctor, a reflexologist, and a naturopath. She had been raised in an urban environment and had a large aboriginal extended family and many contacts, but none of them were elders who did healing, or it had never occurred to her to ask this of her relatives and acquaintances. Nothing had really helped her. The Chinese medicine had resolved her canker sores, which wasn't a major problem for her anyway. The reflexologist had successfully mapped the sore areas on her foot to the body areas that were problematic, but that hadn't changed anything, however amazing it was. The naturopath had tried eliminating all sugars, pork, spice, sauces, dairy, soy, and wheat, which had made no difference. The supplements he prescribed had worsened her stomach pain. She had recently started eating bread and dairy again and was no worse the wear, though she had realized that especially rich foods gave her more stomach discomfort, bloating, and constipation. She had taken the birth control pill, Yaz, to regulate her menses as well as Accutane for acne.
Then I began to look for the story. The last time Sandra remembered being completely well was when she was age 16. That was when her partner, with whom she had been living since age 13, killed himself. She sadly moved back home only for her mother to die two years later. She found another partner with whom she had two children in two years. Then, her favorite aunt died unexpectedly. That's when she had her first asthma attack. Back pain followed suit. Sandra didn't have a theory about how she got asthma but thought that her back pain was the result of carrying two young children around. She continued having moderately severe asthma and back pain for ten years until she became pregnant with her third child. During that pregnancy, her asthma and back pain improved, but then they came back with a vengeance after she gave birth. Suddenly a new very severe symptom appeared -- absolute and complete fatigue, which had continued unabatedly severe until today.
During all this time, Sandra had been running an art cooperative that her mother had started. It managed a number of aboriginal artists' work and had retail outlets throughout the area. Sandra had some tears as she talked about her mother, who had been absolutely driven to succeed and bring her family out of the relative poverty in which they had previously lived. Sandra's grandmother had also been an accomplished artist, had nine children, but had lived in relative poverty even as she supported Sandra's mother to go to art school and be successful in a contemporary sense.
I asked Sandra what she would be doing if she were well and she said she would be out in the world continuing to expand and grow the business that her mother had started. She worried about the business all the time, even though it was doing well. She feared that her limitations would make it suffer.
I asked Sandra what gifts the illness had brought her. Again, she responded immediately. Without the illness, she wouldn't be spending nearly so much time with her children at home and with her husband. She'd be out working. "Like your mother?" I asked. That led to a powerful, tearful story about her mother and how burned out her mother had become and how desperately she thought her mother had wanted to relax and be with her family and be cared for. Her mother had never had that. She feared that she was becoming her mother and worried that she would die at age 36, the same age at which her mother had died.
"How much help do you have?" I asked.
"Help!" she responded incredulously. "Everyone's too busy with all the things they have to do to help me. " She recited a litany of examples of how her children were too busy with their homework, or too young. Her husband worked 6-1/2 days per week to support the family. Her relatives were equally busy. Slowly it became clear that Sandra couldn't ask for help and wouldn't take it, if offered.
"So," I said. "We have a SuperWoman story! Modern aboriginal woman defies all odds, continues to build her mother's business while raising a family and refuses all help because she can do everything, including leaping tall buildings with a single bound and running faster than speeding locomotives."
"Wonderwoman," she said. "Better costume. Invisible airplane. Lasso." I had to agree that Wonderwoman was more cool that SuperWoman. So, here's the story, I said. And your two dogs fighting (a metaphor for conflicting beliefs) is this: one dog says you have to do it all without help and the other dog says your ill and you can't do it all and you need and have to accept help. "Right," she said.
"So," I said. "Did any of your many health practitioners talk to you long enough to get this story?"
"Never," she said.
"And that's the problem with conventional medicine," I said. "Here's what I'd do next. I'd call a meeting of everyone you know -- family, friends, co-workers, fellow artists -- and we'd do a large talking circle in which everyone got to contribute their story about you to your story, and then we'd brain storm about how everyone could be helpful to you." This made her very uncomfortable since she didn't like to ask for or receive help. "This is the indigenous way, in which community heals people whether they ask for it or not. An aboriginal woman elder in the audience invited her to join a women's circle that she led, "whether she needed it or not." This would set the stage for day 4's discussions on community.
However, our trip continues and today we are in Warburton, Victoria, and met some members of the local community who work with children. I gave a lecture at the Warburton Town Hall and, of all people, the Governor of Nambe Pueblo in New Mexico, attended. We were able to chat afterwards and I learned about "The Gathering of Eagles", which will take place at Nambe Pueblo in New Mexico during the last week of July. We were staying at Sancta Sophia Meditation Center in Warburton, a center started by a Carmelite, Sister Kathleen, and a Benedectine, Father Ken. Their mission was inter-religious dialogue, of which we were having much.
Next we focused upon how we would interview within a storied paradigm as compared to diagnostic interviews based upon conventional diagnostic categories. I had the opportunity to interview an aboriginal woman who had defied diagnosis for 12 years except for her asthma and back pain. Her main symptom was severe fatigue, for which her doctors had just prescribed an antidepressant. We quickly reviewed her laboratory studies which were largely unremarkable as is so often the case. There were some signs of chronic, low grade inflammation like a slightly elevated erythrocyte sedimentation rate, a slightly increased platelet count, a slightly low level of triiodothyronine, a slightly reduced estradiol level, a slightly reduced blood hematocrit, and a slightly elevated evening cortisol level, none of which were diagnostic of anything. Her symptoms consisted of some menstrual irregularities, some extra ovarian follicles, moderately severe asthma, back pain, and stomach pain from duodenitis. She had seen conventional doctors and natural healers, including a traditional Chinese doctor, a reflexologist, and a naturopath. She had been raised in an urban environment and had a large aboriginal extended family and many contacts, but none of them were elders who did healing, or it had never occurred to her to ask this of her relatives and acquaintances. Nothing had really helped her. The Chinese medicine had resolved her canker sores, which wasn't a major problem for her anyway. The reflexologist had successfully mapped the sore areas on her foot to the body areas that were problematic, but that hadn't changed anything, however amazing it was. The naturopath had tried eliminating all sugars, pork, spice, sauces, dairy, soy, and wheat, which had made no difference. The supplements he prescribed had worsened her stomach pain. She had recently started eating bread and dairy again and was no worse the wear, though she had realized that especially rich foods gave her more stomach discomfort, bloating, and constipation. She had taken the birth control pill, Yaz, to regulate her menses as well as Accutane for acne.
Then I began to look for the story. The last time Sandra remembered being completely well was when she was age 16. That was when her partner, with whom she had been living since age 13, killed himself. She sadly moved back home only for her mother to die two years later. She found another partner with whom she had two children in two years. Then, her favorite aunt died unexpectedly. That's when she had her first asthma attack. Back pain followed suit. Sandra didn't have a theory about how she got asthma but thought that her back pain was the result of carrying two young children around. She continued having moderately severe asthma and back pain for ten years until she became pregnant with her third child. During that pregnancy, her asthma and back pain improved, but then they came back with a vengeance after she gave birth. Suddenly a new very severe symptom appeared -- absolute and complete fatigue, which had continued unabatedly severe until today.
During all this time, Sandra had been running an art cooperative that her mother had started. It managed a number of aboriginal artists' work and had retail outlets throughout the area. Sandra had some tears as she talked about her mother, who had been absolutely driven to succeed and bring her family out of the relative poverty in which they had previously lived. Sandra's grandmother had also been an accomplished artist, had nine children, but had lived in relative poverty even as she supported Sandra's mother to go to art school and be successful in a contemporary sense.
I asked Sandra what she would be doing if she were well and she said she would be out in the world continuing to expand and grow the business that her mother had started. She worried about the business all the time, even though it was doing well. She feared that her limitations would make it suffer.
I asked Sandra what gifts the illness had brought her. Again, she responded immediately. Without the illness, she wouldn't be spending nearly so much time with her children at home and with her husband. She'd be out working. "Like your mother?" I asked. That led to a powerful, tearful story about her mother and how burned out her mother had become and how desperately she thought her mother had wanted to relax and be with her family and be cared for. Her mother had never had that. She feared that she was becoming her mother and worried that she would die at age 36, the same age at which her mother had died.
"How much help do you have?" I asked.
"Help!" she responded incredulously. "Everyone's too busy with all the things they have to do to help me. " She recited a litany of examples of how her children were too busy with their homework, or too young. Her husband worked 6-1/2 days per week to support the family. Her relatives were equally busy. Slowly it became clear that Sandra couldn't ask for help and wouldn't take it, if offered.
"So," I said. "We have a SuperWoman story! Modern aboriginal woman defies all odds, continues to build her mother's business while raising a family and refuses all help because she can do everything, including leaping tall buildings with a single bound and running faster than speeding locomotives."
"Wonderwoman," she said. "Better costume. Invisible airplane. Lasso." I had to agree that Wonderwoman was more cool that SuperWoman. So, here's the story, I said. And your two dogs fighting (a metaphor for conflicting beliefs) is this: one dog says you have to do it all without help and the other dog says your ill and you can't do it all and you need and have to accept help. "Right," she said.
"So," I said. "Did any of your many health practitioners talk to you long enough to get this story?"
"Never," she said.
"And that's the problem with conventional medicine," I said. "Here's what I'd do next. I'd call a meeting of everyone you know -- family, friends, co-workers, fellow artists -- and we'd do a large talking circle in which everyone got to contribute their story about you to your story, and then we'd brain storm about how everyone could be helpful to you." This made her very uncomfortable since she didn't like to ask for or receive help. "This is the indigenous way, in which community heals people whether they ask for it or not. An aboriginal woman elder in the audience invited her to join a women's circle that she led, "whether she needed it or not." This would set the stage for day 4's discussions on community.
Sunday, March 20, 2011
Drug Abuse Prevention; Why do the American media avoid discussing research findings?
This week on American television, as part of its coverage of the 2010 Vancouver Winter Olympic Games, particularly on the CNN Network each morning at the gym were I exercise, the morning news was astir with discussions of Insite, a Vancouver-based project that provides addicts with a safe site to inject, including clean needles. The American TV was awash with criticisms of this policy, the primary one being that it promoted drug abuse and caused people to abuse drugs even more than they otherwise would. What amazed me was the complete lack of attention to data in the American media. Substantial research has been conducted on Insite and on harm reduction models. It is known that programs like Insite reduce the spread of HIV/AIDS and of hepatitis C and reduce drug overdose. No evidence exists to support its spreading drug abuse.
Why do the American media avoid discussing these research findings? Why are the opinions of uninformed people in towns like Decatur, Georgia, and Cumberland, Maryland, more meaningful than the results of carefully conducted scientific research? Why is evidence-based medicine abandoned when it comes to drugs? Why is the existence of credible research not even mentioned? The best that was done was to mention that the director of the Insite Program believed that lives were being saved. Not mentioned was the hard scientific evidence amassed to back his position. Why does science not matter when it comes to drug policies?
CNN implied that Insite was operating under the legal radar and that the Vancouver Police Department were pretending not to notice its existence. In fact, in 2003, the regional health authority in Vancouver successfully applied to the federal government for a legal operating exemption to pilot Insite.3 This exemption was granted following the release of feasibility data which suggested that Insite had the potential to reduce public drug use and overdose deaths.4,5 Insite was established following prior experience of similar facilities in European and Australian settings. Corresponding research suggested that these facilities had unique potentials to reduce public illicit drug use while promoting the use of sterile syringes and providing emergency care in the event of overdose.6-9 Since opening in 2003, Insite has been a place where people could inject drugs and connect to health care services from primary care to treating disease and infection, to addiction counseling and treatment. Few areas suffer more from the lack of response to research than illicit drug use.1,2
Dr. Evan Wood, Director of the University of British Columbia's Center for Excellence in HIV/AIDS research reported in The Calgary Herald on January 31, 2010, that despite criticisms levied by Conservatives (and the American media), the benefits that Insite provides are real and verified.
Dr. Wood pointed out that drug prohibition has created a massive global revenue stream for organized crime, worth an estimated $320 billion US annually. These enormous proceeds threaten the political stability of entire regions, including Mexico and Afghanistan. In the U.S., where the war on drugs has been fought most vigorously, the incarceration of drug offenders has placed a huge burden on the taxpayer and contributed to the world's highest incarceration rate. Primarily as a result of drug-law enforcement and mandatory minimum sentences, one-in-eight African-American males in the age group 25 to 29 is incarcerated on any given day, despite the fact that ethnic minorities consume illicit drugs at the same rate as white and other sub-populations. Paradoxically, ever-increasing drug enforcement expenditures and incarceration levels have not prevented the drug market from becoming more efficient.
The association between drug prohibition and increased inner-city violence is consistent. A recent international example is the upsurge in severe drug-related violence in Mexico subsequent to Mexican President Felipe Calderon's escalation in the fight against Mexican drug traffickers. Increasing gun violence in Canadian cities has been directly linked to clashes between organized crime groups over the enormous drug market profits.
HIV and overdose death rates are highest in areas where law enforcement is prioritized over evidence-based public health strategies. These harms are significant given HIVs spread beyond its traditional risk groups and its burden on the health system. Each and every case of HIV is estimated to cost $250,000 in medical expenses. For the above reasons, conservative economists like Nobel Prize winner Milton Friedman have long argued that the "war on drugs" does much more harm than good.
Due to their effectiveness, harm reduction policies are now endorsed by all evidence-based scientific consensus bodies, including the U.S. Institutes of Medicine and the World Health Organization. This consensus is based on rigorous reviews of the large volume of international scientific evidence indicating that harm-reduction programs save tax dollars and improve public health by reducing HIV rates while increasing uptake of addiction treatment. To read more from Dr. Evan, see click here
In Europe, more than 65 programs like Insite bring street-based drug addicts indoors where they can be prevented from sharing needles and overdosing while increasing enrollment into addiction treatment. Insite has replicated the European experience, and is undoubtedly the most highly studied health clinic in Canadian history. More than 30 peer-reviewed studies show that Insite reduces public injecting, reduces HIV risk behaviors (e.g., needle sharing), and increases rates of addiction treatment. Studies seeking to identify potential harms of the facility found no evidence of negative impacts. Studies were independently peer-reviewed and published in top scientific periodicals, including the New England Journal of Medicine, The Lancet and the British Medical Journal.
During the period from March 10, 2004 to April 30, 2005, 4,764 individuals registered to use Insite. Heroin was used in nearly half of all injections, and cocaine was injected 37% of the time. There were 273 witnessed overdoses, none of which resulted in a fatality. There were also 2,171 referrals to addiction counseling and other support services. These early results indicated that Insite was being successfully integrated into the community. The facility was attracting a wide cross-section of injection drug users, and staff were successfully intervening in overdose events on site and actively referring drug users to addiction treatment and other services.10
A 2006 study showed that Insite was attracting a large number of hard-to-reach intravenous drug users and that the existence of the facility presented an excellent opportunity to enhance HIV prevention through education, the provision of clean injecting equipment, and the availability of a supervised and sterile environment to self-inject. Finally, the facility was also an important point of contact for HIV-positive individuals who were not yet participating in HIV care and treatment.11
One concern prior to the opening of Insite was whether the facility would encourage injection drug use by making drug injection easier and more comfortable for intravenous drug users. Therefore a study was made to determine whether or not the opening of the facility would be accompanied by a worsening of community drug use patterns. The drug use behaviors of 871 intravenous drug users were observed in the one year period before the opening of Insite and in the one-year period after. The drug use behaviors studied included the rates of relapse into injection drug use among former users and the cessation of injection drug use among current users. The study found that after Insite opened there was no substantial increase in the rate of relapse into injection drug use among former users (the rate of relapse was 17% prior to the opening and 20% after). There was also no substantial decrease in the rate of injection drug use cessation among current users (the rate was 17% prior to Insite's opening and 15% after). This research showed that the benefits of Insite on reducing the high-risk behaviors of intravenous drug users and on increasing public order were not offset by negative effects on drug use patterns among Vancouver's intravenous drug using population.12
Critics suggested that the availability of a supervised injection facility might discourage drug users from seeking treatment for their addiction. A study was conducted to examine the effect of Insite on the use of detoxification services, which is the entry point into the addiction treatment continuum in Vancouver. The study followed more than 1,000 Insite users between December 1, 2003 and March 1, 2005. Of this group, 185 (18%) began a detoxification program at some point during the study period. Individuals who used Insite at least weekly were 1.7 times more likely to enroll in a detox program than those who visited the centre less frequently. The study also found that contact with Insite's addictions counselor significantly increased a person's chances of enrolling in detox. Contrary to fears that Insite might be deterring drug users from seeking treatment, these findings strongly suggested that Insite was facilitating entry into detoxification services among its clients.13
In another study, researchers measured the effect of Insite on the use of detoxification services by comparing rates of detox service use among injection drug users in Vancouver in the year before Insite opened and in the year after it opened. The researchers also investigated whether those individuals who attended Insite and enrolled in detox were subsequently more likely to enroll in methadone maintenance or other drug treatment programs. They learned that, in the year after Insite opened, there was a 33% increase in detoxification service use, compared to the year prior to the opening of the facility. The study also showed that Insite clients who entered detox were 1.6 times more likely to enroll in methadone treatment and 3.7 times more likely to enroll in other forms of addiction treatment. As well, individuals who entered detox visited Insite less frequently in the month after enrolling in detox services than in the month prior to enrollment. This research indicated that Insite encouraged intravenous drug users to enter detox. It also suggested that drug users who enrolled in detox were more likely to remain in subsequent treatment programs and reduce their use of Insite.14
I don't have an answer for why ideology trumps scientific evidence in the United States and its media. Why are the opinions of ordinary people in cities across the United States considered more valid than three dozen rigorous scientific studies? Is this just the American way?
Why do the American media avoid discussing these research findings? Why are the opinions of uninformed people in towns like Decatur, Georgia, and Cumberland, Maryland, more meaningful than the results of carefully conducted scientific research? Why is evidence-based medicine abandoned when it comes to drugs? Why is the existence of credible research not even mentioned? The best that was done was to mention that the director of the Insite Program believed that lives were being saved. Not mentioned was the hard scientific evidence amassed to back his position. Why does science not matter when it comes to drug policies?
CNN implied that Insite was operating under the legal radar and that the Vancouver Police Department were pretending not to notice its existence. In fact, in 2003, the regional health authority in Vancouver successfully applied to the federal government for a legal operating exemption to pilot Insite.3 This exemption was granted following the release of feasibility data which suggested that Insite had the potential to reduce public drug use and overdose deaths.4,5 Insite was established following prior experience of similar facilities in European and Australian settings. Corresponding research suggested that these facilities had unique potentials to reduce public illicit drug use while promoting the use of sterile syringes and providing emergency care in the event of overdose.6-9 Since opening in 2003, Insite has been a place where people could inject drugs and connect to health care services from primary care to treating disease and infection, to addiction counseling and treatment. Few areas suffer more from the lack of response to research than illicit drug use.1,2
Dr. Evan Wood, Director of the University of British Columbia's Center for Excellence in HIV/AIDS research reported in The Calgary Herald on January 31, 2010, that despite criticisms levied by Conservatives (and the American media), the benefits that Insite provides are real and verified.
Dr. Wood pointed out that drug prohibition has created a massive global revenue stream for organized crime, worth an estimated $320 billion US annually. These enormous proceeds threaten the political stability of entire regions, including Mexico and Afghanistan. In the U.S., where the war on drugs has been fought most vigorously, the incarceration of drug offenders has placed a huge burden on the taxpayer and contributed to the world's highest incarceration rate. Primarily as a result of drug-law enforcement and mandatory minimum sentences, one-in-eight African-American males in the age group 25 to 29 is incarcerated on any given day, despite the fact that ethnic minorities consume illicit drugs at the same rate as white and other sub-populations. Paradoxically, ever-increasing drug enforcement expenditures and incarceration levels have not prevented the drug market from becoming more efficient.
The association between drug prohibition and increased inner-city violence is consistent. A recent international example is the upsurge in severe drug-related violence in Mexico subsequent to Mexican President Felipe Calderon's escalation in the fight against Mexican drug traffickers. Increasing gun violence in Canadian cities has been directly linked to clashes between organized crime groups over the enormous drug market profits.
HIV and overdose death rates are highest in areas where law enforcement is prioritized over evidence-based public health strategies. These harms are significant given HIVs spread beyond its traditional risk groups and its burden on the health system. Each and every case of HIV is estimated to cost $250,000 in medical expenses. For the above reasons, conservative economists like Nobel Prize winner Milton Friedman have long argued that the "war on drugs" does much more harm than good.
Due to their effectiveness, harm reduction policies are now endorsed by all evidence-based scientific consensus bodies, including the U.S. Institutes of Medicine and the World Health Organization. This consensus is based on rigorous reviews of the large volume of international scientific evidence indicating that harm-reduction programs save tax dollars and improve public health by reducing HIV rates while increasing uptake of addiction treatment. To read more from Dr. Evan, see click here
In Europe, more than 65 programs like Insite bring street-based drug addicts indoors where they can be prevented from sharing needles and overdosing while increasing enrollment into addiction treatment. Insite has replicated the European experience, and is undoubtedly the most highly studied health clinic in Canadian history. More than 30 peer-reviewed studies show that Insite reduces public injecting, reduces HIV risk behaviors (e.g., needle sharing), and increases rates of addiction treatment. Studies seeking to identify potential harms of the facility found no evidence of negative impacts. Studies were independently peer-reviewed and published in top scientific periodicals, including the New England Journal of Medicine, The Lancet and the British Medical Journal.
During the period from March 10, 2004 to April 30, 2005, 4,764 individuals registered to use Insite. Heroin was used in nearly half of all injections, and cocaine was injected 37% of the time. There were 273 witnessed overdoses, none of which resulted in a fatality. There were also 2,171 referrals to addiction counseling and other support services. These early results indicated that Insite was being successfully integrated into the community. The facility was attracting a wide cross-section of injection drug users, and staff were successfully intervening in overdose events on site and actively referring drug users to addiction treatment and other services.10
A 2006 study showed that Insite was attracting a large number of hard-to-reach intravenous drug users and that the existence of the facility presented an excellent opportunity to enhance HIV prevention through education, the provision of clean injecting equipment, and the availability of a supervised and sterile environment to self-inject. Finally, the facility was also an important point of contact for HIV-positive individuals who were not yet participating in HIV care and treatment.11
One concern prior to the opening of Insite was whether the facility would encourage injection drug use by making drug injection easier and more comfortable for intravenous drug users. Therefore a study was made to determine whether or not the opening of the facility would be accompanied by a worsening of community drug use patterns. The drug use behaviors of 871 intravenous drug users were observed in the one year period before the opening of Insite and in the one-year period after. The drug use behaviors studied included the rates of relapse into injection drug use among former users and the cessation of injection drug use among current users. The study found that after Insite opened there was no substantial increase in the rate of relapse into injection drug use among former users (the rate of relapse was 17% prior to the opening and 20% after). There was also no substantial decrease in the rate of injection drug use cessation among current users (the rate was 17% prior to Insite's opening and 15% after). This research showed that the benefits of Insite on reducing the high-risk behaviors of intravenous drug users and on increasing public order were not offset by negative effects on drug use patterns among Vancouver's intravenous drug using population.12
Critics suggested that the availability of a supervised injection facility might discourage drug users from seeking treatment for their addiction. A study was conducted to examine the effect of Insite on the use of detoxification services, which is the entry point into the addiction treatment continuum in Vancouver. The study followed more than 1,000 Insite users between December 1, 2003 and March 1, 2005. Of this group, 185 (18%) began a detoxification program at some point during the study period. Individuals who used Insite at least weekly were 1.7 times more likely to enroll in a detox program than those who visited the centre less frequently. The study also found that contact with Insite's addictions counselor significantly increased a person's chances of enrolling in detox. Contrary to fears that Insite might be deterring drug users from seeking treatment, these findings strongly suggested that Insite was facilitating entry into detoxification services among its clients.13
In another study, researchers measured the effect of Insite on the use of detoxification services by comparing rates of detox service use among injection drug users in Vancouver in the year before Insite opened and in the year after it opened. The researchers also investigated whether those individuals who attended Insite and enrolled in detox were subsequently more likely to enroll in methadone maintenance or other drug treatment programs. They learned that, in the year after Insite opened, there was a 33% increase in detoxification service use, compared to the year prior to the opening of the facility. The study also showed that Insite clients who entered detox were 1.6 times more likely to enroll in methadone treatment and 3.7 times more likely to enroll in other forms of addiction treatment. As well, individuals who entered detox visited Insite less frequently in the month after enrolling in detox services than in the month prior to enrollment. This research indicated that Insite encouraged intravenous drug users to enter detox. It also suggested that drug users who enrolled in detox were more likely to remain in subsequent treatment programs and reduce their use of Insite.14
I don't have an answer for why ideology trumps scientific evidence in the United States and its media. Why are the opinions of ordinary people in cities across the United States considered more valid than three dozen rigorous scientific studies? Is this just the American way?
Suicide and Mental Health: Australia Journey Day 2
Refresh Tag(s): Aboriginal; Aboriginal; Community; Culture; Healing; Health; Health; Mental Health; Mental Health-Therapy; Mental Illness; (more...) Mind; Spirit; Spirits; Suffering; Suicide, Add Tags (less...)
Add to My Group
March 11, 2011 at 17:12:14
We (Coyote Institute) are on Day 2 of our cross-cultural mental health exchange with aboriginal people in Australia.
Today we met with representatives of Life Is " Foundation to explore some aboriginal concepts of mind and mental health. We began with the problem of suicide. As in most of North America, in Australia, suicide from sadness didn't exist prior to European contact. Suicide, when it occurred, was the result of a social error or transgression so great that they only remedy was to offer up one's life in return. Apparently, some people who were banished from the tribe also chose suicide over life without community. The notion that people get so sad that they kill themselves did not exist. This confirms what we have heard from elders in North America, as well. In North America, to suffer loss and trauma produced a pitiable state which was associated with respect from others. Those who suffered greatly were admired and looked at as examples for how to bear the human condition. One aspired to be worthy of others' pity. This was consistent with what we were told about Australian aboriginal pre-contact conditions.
Apparently the idea that one can become so sad or "depressed" as to kill oneself is a European importation. An elder told us that suicide would have not seemed to have offered much of a solution, because generally people believed that one felt the same way after death as one felt during life. Death was not an end but a passage into spirit world. One's problems didn't go away, but followed one into spirit world. What didn't get resolved in ordinary world would have to be resolved in spirit world.
The fantasy of most of my patients who consider suicide is that it will make the pain go away. All pain will stop. Death represents the ultimate sleep. This idea would have seemed ridiculous to aboriginal people.
As we continued our discussions, we settled on the idea that modern blended culture presents suicide as a way to get back at others, as a way to show them how much they have hurt you, and as a way to make a statement about how bad one feels. Suicide gestures are ways of making definitive statements about one's emotional state. Sometimes people accidentally die in making this communication.
In a sense, suicide is a modern phenomenon. In a world in which no one seems to listen or care, suicide makes a stark statement that "I will be heard". Making a suicide attempt is a way of stating how bad one feels. It becomes a way of expressing inarticulate distress. As such our modern day suicide appears to be a cultural template for expressing severe distress in a way in which others who don't tend to notice how we fee can't help but pay attention. Suicide in modern America and Australia is a cry of distress. The exception, of course, is the people who really want to be dead, who usually quietly succeed in killing themselves without much preamble, though this did not appear to exist either in pre-contact aboriginal life. When one has ongoing relationships to spirits and ancestors and feels accountable to them, then the meaning of suicide becomes entirely different. The felt criticism of those ancestors and spirits can be prohibitive since one would then have to hear their criticism for eternity.
Others have written about the romanticizing of suicide in modern culture. The suicides of prominent role models have made suicide seem like a reasonable choice. Substance abuse also makes suicide all the more likely, which also didn't appear to exist at any appreciable rate in pre-contact aboriginal life.
This discussion led to our discussion about how to respond to the modern crisis of suicide. Everyone present agreed that the biomedical model and the hospitalization model is not working. We wondered what an aboriginal alternative would be. The idea emerged for community safe houses. These would be places where people in distress could go to become instantly ensconced in community. No questions would be asked. The person would not be diagnosed or stigmatized. Community volunteers and elders would be regular visitors to the house. People could participate in talking circles, talk to elders and volunteers, eat a good meal, get "doctored", or perhaps participate in other cultural healing activities like yoga, chi gong, t'ai chi, and the like. Referrals could be made to professionals when appropriate. This model fits well the hocokah concept we have been developing at Coyote Institute. We have been looking for grassroots models for helping in keeping with the idea that ordinary people are well-equipped for being healing for each other. The hocokah concept is that every person needs to be part of a healing circle, preferably including an elder, but able to function without one if none were available. Healing circles meet regularly and provide people with an opportunity to be part of a community of others who care for them. Being able to care for others can also be healing. To have healing circles expand into safe houses or sanctuaries is appealing. For some healing circles to be strong enough to offer sanctuary and respite for the deeply distressed could transform our currently broken mental illness system. Clearly a demonstration project is needed and models exist for more peer-led services. One concept is the clubhouse concept which is for long-term housing. In this concept, people live together and co-manage their lives collaboratively with the help of advisors rather than being administered or managed by others as is often the case today in supported housing for the mentally ill. There are peer counseling centers with drop-in opportunities. In Rochester, New York, the Creative Wellness Coalition runs such a center with free classes in yoga, dance, art, drama, and more. They provide support groups and other potentially therapeutic encounters without participation of any clinicians. It's entirely run by peers and former mental illness system clients. Psychologist Andrew Feldman is helping to create houses in Hungary where people with psychosis can go for peer assistance and the healing voices network has gone international. We have seen groups offered in as far apart areas as Melbourne, Australia and Keene, New Hampshire. The resolution was to form a working group for consideration of safe houses and sanctuaries that could exist outside of the mental illness system. Coyote Institute and Life Is" Foundation will coordinate this and I (Lewis) will explore the creation of a faculty interest group at Union Institute & University. This is one outcome already from our trip. Until tomorrow, g'day mates.
Add to My Group
March 11, 2011 at 17:12:14
We (Coyote Institute) are on Day 2 of our cross-cultural mental health exchange with aboriginal people in Australia.
Today we met with representatives of Life Is " Foundation to explore some aboriginal concepts of mind and mental health. We began with the problem of suicide. As in most of North America, in Australia, suicide from sadness didn't exist prior to European contact. Suicide, when it occurred, was the result of a social error or transgression so great that they only remedy was to offer up one's life in return. Apparently, some people who were banished from the tribe also chose suicide over life without community. The notion that people get so sad that they kill themselves did not exist. This confirms what we have heard from elders in North America, as well. In North America, to suffer loss and trauma produced a pitiable state which was associated with respect from others. Those who suffered greatly were admired and looked at as examples for how to bear the human condition. One aspired to be worthy of others' pity. This was consistent with what we were told about Australian aboriginal pre-contact conditions.
Apparently the idea that one can become so sad or "depressed" as to kill oneself is a European importation. An elder told us that suicide would have not seemed to have offered much of a solution, because generally people believed that one felt the same way after death as one felt during life. Death was not an end but a passage into spirit world. One's problems didn't go away, but followed one into spirit world. What didn't get resolved in ordinary world would have to be resolved in spirit world.
The fantasy of most of my patients who consider suicide is that it will make the pain go away. All pain will stop. Death represents the ultimate sleep. This idea would have seemed ridiculous to aboriginal people.
As we continued our discussions, we settled on the idea that modern blended culture presents suicide as a way to get back at others, as a way to show them how much they have hurt you, and as a way to make a statement about how bad one feels. Suicide gestures are ways of making definitive statements about one's emotional state. Sometimes people accidentally die in making this communication.
In a sense, suicide is a modern phenomenon. In a world in which no one seems to listen or care, suicide makes a stark statement that "I will be heard". Making a suicide attempt is a way of stating how bad one feels. It becomes a way of expressing inarticulate distress. As such our modern day suicide appears to be a cultural template for expressing severe distress in a way in which others who don't tend to notice how we fee can't help but pay attention. Suicide in modern America and Australia is a cry of distress. The exception, of course, is the people who really want to be dead, who usually quietly succeed in killing themselves without much preamble, though this did not appear to exist either in pre-contact aboriginal life. When one has ongoing relationships to spirits and ancestors and feels accountable to them, then the meaning of suicide becomes entirely different. The felt criticism of those ancestors and spirits can be prohibitive since one would then have to hear their criticism for eternity.
Others have written about the romanticizing of suicide in modern culture. The suicides of prominent role models have made suicide seem like a reasonable choice. Substance abuse also makes suicide all the more likely, which also didn't appear to exist at any appreciable rate in pre-contact aboriginal life.
This discussion led to our discussion about how to respond to the modern crisis of suicide. Everyone present agreed that the biomedical model and the hospitalization model is not working. We wondered what an aboriginal alternative would be. The idea emerged for community safe houses. These would be places where people in distress could go to become instantly ensconced in community. No questions would be asked. The person would not be diagnosed or stigmatized. Community volunteers and elders would be regular visitors to the house. People could participate in talking circles, talk to elders and volunteers, eat a good meal, get "doctored", or perhaps participate in other cultural healing activities like yoga, chi gong, t'ai chi, and the like. Referrals could be made to professionals when appropriate. This model fits well the hocokah concept we have been developing at Coyote Institute. We have been looking for grassroots models for helping in keeping with the idea that ordinary people are well-equipped for being healing for each other. The hocokah concept is that every person needs to be part of a healing circle, preferably including an elder, but able to function without one if none were available. Healing circles meet regularly and provide people with an opportunity to be part of a community of others who care for them. Being able to care for others can also be healing. To have healing circles expand into safe houses or sanctuaries is appealing. For some healing circles to be strong enough to offer sanctuary and respite for the deeply distressed could transform our currently broken mental illness system. Clearly a demonstration project is needed and models exist for more peer-led services. One concept is the clubhouse concept which is for long-term housing. In this concept, people live together and co-manage their lives collaboratively with the help of advisors rather than being administered or managed by others as is often the case today in supported housing for the mentally ill. There are peer counseling centers with drop-in opportunities. In Rochester, New York, the Creative Wellness Coalition runs such a center with free classes in yoga, dance, art, drama, and more. They provide support groups and other potentially therapeutic encounters without participation of any clinicians. It's entirely run by peers and former mental illness system clients. Psychologist Andrew Feldman is helping to create houses in Hungary where people with psychosis can go for peer assistance and the healing voices network has gone international. We have seen groups offered in as far apart areas as Melbourne, Australia and Keene, New Hampshire. The resolution was to form a working group for consideration of safe houses and sanctuaries that could exist outside of the mental illness system. Coyote Institute and Life Is" Foundation will coordinate this and I (Lewis) will explore the creation of a faculty interest group at Union Institute & University. This is one outcome already from our trip. Until tomorrow, g'day mates.
Tuesday, March 15, 2011
Treatment Programs - Do they work?
Treatment Programs -" Do they work?
Become a Fan (14 fans) "Live" from the Creativity and Madness conference in Santa Fe, New Mexico, February 14, 2010, Valentine's Day, we consider the question of treatment does it work? Treatment is a billion dollar industry in America. We have treatment programs for everything from alcohol users to drug users to people who have too much sex, to people who have too little sex, to people who eat too much, to people who eat too little, to people who eat and then purge, to people who cut themselves, to people who are too sad, to people who are too happy. So many people go for treatment and so many experts purport to tell people how to reform. The question does it work? Does treatment actually help anyone?
When I worked in Saskatchewan, we attempted to address the simple question of whether "28 day alcohol treatment programs" worked. In general, they didn't. People came home and quickly resumed drinking. At the time I was working with Native people in Northern Saskatchewan. The irony was that we had unlimited funds to send people south to 28 day treatment programs and no funds to organize local support for people coming back from treatment programs.
Previoiusly, when I consulted to an Eating Disorders Treatment Program, I was asked to do a follow-up study of their clients. I discovered that the most successful patients were the "bad patients", those identified by the staff as unlikely ever to succeed. The least successful patients were the "good patients", those who complied, who did everything they were told, who were pleasant and easy. Ironically, the relapse rate of this $1,000 per day, 28 day treatment program was greater than spontaneous recovery rates reported in the literature. Five years after people were diagnosed with eating disorders, 65% had recovered with no treatment. In the treatment program I studied, after 5 years, fewer than 30% recovered with treatment. Apparently treatment did no good.
At this conference, I spoke to a friend about this. He had worked in an adolescent treatment program. He had the same insight. The teenagers who were labelled as bad patients appeared to do the best. These individuals appeared to have "self-agency". They had enough sense of personal power that they could fight the authorities of the treatment program. They could rebel against the treatment staff. In his experience, these patients had the highest likelihood of responding, of recovering. What they had, which apparently we all need, is self-agency, a sense that our efforts can and will make a difference. The compliant patients, the good patients, lacked self-agency. They did what they were told and played the role of good patients, and, once discharged, had no role to play, no direction, and promptly relpased.
Treatment programs of all sorts consume a large amount of the health care budget. Let's examine the assumptions upon which these programs are based. Almost uniformly, they are based upon the assumption that a class of experts exist, who know more about other people than the people themselves know. These experts tell an inferior class of patients how to reform themselves and how to behave to live "the good life". The problem with this is that it doesn't work. Rational expositions of how to live rarely change people's behavior. Largely this is a waste of breath. Why? Because we do not behave as we do out of ignorance. We behave as we do because of our beliefs. They tell us how to behave. Cognitive-behavioral therapists figured this out. But from where do beliefs come? They come from our interpretations of our experience which exist in the form of stories. If you want to know how I cam to believe, ask me to tell a story about an experience which led me to form the conclusion that I have formed. Ask me to tell several stories. I will do so and, whether or not you agree with my interpretations of these experiences, you grasp that I believe my interpretations, and that these stories I tell have come together to generate my conclusions which I now believe wholeheartedly. If you want to change my beliefs (which is necessary to change my behavior), then you need to find stories that contradict the stories I tell to support my belief(s). They need to be compelling, believable stories. They need to convince me. Telling me to think differently or arguing with my beliefs doesn't work.
My friend had an excellent example. He told me a story of a patient who came to him to tell him that the treatment program was a crutch for the girls who were attending it. She described how they preferred to "freak out" and scream and come to treatment than to deal with their problems. He arranged for her to give a lecture to staff about her stories and conclusions and beliefs. She did, but mostly staff ignored her insights, since they definitely knew what was true and this teenager who had no training couldn't possibly know anything.
He told me another story about a girl who was assigned to him because no one else had been able to help her stop cutting. He asked her to talk to "cutting". What did it want? How did it help? She responded with the story of Austin Powers. She said, she had been frozen like him and awakened. When she awakened, she was full of pain. She needed to shut down the pain and cutting did that. It refroze her. My friend proposed a metaphor to her. He asked her to imagine herself as a greenhouse. Each time she tried love, someone broke a window and it got replaced with a wooden board. Eventually, he said, "your greenhouse is mostly covered with plywood and inside has become dark. You need to pick one board at a time to replace with glass, he said. This metaphor worked for her and her cutting reduced.
What was different? He listened to her story. He found a metaphor that resounded to her. He found a metaphor that she could use for change. He didn't tell her what to do. He didn't lecture her. He didn't pretend to know more about her than she knew. He listened to her and then responded to what she said in a way that indicated that he had understood her and then offered her a new twist on her story which could be even more useful. This is the essence of what we call narrative therapy.
My point is that we need to be suspicious of experts. We need to question those who purport to know how to treat others. We need to suspect those who claim to know our minds better than ourselves. We need to question those who would control us and tell us how to make our lives better. We need to suspect those who would do other than empower us.
From a public policy point of view, from a health care reform point of view, from a health care finance point of view, we need to question expensive 28 day treatment programs and focus on more local programs, respectful and empowering, respecting of each person's story, and capable of helping people to transform their story into a better one.
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