Arizona Addiction Rehab & Co-occurring Disorders Blog from Cottonwood de Tucson

Health Care Reform Medicare Payments

2009-07-09T14:08:00.004-07:00

The American Academy of Neurologists has sent a letter to Congress about some concerns regarding any health care reform. What they indicated in their letter is similar to what I have been saying on this blog, that current Medicare reimbursement is inadequate and undervalues many specialties. The letter was also signed off on by the American Society of Hematology, the American College of Allergy, Asthma, and Immunology, the American College of Rheumatology and the American Gastroentrological Association.

You might initially think that this is just some whining by doctors who make enough anyway, why should they be asking for more when we are at a time of cutbacks? But it is not whining. It is stating the reality that in today's medicine procedures are highly reimbursed while time spent with patients is not. I want to emphasize that. Time spent with patients is not adequately reimbursed, not under Medicare and certainly will not be under any Medicare like public health plan. We all want our doctors to take time for us, and these are specialties where time spent with patients is essential not only for diagnosis but for ongoing management of often difficult serious chronic diseases. A neurologist, hematologist, immunologist, or a rheumatologist cannot continue to support a practice at current Medicare reimbursement rates. It is as simple as that. We pay highly for any surgery or specialized procedures but not for taking time with patients.

This reality is not lost upon young physicians who simply are not entering these fields of medicine. Why would they? I think that the letter sent to Congress was a good idea and clearly states the problem but I don't anticipate any reimbursement rates under Medicare going up any time soon.

Thought for the day

If you won't pay for it you won't have it.

Chantix FDA Warning

2009-07-02T07:39:00.006-07:00

The Food and Drug Administration has recommended a safety labeling change for varenicline( Chantix) which is manufactured by Pfizer and is used as an aid to nicotine cessation. This seems to me to be a good idea as it has been known to have psychiatric side effects in some people.

My experience with Chantix has been mixed. It clearly is effective and has worked for a number of my patients who were motivated to quit smoking. But I had a few experiences that have taught me a few lessons and made me more cautious about prescribing this medication. One case is that of Mrs.G, a 45 year old woman who was at Cottonwood for treatment of alcoholism. She had a history of depression and was on antidepressant medication although she was not depressed at the time of admission. She was doing quite well in treatment and understanding the link between tobacco use and alcoholism decided to quit smoking while she was here. She had tried quitting before with the help of the nicotine patch but was unsuccessful so I prescribed Chantix. About one week later she went into a profound depression which was worse than she had ever had before. There had been no apparent psychological trigger so we discontinued the Chantix and about 5-6 days later the depression had resolved completely. Fortunately she was able to quit smoking, used the nicotine patch again and was successful this time.

Not that long afterwards I had a similar experience with Mr. S., a 38 year old man who was at Cottonwood for treatment of polysucbstance dependence. He had a concurrent anxiety disorder which we treated along with his substance abuse problem. He did not want to attempt to quit smoking here but was doing well at the time of discharge so he decided it might be a good time to quit. I prescribed Chantix for him at the time of his going home and did warn him about the possibility of return of anxiety or depressive symptoms while taking Chantix. He called me in a frantic state about 10 days later saying he had a severe exacerbation of his anxiety disorder. I recommended he stop taking the Chantix and several days later his anxiety resolved. Interestingly enough to me he had not recalled our previous conversation about Chantix side effects. This taught me two lessons, first to not prescribe any new medication as the patient is leaving, and secondly a reminder that many patients have too much to remember and may not remember verbal instructions.

It has been known since February of 2008 that some people on Chantix develop behavior changes, depression, or suicidal thoughts. The manufacturer Pfizer did not attempt to hide this data but immediately made changes in the product labeling to include these side effects. What is new in the FDA recommendation is that Chantix carry a "black box " warning in the prescribing instructions. The black box warning means that this information is highlighted in bold letters in a black box which is the first thing a prescriber will see when looking up the medication.

Does this mean Chantix should not be used? This information about Chantix needs to be taken to account in the context that tobacco related illnesses are by far the greatest cause of death in the United States. The people that I see at Cottonwood though may represent a high risk group for psychiatric side effects so will continue to use Chantix only when other smoking cessation efforts fail.

Thought for the day

I will say it once more. All medical treatments carry some risk as well as their benefits.

Suicide Alcohol Abuse Link

2009-07-01T09:25:00.004-07:00

A recent report in the Center for Disease Control and Prevention's (CDC's) Morbidity and Mortality Weekly Report (MMWR) confirmed what many of us in the substance abuse field have long seen, the connection and link between suicide and alcohol abuse. Here at Cottonwood we see many patients who have made suicide attempts, sometimes multiple attempts, in states of intoxication but who never struggle with suicidality when sober. The report does not touch on non successful suicide attempters but indicates that 24% of those who die from suicide showed evidence of alcohol intoxication.

It is not surprising to me that the CDC was able to clearly establish a link. The rates are lower than I expected , though they were higher than the CDC researchers expected. One important finding was that alcohol involvement was a factor across all populations and age groups. It highlights the need for all suicide prevention programs and all mental health centers to address substance abuse problems as a major part of treatment. Unfortunately this is not usually done to to funding issues and historical precedent. I am very happy that I work at a facility that takes both mental health problems and substance abuse problems as truly co occurring.

Thought for the day

We cannot address mental health problems without addressing the substance abuse problems that are highly prevalent and co occurring.

Michael Jackson Opioids Addiction

2009-06-29T12:30:00.004-07:00

Like most people I was sad to hear of Michael Jackson's untimely death. I really did not care much for his music and didn't listen to it but he did have remarkable talent and charisma.

What is especially saddening to me is to learn that he was addicted to opioids. As I have discussed before in this blog oral opioids (pain pills) are the biggest drugs of abuse now with the exception of alcohol and tobacco and are increasingly being used now even by young adolescents. I haven't heard anything about the toxicology reports on Michael Jackson but I will not be surprised if it is determined that opioids were somehow implicated in his death.

Whether or not opioids were a cause or factor it is also sad to me that he didn't receive treatment. Either he stayed in denial or was enabled by those around him to continue his addiction. It does show again that addictions know no bounds and transcend all socioenomic demographics.

Thought for the day,

May God bless all those family members whose lives have been torn apart by addictions.

Serotonin Transporter Gene Depression

2009-06-26T02:08:00.004-07:00

The Daily Musings of an Addiction Psychiatrist is back after a short hiatus. For some reason I have not been sleeping well so instead of getting up early which I enjoy and writing I have been dragging myself to work at the last possible minute. Maybe it is a guilty conscience as they say but I don't feel anxiuous at night - just awake.

A recent study has once again caused dissapointment in those of us who are continuing to hope that we will learn more about the genetic links that predispose us to depression. It had recently been thought that mutations in the gene coding for the serotonin transporter protein might be one of those factors. This seemed to make sense as we have known that the neurotrasmitter serotonin is associated with depression and that many of our antidepressant medications have an effect on serotonin. A large scale study though has shown that this gene is not a factor. Instead what is more associated with depression are the number of stressful life events.

This once again show that enviromental factors strongly influence the occurence of depression but leaves us wondering what the genetic differences are that would make one person respond to life stressful events with depression and another doesn't. What are the genetic differences that either protect us from or make us more vulnerable to depreesion? We still don't know.

Thought for the day

"In all things give thanks".

St. Paul

Attention Deficit Hyperactivity Disorder Update

2009-06-19T06:20:00.004-07:00

I recently completed a series on Attention Deficit Hyperactivity Disorder (ADHD) where I mentioned the possibility of increased risk of sudden cardiac death in those children taking Ritalin or other stimulant medication. This was based on anecdotal reports. A study just published in the American Journal of Psychiatry demonstrates fairly conclusively that there is some small risk. This has been difficult to study as sudden death in children is a very rare event. Because of this and the methodological limitations of the study the FDA has urged caution in interpreting the results.

The FDA released a statement that says "Given the limitation of this study's methodology, the FDA is unable to conclude that these data affect the overall risk and benefit profile of stimulant medication used to treat ADHD in children. FDA believes that this study should not serve as a basis for parents to stop a child's stimulant medication".

It does serve as a reminder though that all medical treatments carry some risk. It also confirms my idea that the American Heart Association is correct by recommending routine electrocardiogram screening in addition to taking a careful history prior to stating someone on stimulant medication for ADHD. The American Academy of Pediatrics has disagreed with this recommendation but perhaps may change their viewpoint in light of this study.

Thought for the day

All medical treatments carry some risk.

Health Care Reform, American Medical Association, Public Health Insurance Option

2009-06-12T08:51:00.005-07:00

I read an article in the New York Times the other day that indicated the American Medical Association submitted comments to Congress in opposition to a public run insurance option for those who are non disabled and under 65 years of age. The public run insurance option is being strongly pushed by the Obama administration. I have previously discussed this option in my series on health care reform. This plan is essentially Medicare for everyone. While clearly needing reform, the public health insurance option has the potential of completely destroying the health care system we have now including the many parts of the system that do work. For this reason it is opposed by the American Medical Association which comments to the Senate Finance Committee.

Why is a public health insurance option a bad idea? It sounds at first look like a pretty good idea. After all, Medicare seems to work fairly well. The problem is though that Medicare works only because 70 % of patient care is provided under private insurance programs. Medicare payments are not enough to keep hospitals in business nor some medical practices, particularly psychiatric practices. While the Obama administration says it wants a publicly funded plan to keep private insurers fair and honest there are many other ways of doing this. Issues of preexisting conditions and excessive rates do need to be dealt with. A publicly funded plan will do more than keep private insurers honest and fair though. It will drive them out of business.

Another problem with this plan is the question of where the public funding will come from. Medicare is facing a financial crisis. To open up a similar plan to all Americans would come at an exorbitant cost, transferring many of the health care costs from private insurers to taxpayers. In regard to health care reform ideas the American Medical Association is right in my opinion to oppose any plan that includes an expansion of a public health insurance option.

Thought for the day

"All good gifts come from above"

St. James

Attention Deficit Hyperactivity Disorder part 7

2009-06-09T07:27:00.006-07:00

This is a last in a series on Attention Deficit Hyperactivity Disorder (ADHD). I would like to talk a bit on psychosocial treatments which are very effective when combined with medication use. The focus is on various aspects of behavior modification which includes behavioral treatment, parent education and training, school interventions, and home interventions. Various other "talk therapies" have been tried but behavioral modification is the only treatment that has shown effectiveness with this disorder.

What is behavioral modification? It is a treatment where parents, teachers, and children learn specific techniques and skills which are used consistently in daily interactions. Behavioral modification focuses on identifying things that set off troublesome behavior, the behaviors themselves, and the consequences of the behavior such as how parents and teachers act in response to the behavior. The idea is to teach everyone skills in how to react differently and make the child's environment and experiences better when the good behavior that is desired is engaged in by the child. The only problem I have seen with behavioral interventions is that some people make them too complex. They must be simple and easy to implement and easily sustained over long periods of time. Many of them seem to be common sense approaches but parents and teachers must be encouraged to use the interventions as many of the behaviors with ADHD are very trying and tend to bring about negative reactions from parents and teachers.

Some behavioral interventions include ignoring mild inappropriate behaviors (choose your battles) use many more praises than negative comments, use clear short and specific instructions, reprimands should be brief, clear, neutral in tone, and as immediate as possible, placing the student's desk near the teacher, computer assisted instruction, simple behavior charts with points or tokens that can later be exchanged for rewards and many others. Again a lot of common sense approaches. I think one of the most difficult things is keeping reprimands brief and neutral in tone. We tend to speak angrily and give too many long explanations for why we are criticizing the behavior.

For more information on ADHD and behavioral strategies you can go to http://www.help4adhd.org/.

Thought for the day

Everyone deserves respect.

Narcissists & Their Relationships by Rokelle Lerner

2009-06-03T13:04:00.016-07:00

In 1958, Bill Wilson in the newsletter The Grapevine said, "the first job in recovery is sobriety, the second is emotional recovery." We all know that sobriety is quite different than recovery. Recovery means finding a way of living that works; physically, emotionally and spiritually. Sadly, many can get sober, but are still left with behaviors that don't disappear with treatment or sobriety. In fact, sometimes the qualities of entitlement and contempt are worse after treatment than before. It's for this reason I wrote a book on narcissism and how it relates to addiction recovery.

We are all aware of the term "King Baby." Although the image conjured up by this phrase is someone who's arrogant, snobbish, demanding, and aloof, the truth is that these are the very men who feel painfully inferior inside. In fact, the more a person displays this "kingly" behavior, the more second-rate he feels. These addicts/alcoholics are hiding tremendous shame with their pride. Feelings of entitlement, grandiosity, and contempt are a part of the disease of addiction. For someone living with a narcissistic addict or alcoholic, the devastation caused by addiction coupled with narcissistic traits feels insurmountable.

An addict has difficulty coping with the normal frustrations of life. The "king," however, because of his feeling of omnipotence and impatience, is constantly creating unnecessary roadblocks by storming ahead despite the cost. The narcissistic alcoholic shouldn't have to be bothered with recovery and may see the fellowship as trivial and boring; that is, unless he's in charge. He has little staying power for sobriety and expects quick results. Since recovery is one day at a time, and the surrender to the notion of powerlessness is tantamount to recovery, the prognosis is questionable, but not hopeless. There's always the chance that he'll pick up a sponsor who has some good recovery from addiction as well as entitlement.

Bob Brissette in his lecture at Hazelden in 1971 gave the following description of "king baby."
"Like babies, alcoholics assume that the world is our little private oyster. We tyrannize our homes, our wives, and our children: we demand meals to be served before there has been an opportunity to prepare them. Then we throw tantrums if everything isn't done thoroughly. We demand that food be of our choice, not the family's choice. We demand that our TV program be tuned in, not the family's program. And we deserve this, we tell ourselves--didn't we work hard all day down at the office? What if we did have five coffee breaks, a three-martini lunch that lasted 'til 2:45, and a couple of long, warm counseling sessions with that pretty girl employee who told us how kind and understanding we were. He's adept at twisting knives, cutting people up and humiliating them and making them frightened and insecure about their jobs. And he does this because it makes him feel better; it makes him feel more powerful."

I would be remiss if I didn't point out that the king baby has a female counterpart called the "Queen." Although we rarely speak about this female counterpart, some women possess these characteristics in spades. We all know those females that sweep into the room a half-hour late and demand that everyone must drop what they're doing and notice her. Her great need is to be the constant center of attention wherever she is. Frequently she speaks and laughs in a loud voice and assumes that what she has to say is absolutely fascinating--but it isn't. If the queen feels like granting you a sexual favor, you are expected to be grateful to her to your death for having had the privilege of romancing her. She demands absolute respect from her family and children. She whines and whimpers when all of her demands are not met promptly. (And whining, by the way, is anger coming through a tiny opening.) She feels entitled to proper gratitude for your having the privilege of serving her.

The queen is in deadly competition with her daughters. When they get to be teenagers and mom is starting to sag a little, an ugly, hateful battle develops between the queen and her children. Like the king, she sees other people as things, not as human beings or equals. To her, people are objects to be terrorized, bullied, and manipulated into loving, serving, and being loyal to her.

If you're reading this and diagnosing yourself or your loved ones as narcissists, please stop! Everyone is a bit narcissistic and only a caring, empathic therapist can make this diagnosis. Also, we need to have compassion for those that have this disorder. For the most part, narcissism is developed from an upbringing of trauma and neglect. However, since entitlement is such a part of the disease of addiction, emotional recovery means that we must do a fearless inventory on how our behavior affects others. Only then do our relationships begin to thrive.

Rokelle Lerner is one of the most sought after speakers and trainers on relationships, women's issues and addicted family systems. She has inspired audiences throughout the world with her ability to address difficulties with insight, humor, and astounding clarity.

She has received numerous awards for her work with children and families including Esquire Magazine's "Top 100 Women in the U.S. Who Are Changing the Nation." Rokelle has been an advisor and consultant with foreign governments, US agencies, corporations, schools and hundreds of individuals on relationships, boundary issues and addiction. She is also co-founder and consultant to Children Are People, Inc., a program used in thousands of schools throughout the country. Rokelle has appeared as a guest consultant on numerous television shows such as Oprah, Good Morning America, CBS Morning News and 20/20. Her articles and interviews have been featured in the Washington Post, New York Times, Newsweek, Time, People Magazine and Parents Magazine.

Rokelle has published the best selling books, Living in the Comfort Zone: The Gift of Boundaries in Relationships, Affirmations for Adult Children of Alcoholics and Affirmations for the Inner Child. Her latest book is The Object of My Affection is in My Reflection: Narcissists and Their Relationships. Ms. Lerner also facilitates the InnerPath Retreats for Cottonwood de Tucson in Arizona.

Attention Deficit Disorder part 6

2009-06-03T07:01:00.002-07:00

This is the second to the last in a series on Attention Deficit Hyperactivity Disorder (ADHD). Today I would like to talk about the unique medication atomoxatine or Strattera. Next we will review some behavioral and psychosocial treatments.

Strattera is the only non stimulant medication that is FDA approved for the treatment of ADHD. It is a selective norepinephrine reuptake inhibitor that works by making available more of the neurotransmitter norepinephrine which is responsible for alertness and attention focusing. It is very similar to some antidepressant medications and unlike stimulants has no abuse potential. This makes it an ideal medication to use in those patients who have substance abuse problems as well as ADHD.

Unlike the stimulants Strattera does not carry a "black box warning" about abuse potential. Instead, like antidepressants it carries a black box warning of increased risk of suicidal ideation in children or adolescents which is the same for all
antidepressants. The black box indicates though that no suicides have been reported and recommends close monitoring. Like all medication it carries some risks and I will discuss these below.

Like the stimulants two of the major risks are cardiovascular and psychiatric. Strattera does increase the blood pressure to a small degree and should be used with caution in those who have hypertension, cerebral vasular disease or underlying cardiac disease. There have been reports of sudden death in those taking Strattera who have underlying cardiac disease and like the stimulants I strongly recommend a baseline electrocardiogram as well as a careful medical history. Unlike the stimulants it has no net effect on growth taken long term. The psychiatric risks of Strattera are the same as for the stimulants and include emergence of new manic or psychotic symptoms as well as increase in aggression or hostility. So the main difference between Strattera and the stimulants is the lack of abuse potential.

After reading of the possible risks of both the stimulants and Strattera you may be wondering why anyone would even take these medications? There are three factors to take into consideration. The first is that these risks are relatively small. The second is to realize that all medications of any type carry some possible serious risks. The third is that ADHD is very often severely disabling and affects psychological development, school and occupational functioning, and impairs interpersonal relationships to a great extent. I am bringing the problems with these medications to attention to emphasize that the use of ADHD medications should not be taken lightly, involve a thorough assessment and require close monitoring which is not the normal standard practice among many pediatricians, primary care physicians,and psychiatrists at this time. This leads to charges of overuse and inappropriate use which threaten the availability of these medications for those who very much need them.

Again I welcome any comments or questions.

Thought for the day

The same as yesterday. All medical treatments involve possible risks as well as benefits.

Attention Deficit Hyperactivity Disorder part 5

2009-06-02T10:25:00.004-07:00

Yesterday I discussed the medications that are used to treat Attention Deficit Hyperactivity Disorder (ADHD). Today I want to talk a bit about the potential side effects and risks of the medications. I will take the stimulants first as the possible problems are basically the same for all of them and secondly to review Strattera.

Adderall and the other stimulants all carry a "black box warning". This refers to the FDA instruction to manufacturers requiring them to outline a particular drug risk, put in in a box with the warning highlighted as the first piece of prescribing information that any clinician will review. The stimulants all carry the warning of the possibility of misuse and drug dependence as well as the risk for serious cardiovascular complications if misused. Although it appears that almost any medication can occasionally cause almost any side effects the main risks are the cardiovascular events, psychiatric events, drug dependency, and growth retardation.

Stimulants can increase the heart rate, blood pressure, put more demands upon the heart, and in people with underlying structural cardiac defects or other serious heart problems there have been reports of sudden death. For this reason the American Heart Association has recommended that all patients being placed on stimulants be prescreened with a baseline electrocardiogram or EKG. Because this raises the cost of providing treatment this stance is somewhat controversial as the history, family history, and physical exam are likely to pick up any heart problems.The American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry have not yet adopted this position but it is one that I very much agree with and I will not start a patient on stimulant medication without having a baseline EKG.

The second group of potential complications are psychiatric problems. Although these medications are used to treat a psychiatric disorder they can occasionally cause exacerbation of symptoms of patients with an underlying psychotic disorder, induce mania in patients with bipolar disorder, cause treatment emergent new onset of manic or psychotic symptoms, and aggressive behavior or hostility.

Careful followup studies have shown that persistent use of the medications seven days per week can result in growth suppression between the ages 5 to 10 or 13 of an average of 2 centimeters of height and 2.7 kilograms of weight with no growth rebound after cessation of the medication. Two centimeters average in itself is not a huge issue but this average means that some children have significantly more growth retardation therefore growth rates need to be monitored.

The issue of drug dependency is a difficult one. Most patients on stimulants for ADHD do not develop a drug dependency, need for higher and higher doses of the medication or misuse the medication but the possibility exists. The complicated thing however is that substance abuse is a risk of untreated AHDH so many with this disorder have co occurring substance abuse problems. In many cases the problems can be avoided by treating ADHD with Strattera instead of stimulants but what about the many patients who do benefit from or cannot tolerate Strattera? The decision of whether or not to use stimulants in patients with any kind of substance abuse disorder needs to be individualized but I will not use these medications in anyone with a history of stimulant, cocaine, or methamphetamine abuse. For others risk can be decreased by using one of the stimulant formulations that are slow release and compounded in a way unlikely to give the high that people are seeking. These are methylphenidate in the form of Concerta and amphetamine in the form of Vyvanse but both are expensive medications with no generic substitutions available.

I will talk about the problems of Strattera tomorrow. I welcome any questions or comments.

Thought for the day

All medical treatments involve both potential benefits as well as risks.

Attention Deficit Hyperactivity Disorder part 4

2009-06-01T07:49:00.007-07:00

I want to talk a little bit about medication treatment for Attention Deficit Hyperactivity Disorder (ADHD). First of all, medications are effective at improving not only symptoms of the disorder but also can increase the level of functioning and complications of the associated features such as poor academic performance, decreased self esteem and demoralization, anger outbursts and mood problems as well as decreasing the likelihood of development of Oppositional Defiant Disorder and Conduct Disorder. Secondly as I mentioned before the psychosocial and behavioral interventions for this disorder are generally not very effective in the absence of medication treatment. Thirdly, any medication is not without it's hazards and difficulty and the medications used to treat ADHD are no different.

A number of medications have been tried and used for ADHD including antidepressants, anti hypertensives, and stimulants but there are two groups of medications that have current FDA approval for the treatment of this disorder. The first are the stimulants. These are amphetamines or amphetamine like drugs. Some commonly known ones are methlyphenidate (Ritalin), and the amphetamines Adderall and Dexedrine. Methlyphenidate now comes in various extended release forms for ease of use which include Concerta, Focalin, and the transdermal patch Daytrana. In addition to the amphetamines Dexedrine and Adderall there is a relatively new medication, Vyvanse, which when first metabolized becomes dextroamphetamine. All of these medications work by increasing the availability of the neurotransmitter dopamine. The second type of medication FDA approved for the treatment of ADHD has only one drug, atomoxatine (Strattera) which works by increasing the availability of the neurotransmitter norepinephrine. Both dopamine and norepinephrine are neurotransmitters that are necessary for many brain functions and include the functioning of the prefrontal cortex which is responsible for planning and foresight, monitoring and error correction, delayed gratification, impulse inhibition ,decision making, abstract thinking, attention shifting, information manipulation and social functioning all of which are impaired in ADHD.

Like all medications the use of the stimulants and atomoxatine carry some risks as well as benefits and these must be carefully weighed in each individual situation. I will outline some of these tomorrow.

Thought for the day

" Sometimes and ending can be the beginning of something wonderful".

Winnie Haller

Attention Deficit Hyperactivity Disorder part 3

2009-05-29T07:34:00.004-07:00

Before I talk about treatments for ADHD I want to talk a little bit about the causes of this disorder. Basically we do not know a lot. We do know that ADHD has a heritable component, that it does run in families. We know that those infants with low birth weight (which is a nonspecific marker for problems in fetal development) have a higher incidence of ADHD. However most children with low birth weights do not develop ADHD and most children with ADHD did not have low birth rates. One environmental cause is the use of alcohol in pregnancy. There may be but I do not know whether or not there is any association with use of tobacco. But overall we do not know enough about the causes of this disorder.

Well how about treatment? This is an area where there is controversy. There is no controversy within the medical field about the benefits of ADHD medications. Evidence demonstrates their effectiveness. But there is some controversy in our society as a whole about the whole idea of using medications that affect the brain in children and adolescents. One thing I think people need to keep in mind is that the brain is an organ of the human body. In fact it is our most complicated organ. We know that disease states can affect every other organ. It only stands to reason that there can be problems with the brain itself. Yet very few people would take the position that we should not treat other organs but for some reason people put the brain in a separate category as if there can be no disorder in this particular part of our body. There is no question that children with this disorder suffer greatly and that their families suffer as well. I think it is extremely arrogant for those who oppose medication treatment for ADHD to want to make these medications unavailable.

What about psychosocial interventions? Wouldn't there be effectiveness in this approach? It only makes sense that there would be behavioral interventions that make a difference. However numerous studies have shown the same thing. Behavioral and psychosocial interventions are very effective, but only in those who are on medication treatment. Psychosocial and behavioral interventions in the absence of medication treatment are no more effective than no intervention at all. This only make sense when one considers that ADHD is a brain disorder. This is no different than in other areas of medicine and in disorders of other body organs. Exercise and proper diet as well as the cessation of smoking are very helpful in the treatment of coronary artery disease but the vessels must be clear by medical interventions before these behavioral approaches will work. Behavioral interventions and lifestyle changes are very useful in treatment of diabetes but the blood glucose levels must be brought down to normal to have these interventions make a significant difference. So disorders of the brain like ADHD are no different in this respect from other body organ problems.

In my next post I will discuss specific treatments and we will review not only medications but also effective psychosocial and behavioral treatments.

Thought for the day

We need to be empathetic and not critical and judgmental with parents whose children have emotional or behavioral problems.

Attention Deficit Hyperactivity Disorder part 2

2009-05-27T07:59:00.006-07:00

This is the second in a series on Attention Deficit Hyperactivity Disorder (ADHD). I said yesterday that I would describe the disorder and it's associated features. ADHD affects about
3% of the school age population. Some studies put the number at 6-7% but I believe that those figures include over diagnosis as the rates of the disorder before there were medications and while still called minimal brain dysfunction were about 3%. Males are affected at higher rates than females. ADHD symptoms change with maturation but the disorder does persist into adulthood. It is a very common co-occurring problem we see here at Cottonwood as one of the problems with ADHD is a much higher rate of substance abuse problems.

Attention Deficit Hyperactivity disorder begins in childhood. It represents a neurodevelopmental problem from birth and truly is a brain disorder. It cannot be diagnosed before age 5 as the symptoms overlap with normal childhood development. But in order to diagnose ADHD there must be symptoms present before age 7. ADHD is often not diagnosed until much later but the disorder begins early. Attentional and behavioral problems with onset after seven are very likely due to other causes. Two additional factors must be present for the diagnosis. The symptoms must occur in two or more settings such as home and school or at home and at work. There also must be significant social, academic, or occupational impairment as to adversely affect the ability to function as needed.

Attention Deficit Hyperactivity disorder is characterized by inattentive symptoms, hyperactivity and impulsivity or both as well as a number of associated features that are not part of the diagnostic criteria. The associated features are often the more disabling aspects of this illness. It can be diagnosed as ADHD - inattentive type or ADHD hyperactive type, or more commonly ADHD - combined type.

The symptoms of inattentiveness include failing to give close attention to details or making careless mistakes in schoolwork work or other activities, difficulty sustaining attention in tasks or play, difficulty listening when directly spoken to, inability to follow through on instructions and failure to finish tasks, difficulty organizing work or play activities, avoidance of tasks that require sustained mental effort, tendency to lose things, be easily distracted by extraneous stimuli, and forgetful in daily activities.

The symptoms of hyperactivity and impulsivity include tendency to fidget or be restless, leaving seat or situation in which it is expected to stay, runs about or climbs excessively or in adults easy restlessness or boredom, difficulty with engaging in leisure activities, tendency to be often on the go or act as if driven by a motor, talking excessively, blurting out things, difficulty waiting or taking turns and a tendency to interrupt.

The associated features include low frustration tolerance, temper outbursts, bossiness, excessive expectation and insistence that needs be met, mood swings, depression, demoralization, peer rejection, poor self esteem, academic impairment and development of oppositional and defiant behavior. In addition there is an increased risk of developing a substance abuse problem.

So we can see that this disorder is all pervasive, is not restricted to attention alone, and clearly is not made up by the pharmaceutical companies. I will talk some about treatment tomorrow.

Thought for the day

" Those who don't follow the movements of their own soul will be unhappy".

Marcus Aurelius

Attention Deficit Hyperactivity Disorder

2009-05-26T07:24:00.006-07:00

First of all I would like to thank those who have kindly inquired about my health following the bike accident. It was not my accident but unfortunatley happened to one of my colleauges here. It sounds like a harrowing experience and I am glad there were no serious injuries.

I have been asked by a reader to do another didactic series so I decided I would wade into the often controversial subject of Attention Deficit Hyperactivity Disorder (ADHD). It is controversial because it involves different ideas about the causes of behavioral problems as well as the use of psychotropic medication in children. This is further complicated by the reality that pharmaceutical companies make a lot of money from ADHD medications. I will say that I think this debate like many others is too polarized and often doesn't take into account that reality is often more complicated than our dogmatic assertions. In my opinion ADHD exists, and there is both under and overdiagnosis of the condition as well as both underutilization and over utilization of pyschotropic medication in children.

As I have discussed before most psychiatric diagnoses are phenomenologically based. That is they are based upon signs and symptoms. There are as yet no laboratory tests to confirm a diagnosis. This leads to the charge by some that psychiatric diagnoses are too subjective. However phenomenologic diagnoses have been helpful in the history of medicine and remain useful in some other conditions such as migraine and epilepsy. With this type of diagnosis the more severe the symptoms present the more likelihood that we are dealing with a common entity and the more mild the symptoms the more likely we are dealing with a behavior spectrum that ranges from moderate to normal behavior. This is further complicated in children in that the younger the child the more limited the repitiore of behavioral expression. An infant crying can mean many things and a six or seven year old child's behavioral problems can result from many causes all of which look very similar in this age grouop. As we grow to maturity we develop a wider range of ways in which to express internal distress. So in ADHD greater the severity of symptoms results in a greater likelihood that we are dealing with an actual entity and the milder the symptoms results in greater likelihood that we are seeing is behavior on a spectrum of problematic to normal varience.

Tomorrow I will define and describe Attention Deficit Hyperactivity Disorder. One thing is clear. This disorder is not one made up by the pharmaceutical companies. There are classic descriptions of this disorder dating back to the 19th century and early twentieth century long before there were any medication treatments available.

Thought for the day

"It is possible not only not to be angry with the insensitive and ungrateful but even to care for them".

Marcus Aurelius

Pfizer Assistance Program

2009-05-20T09:48:00.004-07:00

I read the other day that the pharmaceutical company Pfizer has announced that it will provide continuation of medication for those on their drugs free of charge for one year to everyone who has lost their job due to the recession. Pfizer is the maker of the popular and big selling medications such as Lipitor, Viagra, Chantix, Geodon, and Lyrica. Although ultimately this is a self serving action it will provide genuine help for millions of people who otherwise could not afford to continue to take their medications and is another example of a win - win situation where both self serving interests and the public interests coincide..

The reason that this action is self serving is that Pfizer wants to maintain brand loyalty. People tend to stick with the medication that works for them and lack of access to the medications for a year would result in a number of people who would not restart their medication but either use cheaper generics or possibly obtain prescriptions for medications from a pharmaceutical rivalry. Lipitor will go generic very soon and there are alternatives to Geodon, Viagra, and Lyrica. It is an expensive but still very good idea for Pfizer and one in which other pharmaceutical companies may follow suit. I hope so as many people would not otherwise have access to continue their medications and if that is also good for the company that is OK by me.

Thought for the day

Make a difference one life at a time.

Technical Difficulties

2009-05-19T14:45:00.001-07:00

I have a great staff member to introduce you to but I am having technical difficulties and can't get her picture up. Hopefully this is cleared up by tomorrow.

Health Care Reform House Version

2009-05-15T09:23:00.003-07:00

This will be my last in a series of discussion of health care reform for now. I will probably come back to this subject as the House and Senate pass their own versions of reform.

I am glad that many on the House Energy and Commerce Committee are considering some public-private joint ventures that would not dismantle those aspects of the health care system that do work. The House plan proposes that all Americans be required to carry health care insurance with government subsidies to help families making less than $88,000/year pay for the costs. The requirements would make employers, individuals, and the government all have responsibilities. The proposal would include greater consumer protections so that there will not be denials based upon pre existing conditions nor could insurers charge extraordinary rates. The House proposals are designed to minimize disruption by allowing people to keep their own existing health plans. The government would also create purchasing pools called "exchanges" to make private insurance coverage more affordable for individuals and small businesses.

One problem with the House proposals so far is the inclusion of a government plan that would compete with the private insurers. Like Senator Schumer's proposal this plan would have to be paid for by premiums rather than tax dollars. Reimbursement rates however could be low enough to drive the private insurers out of business and establish a government monopoly. As I indicated before a psychiatrist in private practice cannot maintain a business with current government rates through either the Medicare or Medicaid programs.

I appreciate any further comments on the various health care reform proposals.

Thought for the day

"Encourage the fainthearted, help the weak, be patient with everyone".

St. Paul

Health Care Reform

2009-05-14T05:45:00.003-07:00

I want to continue talking about health care reform proposals. I again want to emphasize that the views expressed here are my own and not those of Cottonwood.

I am disappointed that the Obama administration is rushing health care reform without adequate input from doctors, hospitals, private insurers, and consumer groups. The plan is to get legislation signed by mid summer and I think this is way too fast. The Senate Finance Committee is meeting behind closed doors to consider four different plans none of which includes any possibility of public-private ventures. All the plans are a one size fits all which I think is unwise and may threaten those aspects of our current health care system that do work.

One proposal is the Medicare like plan that I previously talked about in which the government directly competes with private insurers which will after a time drive the private insurers out of business and leave us with a single payer system. Another proposal being considered is no public plan at all which I don't think is being seriously considered by anyone. Another plan would be to allow states to set up their own public plans. This at least gives some flexibility to allow changes and course corrections if things don't work well. The Arizona Medicaid AHCCCS program partially works, though doctors and hospitals can't survive if that is the only plan available. The Tennessee TennCare plan turned out to be a disaster and had to be drastically altered to keep the state from going bankrupt. But at least there was the opportunity for more local self correction.

The fourth plan being considered is a proposal by Senator Charles Schumer of New York. His idea is a Medicare like plan that would have to be paid for by premiums, not tax dollars. The public plan would have to follow the same rules as private insurers, maintaining a reserve fund to cover liabilities as well as having the same consumer protection rules with doctors and hospitals free to participate or not. This is as close to a private-public plan that is being considered and has some merit although it is very unlikely that in practice doctors or hospitals really would be able to not participate.

Overall I am disappointed that these are the only ideas being considered and do not think it is wise to rush to a decision with no real outside input.

Thought for the day

" If anything matters then everything matters".

W.M. Paul Young

Falling off my bike at age fifty-seven

2009-05-13T07:45:00.003-07:00

Falling Off My Bike at Age Fifty-Seven

It was a great idea. I had a meeting at 7:15 am and it was only three miles each way. I was going to get in a meeting and my exercise in one fell swoop. At the meeting everyone was adequately impressed with my aging attempt at cardio exercise even though I never broke a sweat. The meeting was over in an hour and I was feeling good, so I decided(in my perfectionism)that three miles back home was way too easy. I would make a detour to Alvernon and put in another two miles. Yeah, I was doing it all right; after all...what could go wrong?

Alvernon is a wide, steady moving example of inter-city congestion. I knew it had a bike lane and felt like it was a safe road to travel. I biked from Country Club to Alvernon with no mishaps. It was great. As I started riding on Alvernon, I noticed that that the road had gaps of about three inches wide every so often. I never noticed that before and preferred to have a smoother ride if possible. So I decide to move onto the sidewalk; less bumpy and I've always felt that it is a safer place to ride. As I made my move, I saw the lip of concrete that separates the street from the driveway entrance. Did you know that a one-inch high piece of concrete could literally mangle you? As I expertly (NOT!) guide my bike onto the driveway towards the sidewalk...BAM! I didn't have time to react or scream. My transportation once my friend had suddenly turned on me or should I say slipped on me. One second I was happily riding along, the next second I was on the ground. The bike slid out from under me as easy as butter melting in a hot pan.

I lay there, my 57-year-old overweight form lying halfway in the bike lane and halfway in the driveway, my bike resting partially on my body. All I could do was be still. Okay I tell myself, don't panic, take nice deep breathes. Breathe, breathe. I breathe and I pray. Three minutes seems like eternity when concrete and flesh meet. The morning rush hour traffic is moving by my horizontal body at a predictable speed. One woman bless her soul, shouts out her car window, asking if I want her to call 911. She is halfway down the block before I could stoically say no don't bother. I lie there looking at the sky wondering what all these people must be thinking of me. Do they think I'm dead? Do they think I am drunk? On the other hand, do they just think I'm stupid? They are probably not thinking of me at all.

I take stock of my situation. Nothing seems to be broken, although my ego is bruised. I sit up slowly, unable to make any sudden moves. I start taking inventory of my body...ams, legs, hips, shoulders, everything seems to be in order. Could it be I fell and didn't hurt myself? A few bruises and scrapes but that was all. A woman walks over and asks me if she could call someone for me. That was nice. I told her I was all right and that I have a phone. Whom would I call? Why would I call? I'm not hurt, my bike seems okay. I get back on my bike and finish the ride. I finally arrive home to safety. I am afraid of how this fall will affect me later.

All of a sudden I realize how frail and vulnerable I feel. Of course, I do all the right stuff; ice, ibuprofen, relax, breathe, pray, call work. I could have done without this one adventure. As I lay on the couch nursing my wounds, I wonder if I should give up bike riding. Am I too old? Should they have remedial classes for bike riding specifically for the age-challenged? This accident makes me feel old. I have never felt old before. This is not a good feeling. Thank God feelings are not facts. Well, I have felt worse things, like cement forcefully interacting with my body. I think I am taking myself too seriously. However, I do know this, I will get back on that bike. I will get back on that freaking bike if it kills me! What is the definition of insanity...doing the same thing over and over again expecting different results? That's me.

Fifty-seven and holding

Health Care Reform Proposals

2009-05-13T07:41:00.005-07:00

As I indicated before I will spend some time over the next few days to review some of the proposals for health care reform that are being considered by the US Senate and the Obama administration. Again the opinions expressed here are my own and do not represent the opinions of Cottonwood.

One proposal being considered is that of eliminating the tax exempt status of health care benefits and discontinuing flexible spending accounts. Currently this tax exempt status is a tax break available only to those that have health insurance through employers and unavailable to those without health insurance. There is an anticipated savings of over 200 billion dollars per year on what essentially is a tax hike. But it also is essentially a "salary reduction" on those who have employer sponsored health insurance. These salary reductions do not affect the employers' bottom line as the changes really directly affect the worker. I don't really know what to make of this proposal. On the one hand the "haves" get more through health insurance tax breaks but this is also true for the tax break on home owner's interest payments and I don't think anyone would seriously considering eliminating that.

I am just not sure that a tax increase and effective salary reduction is a good idea in a time of recession. I would love to hear what other people think on this issue and really would like comments. Thanks.

Thought for the day

There are no easy answers.

Health Care Reform

2009-05-12T11:14:00.006-07:00

I am back after having been gone to Dekalb, Illinois to see my oldest daughter graduate with her Master's degree in philosophy. It was a very fun trip and I enjoy spending time with her.

I want to talk a little bit about health care reform as that is currently being considered by the US Senate and the Obama administration. I will outline the various options that are being considered but today I just want to look at one of them, the idea of making a Medicare like program to all Americans. My views are my own and do not reflect the views of Cottonwood. This is my personal opinion.

Medicare has been a program that provides insurance coverage by the Federal government for all adults 65 or older. In many ways it as been a successful program but it is in financial difficulty now and there are proposed payment rate reductions to both health care providers and hospitals.

One problem I have had with the program all along is the lack of choice available to seniors. A person age 65 or older does not have to use Medicare. However if a patient wishes to go to a physician and pay out of pocket he or she is prevented from doing so as the doctor is not permitted to charge the patient outside the Medicare program if he or she sees any Medicare patients at all. So while I had my office practice no patient for confidentiality purposes could pay out of pocket or I would have run afoul of federal regulations with severe penalties. I had to bill Medicare. That is just not right. For psychiatric patients the reimbursement was only 50 % of the Medicare charge. I did see a number of geriatric patients but each one was a financial loss. If a Medicare like program was available to all Americans I do not see how a psychiatrist could maintain a private practice. Hospitals cannot survive on Medicare payments as well.

Another problem with this approach to health care reform is that because of lower government set rates the private insurers will be gradually driven out of business and the Medicare like program would then be the only insurer, restricting both patient choice and and resulting in restriction of services.

I hope that this approach to health care reform is not adopted.

Thought for the day

One size does not fit all.

Graduation

2009-05-06T10:25:00.004-07:00

Friday is an exciting day for me! My oldest daughter is graduating from her Master's degree program at Northern Illinois University. She will be entering a doctoral program in philosophy at Notre Dame this fall which she has been working toward a long time. I am very proud of her and it will be nice to see her again. Our younger daughter is going with us. She and her sister are very close. My guess is that they will want to catch the first midnight showing of the new Star Trek movie when it is released this weekend.

It will be a short trip for me. I will be off blog for several days but will be back on Monday. Until then,

Thought for the day

It is a blessing to be a father.

NIDA Alcohol Smoking and Substance Involvement Screening NIDAMED

2009-05-05T09:05:00.005-07:00

The National Institute on Drug Abuse (NIDA) has released a new program designed to help physicians be more proactive and more proficient at asking patients about and screening for alcohol and other substance abuse problems. Overall, we as physicians have not been very good about screening for these disorders despite taking care of the many medical and surgical/trauma complications from substance abuse that we see everyday. It has never really been clear to me why this is the case as we know that those with substance abuse use an inordinate share of medical resources. It has been somewhat of a mystery to me why we have been so poor at this. There are signs of changes. For instance the American College of Obstetrics and Gynecology has recommended substance abuse screening for all patients. Trauma centers must screen for substance abuse in order to maintain accreditation.

One problem maybe is that physicians as a group don't really know how to ask about alcohol and drug abuse problems. The National Institute on Drug Abuse has now provided a way to make that task easier. Through their NIDAMED resource center there is now an interactive web based program, the NIDA Alcohol Smoking and Substance Involvement Screening (NIDA-Modified ASSIST) which guides the physician through initial screening questions and then with follow-up questions. If the initial screening questions are negative the program ends but if there is an initial yes answer the program moves forward. Not only are the follow-up questions computer program driven but it also provides recommendations for what interventions may be appropriate. The questions and recommendations also can be used in a printed form. I have looked at these and they look pretty good. Another feature is that this program can be integrated into the electronic medical record (EMR) which is becoming increasingly necessary today.

So I recommend that physicians take a look at the NIDA Alcohol Smoking and Substance Involvement Screening which can be found through NIDAMED at www.drugabuse.gov

Thought for the day

The web is amazing.

Telaprevir Chronic Hepatitis C Infection

2009-05-04T08:26:00.007-07:00

I read a news report the other day about a potential advance in the treatment of hepatitis C. Telaprevir is a new experimental drug that may decrease the number of people who develop severe complications from chronic hepatitis C infection.

Hepatitis C (HCV) is a viral induced liver disease that affects approximately 3 million Americans and over 170 million people worldwide. It is the most common blood borne infection in the United States. It is transmitted from person to person by contact with the infected individual's blood such as sharing dirty needles, blood transfusions before hepatitis C was recognized, needle sticks, and any blood to blod contact with sexual activity. It is a slowly developing disease and most people who have it do not know they are affected as it might be years before symptoms develop. It is a chronic infection in that the virus continues to live and cause liver damage. It is a potentially fatal disease as those with chronic hepatitic C infection are highly likely to develop liver cancer or liver scarring leading to cirrhosis. There is no vaccine for hepatitis C. The only treatment available has been peginteferon and ribavarin administered for 24 - 48 weeks. Peginteferon and ribivarin helps the immune system fight off the virus which in about half the cases leads to eradication of the virus as measured by loss of serum HCV virus RNA. But less than half of all patients respond and continued treatment in those in whom it is not eradicated initially does not affect the outcome. So better treatments are needed.

Vertex Pharmaceuticals is in process of testing the new drug telaprevir which is suppossed to directly attack the virus. Initial studies show that telaprevir is effective in about 65% of patients who take it along with standard treatment for one year. This is a considerable advance but like many treatments is associated with some significant side effects and many patients quit taking the drug primarily because of rashes and gastrointestinal complaints. So at least there is a new option for treatment, telaprivir, which may be available soon and help save the lives of a number of people with chronic hepatitis C infection who are not helped by current treatment but as in most areas of medicine more research and other possibilites are needed.

Thought for the day

"Which one of you by worrying can add even one hour to his life?"

Jesus of Nazareth