Much of U.S. Healthcare Is Broken: How to Fix It (Chapter 2, Part 8)

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Editor’s Note: Over the next several months, Mad in America is publishing a serialized version of Les Ruthven’s book, Much of U.S. Healthcare is Broken: How to Fix It. In this blog, he addresses benzodiazepines and whether substance abuse disorders should be considered brain diseases. Each Monday, a new section of the book is published, and all chapters are archived here.

SSRI treatment of the anxiety disorders.

The clinical efficacy of SSRIs in treating various anxiety disorders for which these drugs have FDA approval is no better than their record in treating depression. In one study by Bellew,19 36% of patients receiving Paxil for generalized anxiety disorder (GAD) achieved “remission” (as defined by the study) versus 23% for those receiving inert placebo, a 13% difference in favor of the drug. This difference is even less than the drug-placebo difference in the average antidepressant (ADM) clinical trials. As usual in studies designed to favor a drug effect, all subjects had a placebo 1-week run in (washout) phase before the start of drug treatment. As I have said previously, if blood pressure drugs were no better at reducing blood pressure than SSRIs are in treating generalized anxiety disorders there would be no blood pressure medications on the market. As an aside, how can psychiatry call anxiety a disease when in the study 23% of well-diagnosed anxiety disorders were “cured” with a sugar pill! Would 23% of newly diagnosed cancer patients get better on placebo?

Miniature photography. Blue and white pills and blue hazmat-suit figures

Should Xanax-type drugs be used for treating stress-anxiety?

I was going to report on some of the scientific literature on the effectiveness of these drugs in treating a host of anxiety disorders such as panic disorders and others. However, the first rule of medicine (or psychology) is to do no harm. There are some legitimate uses in medicine for the benzodiazepines, such as to stop grand mal seizures and to calm patients prior to major surgery, but since we know these medicines are highly addictive (as are ADMs) we might look at their side effect profile before considering their efficacy to treat diagnosable anxiety as well as every day stresses, especially since we know that these drugs do not treat the causes of anxiety and only mask the anxiety.

Moreover, from the Center for Drug Evaluation and Research21, the most commonly reported treatment-emergent adverse events attributed to alprazolam XR (Xanax) are sedation (45%), somnolence (23%), memory impairment (15.4%), fatigue (13.9%), depression (12.1%), dysarthria (11%), impaired coordination (9.4%), cognitive impairment (7.2%), ataxia (7.2%), and decreased libido (11%). The most commonly reported adverse events attributed to discontinuation of alprazolam XR treatment (and other anxiolytics) are anxiety (30%), tremor (28%), dizziness (27%), headache (26%), insomnia (24%), depression (27%), decreased appetite (9.5%), hyperventilation (8.5%), and de-realization (8%). Knowing the side effects of benzodiazepines why in the world would anyone take such medications and why would any physician prescribe these drugs to a patient? The answer is the patient and the doctor both feel better! The benzodiazepines (and many other drugs as well) are deserving an award generating hundreds of new health problems to be treated and also adding significant healthcare costs as well.  Moreover, physicians as a group use these drugs liberally because that’s their only tool!

I am not an expert on intoxication but a number of these symptoms suggest drunkenness to me but a great deal more than drunkenness. Sophie Billioti de Gage22 conducted a study on benzo use and its effects on the brain. In this study benzo use was associated with a 51% increased risk in developing Alzheimer’s disease. The risk is increased with longer exposure, with an 84% increased risk of Alzheimer’s with drug use for more than six months. One can expect that psychiatrists and Big Pharma were not pleased with the study outcome and psychiatrists began recommending that benzo use should be used short-term, i.e., less than three months but I doubt most physicians follow such guidelines.

Benzodiazepines are frequently found along with opioids in overdose deaths. As we have seen too often, traditional medical care intervenes after the fact, after a sedentary lifestyle and weight gain result in Type 2 diabetes, and the proliferation of Xanax type drugs is a part of the same medical tradition. Many times, good and appropriate healthcare requires something more than making the patient feel good and many times good health requires behavior change.

More about benzodiazepines and their iatrogenic consequences.

This class of drugs such Valium and Xanax (two of 15 or so brands), one of America’s top selling drug classes, has become even more popular with the American public than ADMs and have become a significant part of the daily lives of too many Americans. I have pointed out previously that these drugs have a few genuine medical uses but in general these drugs are primarily used as “feel good” stress “reducers.” Because of habituation (the calming effect is lost unless the dosage is increased) and addiction properties, these drugs are supposed to be limited to short-term use and a maximum dosage as well; however, most physicians ignore the caveat both against long-term use and safe dosages, which often leads to tragic consequences for many of these patients. For the calming, sedative effect the user pays the price of significant ongoing brain dysfunction and behavioral dysfunctions such as falls, accidents, dizziness, inability to talk or respond, agitation and other behavioral consequences of brain dysfunction, which one does not often hear about from the prescribing physician.

Speaking of benzodiazepines there is an interesting story about the FDA approval of Xanax, at one time the most prescribed and revenue producing drug leader. In the FDA clinical trials Xanax proved superior to placebo at four weeks but at eight weeks (as typical for these drugs) there was no benefit of the drug over placebo in treating anxiety. This is consistent with the fact that without dosage increase (to avoid addiction) the drug effect habituates and functions no better than an inert placebo. The marketing focus of Xanax was on the benefit of the drug at four weeks but somehow the drug maker “forgot” to report the eight-week results in which the placebo was equally effective as the drug! Because of habituation these drugs are no better than a placebo after short-term use since the dosages should not be increased because of their highly addictive properties. Despite this, many physicians prescribe these drugs to their patients for long-term and at times lifetime use and at dosages above a safe level.

Are the substance abuse disorders brain diseases?

In the late 1960s in Wichita as a psychologist I was invited along with a physician addiction specialist and a substance abuse counselor to speak on the addictions to medical students at the then St. Joseph Hospital. The talks by the physician and the drug counselor both stressed the chronic and relapsing nature of these brain disease causes of the addictions. As all psychologists, I was on the Allied staff at the hospital and my access to hospital patients could be terminated without cause. Then, as now, the concept of addiction as a chronic, relapsing disease had taken hold so much that it has become a “sacred” cow of medicine, one that is “untouchable” and unworthy of questioning its truth. I knew if I addressed the chronic, relapsing disease notion of addiction and said there was no scientific merit to such speculation—and that it would only assist some addicted patients to stay on the sauce—I would have had my position at the hospital terminated the next day.

Not everyone has climbed on board the bandwagon claiming addiction as disease and a few individuals and research studies have challenged the conventional wisdom. An article by Elly Vintiadis in Scientific American23 asked the question “Is Addiction a Disease”? The article reports a study by Lee Robins in 1974 of servicemen addicted to heroin in Vietnam; Robins found the remission rate quite surprisingly high following return to the states. 20% of the soldiers were addicted to heroin in Vietnam and only 7% of those used heroin after returning to the U.S! Only about 1 to 2% of those had a relapse, even briefly, into addiction. The vast majority of the soldiers stopped using on their own! Does this sound like a chronic, relapsing disease? With regard to the topic of addictions, years ago I had a friend who had a quite serious (and expensive) heroin addiction who, one day, quit cold turkey, went back to graduate school and became a college professor! He was able to achieve this without rehab or any kind of treatment.  So much for a disease.

In the 1970s, Lee Robins described the famous “Rat Park” experiment in which caged white rats self-administered ever increasing doses of morphine when no other alternative (such as a companion) was available in the cage. However, when these rats were given a mate and alternatives to drugs the addicted rats stopped taking the drug even though the heroin continued to be available to the rat. So much about a chronic, relapsing disease. Robins also reports on a 1982 study by the sociologist Stanley Schachter who found evidence that most smokers and obese people overcome their addiction without any help. For example, in 1964, the day the Surgeon General’s report on Smoking and Health came out, I quit a two pack a day smoking habit and years later when I was diagnosed with Type 2 diabetes I lost 45 pounds (and kept it off to this day) with changing my behavior about eating and exercise. Being a psychologist, I knew how to do it on my own but many of those with poor health habits require professional help to change their behavior but they won’t get that at their doctor’s office!

In the 1960s, I read a research article (I am sorry but I have not been able to locate this study since) in which chronic alcoholics were randomly assigned to a 28-day inpatient rehab program, a second group to an intensive outpatient program, and the third group received one telephone assessment and behavioral recommendations by an alcohol counselor and were mailed a self-help alcohol treatment program. Yes, you are right: all three conditions were equally effective, and the results contradict the time-honored beliefs in the value of inpatient rehab for the addictions.

More on the conception of addictions as brain diseases, the increasing use of psychiatric medications in treating the addictions and the continuing prevalence of inpatient treatment of the addictions.

I also believe that making these disorders of behavior into chronic, relapsing brain diseases works against recovery, including the ever-expanding role of using medications (psychiatric drugs, methadone and anti-addiction drugs) as often a central part of addiction treatment.

In 22 years of managing comprehensive behavioral healthcare (as I will describe in Chapter 4) my company never authorized the popular 28-day inpatient substance abuse programs for all of our self-insured large employer clients. If needed, we did, however, authorize a three- to four-day medical detox program prior to outpatient services such as AA, NA, psychologist or non-psychologist addiction specialists. For highly addicted patients, the brain is compromised in its ability to learn; the ability to learn anything new is necessary for the addicted person to profit from any rehabilitation.

The scientific literature at the time1 indicated no advantage of inpatient rehab versus outpatient services, which is true today. Also, my reading of the literature did not support the overwhelming belief (then as now) that the addictions are chronic, relapsing diseases, a bogus “theory” that gave support to both the need for impatient treatment and that medical care in the form of drugs is often a necessary element in recovery from addiction! There was and is of course no scientific support for such a pattern of belief or treatment, but one must say that this conceptualization of the addictions and their treatment has been an effective marketing program! Moreover, when the addicted patient fails the treatment and starts using again the “medical” provider can fall back on the notion “Well after all, it is a chronic and relapsing disease!

For one large beef packing company, my company developed a program for on the job injured workers whose toxicology report included either alcohol or illegal substances at the time of the injury/accident. These employees were offered either termination or calling my company, getting an assessment from one of our psychologists on the telephone and having three sessions with an addiction professional in their area. I knew that quality and not the amount of outpatient treatment of the addicted patient was critical. As I recall, every such employee chose the referral program and most continued their employment with the understanding the employer could ask for a drug screening at any time (however, this was rarely requested of the worker by the company). The threat of random toxicology screening helped to keep these employees “clean” and on the job.  My company was never told that one of these workers were ever terminated.

A very sound and large current study on the topic24 examined four treatment modalities (inpatient, residential, outpatient detox/methadone, and outpatient drug free) involving patient records and comprehensive interviews with 1,799 of these individuals five years after discharge. The cost per successfully treated abstinent case in the least costly modality, the outpatient drug-free program, was $6,300.00 (range $5,200-$7,900) in 1990 dollars. There were only minor, non-significant differences between the various treatments with regard to effectiveness.

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To see the list of all references cited, click here.

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

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