Mental Illness: What Are We Going To Do About It?

My family and I just got back from a trip to our nation's capital (read: I just dragged my three children through a three day, 25 mile hike that will forever be known as The Monument March).  I wanted them to see the White House, the Capitol, the Supreme Court... I wanted them to see our founding documents - The Declaration of Independence, the Constitution, the Bill of Rights... I wanted them to see my alma mater, Georgetown University, and the places I lived and worked during my years in DC.  And we did all of that and more in 95 degree heat with surprisingly few complaints.

There were some surprises on our trip, too, things we had not planned to see.  I happened upon Thomas Jefferson's personal library on display at the Library of Congress.  We encountered a free live jazz concert inside of the Smithsonian Museum of Art and I played checkers with my seven year old daughter while listening to great music and sitting amidst the original portraits of most of the founding fathers.  And at the Smithsonian National Air and Space Museum, we found a full sized Douglas A4 Skyhawk suspended from the ceiling, the plane my father-in-law flew in combat in Vietnam.

And my children encountered homelessness and mental illness for the first time.

Sitting on a bench in Union Station, a woman close by was engaged in a heated argument regarding Social Security, the banking system, and the wisdom of 30 year mortgages.  She was gesticulating wildly and was clearly talking to someone she believed was sitting next to her.  In this age of gadgetry, my kids initially assumed she was talking on a blue tooth head set.  But I knew better.  All of her belongings were in a shopping cart next to her and she clearly hadn't bathed in quite some time.  While we walked from Union Station to the Capitol building, I tried to explain to my kids what they had seen.  At twelve, ten, and seven years old, this was a new experience and they were having trouble processing it.  They began to notice that many of the benches on the US Capitol grounds were occupied by homeless people.  The following conversation with my ten year old ensued:

Will: "How do you become homeless?"
Me [thinking hard about how to explain this to a 10 year old]: "There are a lot of ways people end up homeless... but many people become homeless due to mental illness."
Will: "What's mental illness?"
Me [definitely not a clinician]: "The human brain is a really complex thing... and sometimes, it breaks... it doesn't work right... and the person suffering from mental illness loses touch with reality. They have a really hard time doing normal things like sleeping, working, and talking with others."
Will: "So they're sick?"
Me: "Yes."
Will [thinking this over and jumping right to the heart of the matter]: "What are we going to do about it?"

This incredibly insightful question was put to me by my ten year old in the literal shadow of the US Capitol building.  His timing couldn't have been better.  "A big part of the answer," I told him, "starts right here with the people who were elected to sit in this building."

I'll spare you the detailed policy proposal, but suffice it to say that homelessness and mental illness have become problems we deal with predominantly through the criminal justice system.  Therein, the patient must minister to himself, giving us little to no hope of long term recovery for the mentally ill, including (perhaps especially) those suffering from addiction disorders.  Instead, we need to treat mental illness through the healthcare system, including the appropriate funding (enter Congress) that will entail.

Mental health parity provisions in the Affordable Care Act are a start.  The Comprehensive Addiction Recovery Act is a start.  But to really answer my ten year old's question (what are we going to do about it?), we're going to need broad social, moral, and political commitment to helping those who cannot help themselves.

Michael
On Twitter @PRIUM1

Drug Abuse and the 2016 Presidential Election

In last week's State of the Union address, President Obama mentioned prescription drug abuse as an issue where he saw opportunity for bipartisan compromise.  Notably, he mentioned this in the first three minutes of the speech.  And not coincidentally, he mentioned it in the same breath as another, related issue that will be a necessary component of prescription drug abuse mitigation: criminal justice reform.

Governor Chris Christie has made prescription drug abuse a centerpiece of his stump speech.  He regularly shares a personal experience of losing a close friend from law school to an overdose.  Just last week, Christie made headlines by shutting down a New Jersey prison in order to convert it to a drug addiction treatment facility.  "The victims of addiction deserve treatment..." he said.

In last night's Democratic primary debate, Secretary Clinton and Senator Sanders both touched on the subject.  After noting that she hears of horrible stories wherever she goes on the campaign trail and after advocating for first responders to carry and be authorized to use Narcan, she closed her comments along the same lines as Governor Christie: "We have to move away from treating the use of drugs as a crime and instead, move it to where it belongs, as a health issue.  And we need to divert more people from the criminal justice system into drug courts, into treatment, and recovery."  Senator Sanders added, after placing at least some of the blame at the feet of the pharmaceutical companies, that "we need a revolution in this country in terms of mental health treatment."

This is clearly going to be a 2016 presidential campaign issue.  Beyond the mere fact that crises often make for strange bedfellows (Clinton and Christie offering nearly interchangeable quotes?!?!), why are we hearing more about prescription drug abuse from candidates now than ever before?

First, New Hampshire.  Everyone knows the Granite State figures prominently as the first primary - on February 9 - in both parties' nomination process (Iowa - on February 1 - is a caucus, not a primary).  What many may fail to recognize is that New Hampshire's citizens have been hit especially hard by the opioid/heroin epidemic over the last several years.  A quarter of New Hampshire voters believe prescription drug and heroin abuse is the single most important issue of the 2016 election, marking the first time in eight years a plurality of voters have ranked any issue more important than jobs and the economy.  If you're going to win the New Hampshire primary - from either party - you better be prepared to address prescription drug misuse and abuse.  

Second, it's not an exaggeration to say that we're losing a material portion of entire generation of Americans to this epidemic.  First, we saw the findings of a recent study from the National Academy of Sciences indicating that the death rate among white, middle-aged Americans has grown over the last two decades while the death rate among almost all other groups has declined.  Now, the New York Times has analyzed nearly 60 million death certificates collected by the CDC and found that the death rate among young, white adults has risen to levels not seen since the AIDS epidemic of the late 1980s and early 1990s.  This generation will be the first since the Vietnam War to experience higher death rates in early adulthood than the generation that preceded it.  The figures indicate that the 2014 death rate from prescription drug and heroin overdose among 25 to 34 year olds was five times its level in 1999.  

We have presidential candidates talking about this issue because it is the preeminent public health issue of our time.  If there's any comfort for us at all, it's that both parties appear to be taking it seriously.  If there's to be a concern, it's that whoever wins will need to make difficult decisions and real progress.  We're losing a generation of Americans.  

Michael
On Twitter @PRIUM1

Primary Care Physicians Aren't Prepared for Substance Abuse Issues

In the course of consuming news, studies, and other information related to prescription drug misuse and abuse, I sometimes come across seemingly unrelated data sets that paint a picture of broad, systemic issues.  Often, connecting these dots can illuminate a potential path forward, focus our efforts, and create progress toward solutions.  This week's example: 

Data Set #1

First, the CDC's latest data on drug poisoning deaths is disheartening.  After leveling off and even slightly declining in 2010-2013, the opioid death rate jumped considerably in 2014.  Meanwhile, heroin overdose deaths have continued a depressingly steady climb that goes back nearly two decades, but has clearly accelerated within the last 5 years.  Certainly, we have seen better days.  

Data Set #2

Health Affairs published an interesting piece in its December 2015 issue comparing primary care systems across 10 countries.  Primary care doctors were surveyed regarding general capabilities and attitudes.  While the survey was wide ranging, one of the categories stood out to me: the % of primary care doctors who report their practice is well prepared to manage the care of patients with complex needs.  Two key data points:

1. Patients with substance-use related issues:
• US primary care docs: 16% are well prepared.  This ranked near the bottom of the 10 country survey.  The UK was at the top of the list with 41% of primary care physicians reporting that they're well prepared to deal with substance-use related issues. 
2. Patients with severe mental health problems:
• US primary care docs: 16% are well prepared.  This ranked second to last (just behind Sweden at 14%) among the ten countries.  The UK also topped this category with 43% of primary care docs reporting they feel well prepared to deal with severe mental illness.  

To sum up... 

We have an escalating death rate from opioid and heroin overdose deaths in this country, driven in large part by substance-use related issues and mental illness.  And we have a primary care system not equipped to deal with the complexity of these patients.  

Help may be on the way in form of increased and mandated reimbursement for substance abuse and mental/behavioral health treatment via the Affordable Care Act.  But I'm struck by the fact that the vast majority of opioid prescribing occurs at the primary care level, not in the specialist's office.  If we're to make any progress, we need to focus education, resources, and tools within the primary care community so that a-heck-of-a-lot more than 16% of primary care physicians feel they're well prepared to help this complex group of patients.  

Michael 

On Twitter @PRIUM1

Mental Health and Addiction: What if We Had What We Really Need?

Consider several seemingly unrelated articles that all ended up in my stack of "articles to read" just in the last three days:

First, a report from the Proceedings of the National Academy of Sciences that found that the death rate among white, middle-aged Americans has grown since the 1990s, while death rates among the same age cohort within other ethnicities and countries has continued to decline.  From the report: "Rising midlife mortality rates among non-Hispanics were paralleled by increases in midlife morbidity.  Self-reported declines in health, mental health, and ability to conduct activities of daily living, and increases in chronic pain and inability to work, as well as clinically measured deteriorations in liver function, all point to growing distress in this population."  The researchers speculated that relatively easy access to opioid pain killers may be linked to the rise in incidence of mental illness.  While I think they have the cause and effect backward, there's little doubt in my mind that the two are related.

Second, a report from WESH in Orlando on a US government study that estimates there are 4 million baby boomers struggling with addiction.  "Baby boomers," the group of Americans born within the 19 year period following WWII, are now in their 50s and 60s and they're suffering from drug and alcohol addiction at a rate that rehabilitation and recovery services cannot accommodate.  "It's hard to imagine grandma with a heroin problem," says Dr. Heather Luing, medical director at Recovery Village, "but that's the reality we sometimes see."

Third, there was a lot of international coverage of a controversial paper from the United Nations Office on Drugs and Crime (UNODC) that suggested UN-member countries should consider "decriminalizing drug possession for personal consumption."  The paper was retracted by UNODC leadership with an explanation that it was written by a mid-level policy person simply expressing a viewpoint and was never sanctioned or adopted as a formal UNODC position.  This public policy approach, however, has been tested, perhaps most notably in Portugal.  Despite warnings of potentially dire consequences, Portugal decriminalized the simple possession of all drugs back in 2001.  Since that time, Portugal has seen overall drug use fall, it has the second lowest overdose death rate in all of Europe, and HIV infections among drug users are dramatically lower,  The resources formerly focused on arresting and prosecuting simple drug possession were instead poured into mental and behavioral health, education, and job training/placement programs.  And if you think such a program wouldn't be possible in the US, check out what Worcester, MA is doing.  

What are the common themes here?

1. People are dying.  That much is statistically evident.  
2. These deaths appear to be correlated with chronic pain, drug use, mental illness, and addiction. 
3. Efforts over the last three decades to deal with the issue from a criminal justice standpoint appear to be at least ineffective and at most counterproductive.  
4. The current supply of mental and behavioral health resources in the US is nowhere near sufficient to meet demand.  

So if the demand is there, why don't we have the mental/behavioral health resources we need? Because we've never devoted the reimbursement dollars necessary, either public or private, to ensure such programs were economically viable.  But now, with the Affordable Care Act's parity provisions, we have legislatively mandated reimbursement policies around mental health coverage offered by private insurers.  The resources haven't yet caught up to the demand, but billions of dollars of private equity investment is being poured into the sector.  Hopefully, it's just a matter of time before the number of trained professionals and the facilities and technologies they need to practice are in place.

And that leads us to an interesting thought experiment: What if we did have the mental and behavioral health infrastructure we so desperately need? Could we fundamentally change how we approach drug abuse in our society?

Michael
On Twitter @PRIUM1
 

Where Does Pain Come From?

[Part 1 of a two part guest post from Dr. Pamella Thomas, PRIUM's Medical Director]

What is Pain?

Chronic pain initially begins, appropriately, as acute pain – a biological event in response to noxious stimuli.  However, as time progresses, social, psychological, and cultural factors impede and complicate recovery. 

Pain, generally, is defined by the IASP Task Force on Taxonomy, 1994, as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.¹  The individual’s experience of pain is mediated by the brain; pain is always subjective.  Commonly the experience of pain is due to physical injury; however, it may also be caused or intensified due to emotional stress: anxiety, depression, exhaustion. The prefrontal cortex of the brain’s frontal lobe plays an important role in interpreting and mediating both types of pain perception.

Role of the Brain

Our understanding of the brain’s role in pain perception has advanced significantly.  For example, we now understand that one's prior experience involving pain, its consequences, and associated moods and stressors, plays an important role in a person’s experience of pain.   One hypothesis is that early adverse experiences and early-onset mental disorders may contribute to a chronic imbalance in hormonal and neurotransmitter mediators linked to neuronal stress response pathways.²  This in turn has been linked to a range of adverse metabolic, cardiovascular, immunological and cognitive effects.^3,4 

Adverse Childhood Events

Additionally we know that adverse experiences with pain occurring prior to age 18 heavily influence our ultimate perception of pain.  Adverse experiences such as abuse, neglect, poverty, parental death, divorce, drug use, and incarceration have been shown in numerous studies to have profound effects on a child’s temperament and psychological and physiological development.

Studies from the Centers for Disease Control and Prevention (CDC) and international surveys from the World Health Organization (WHO) provide mounting evidence and weight to the theory that Adverse Childhood Events (ACEs) predispose a person to poor health as an adult.  Of note, ACEs causing anxiety and/or depression in childhood were positively correlated with chronic pain in adulthood.  Most interestingly, these emotional stressors from childhood are directly correlated with physical disease states in adulthood. Individuals with a history of three or more ACEs were more likely to be diagnosed with each of the six physical conditions measured by the WHO: heart disease, asthma, diabetes, arthritis, chronic spinal pain, and chronic headache.  Those individuals who had suffered from childhood physical abuse had an even longer list of adult chronic disease.

These results suggest that early onset mental disorders may function as endogenous psychosocial stressors that can be associated with poor physical health in adulthood caused not only through increased risky health behaviors, but also through direct biological mechanisms.

Authors KM Scot et al., found in their study, “These results are consistent with the hypothesis that childhood adversities and early onset mental disorders have independent broad spectrum events that increase the risk of diverse chronic physical conditions later in life.”⁵

Anecdotal Experience

As a former medical director overseeing an onsite employer clinic, I had specific insight into the chronicity of some of the workers’ compensation patients filing claims.  Some employees had charts over two inches thick with frequent claims and follow-up visits. I affectionately referred to them as my frequent flyer work comp club members. Given their frequent visits and extensive charts, I began to interview some of these employees and ask questions about their work environment and about their childhood up until 18 years of age. I wanted to see if there were any common experiential themes amongst this population.

I heard frequently from the employees that they had issues with their supervisors or others in authority.  Similarly they had disagreements with those they interacted with at home.  I also frequently heard anecdotally that these employees suffered through poor in-home security, lower socioeconomic status, and circumstances that caused frequent fear and anger in their homes from an early age.

The Doctor-Patient Relationship

Though I likely missed a great opportunity to reproduce the results found in the ACE study, I found that just by taking the time to engage these injured workers in conversation, addressing factors outside those reported as part of the injury, that some seemed to have fewer ongoing problems going forward.  Being heard and validated proved therapeutic for these oft troubled employees.  Actively listening to patients may help prevent chronic pain and its complications from certain treatments. It is my conclusion that the physician-patient relationship should be seen as the critical piece in treating workers’ compensation claims, especially for workers that display a particular subset of characteristics that I will detail in a follow-up post.

1.            Merskey H, Bogduk N. Classification of chronic pain, IASP Task Force on Taxonomy. Seattle, WA Int Assoc Study Pain Press available online www iasp-pain org). 1994.

2.            McEwen BS. Protective and Damaging Effects of Stress Mediators. N Engl J Med. 1998;338(3):171-179. doi:10.1056/NEJM199801153380307.

3.            Miller GE, Cohen S, Ritchey AK. Chronic psychological stress and the regulation of pro-inflammatory cytokines: A glucocorticoid-resistance model.

4.            Chrousos GP, Kino T. Glucocorticoid action networks and complex psychiatric and/or somatic disorders. Stress. 2007;10(2):213-219.

5.            Scott KM, Von Korff M, Angermeyer MC, et al. Association of childhood adversities and early-onset mental disorders with adult-onset chronic physical conditions. Arch Gen Psychiatry. 2011;68(8):838-844. doi:10.1001/archgenpsychiatry.2011.77.

Smoking, Obesity, Mental Illness and Chronic Pain

A study published late last year (but which I just now got around to reading...) establishes a clear link between smoking and chronic back pain.  I know what you're thinking: file that under "stuff we already knew and didn't need an academic study to prove."  But this study is interesting not simply because it establishes a link we all observe daily in workers' compensation claims management; it also focuses on the underlying mechanism that associates the behavior of smoking and the condition we know as chronic back pain.

The study concludes that the risk of sub-acute back pain progressing to chronic back pain is 3X greater among smokers vs. non-smokers.  Further, the subjects were subjected to functional MRI scans and it turns out that the relationship between smoking and chronic back pain is "mediated by corticostriatal circuitry involved in addictive behavior and motivated learning."  I don't know what that means, exactly, but it's clear that smoking wires the brain in such a way that chronic pain becomes a common outcome of acute injury.

Here's the hard question: What can we do about it?  If we know, objectively, that the likelihood of a workplace injury developing into chronic pain is significantly increased due to smoking... what are our options?   Some of you have access to fancy algorithms (or predictive models, I think you call them) that will tell you to put a case manager on a claim like this right away.  And I think that's great.  But what options does the case manager have?

I'm asking because I think this is one of three fundamental issues the workers' compensation medical management world is going to deal with over the next five years.

• How do we deal with chronic pain in light of smoking?
• How do we deal with chronic pain in light of obesity?
• How do we deal with chronic pain in light of mental/behavioral illness?  

Most of you are dealing with claims wherein all three of these crucial questions have come together in a perfect storm of complexity, confusion, and cost.

So...
How do we (legally) avoid hiring high risk people in the first place?
How do we prevent them from getting injured once we do employ them?
And the hardest question of all: How do we fix them once they're injured?

We spend so much time focused on the last question.  The answers are hard to devise and even harder to implement.  I suppose the least we can do is put some focus on the first two questions in an attempt to limit the number of times we have to find answers to the third.

Michael
On Twitter @PRIUM1