Adam Bisaga, MD, is an addiction psychiatrist, clinician, researcher, and professor of psychiatry at Columbia University. This week he published an important new book, co-written with health writer Karen Chernyaev: Overcoming Opioid Addiction: The Authoritative Medical Guide for Patients, Families, Doctors, and Therapists (The Experiment; paperback; 285 pp; $16.95).
Last week, Bisaga, 55, sat down with Opioid Watch for a far-ranging interview touching on, among other issues, why, in his view, opioid addiction is unique; why referring patients to most opioid treatment centers today has become unethical; how insurance and emergency room practices should be changed; whether “medical” patients differ from “addicts”; whether the anti-opioid pendulum has swung too far; how patients should chose from among different treatment drugs; and how stigma distorts doctors’ perceptions of patients with opioid use disorder (OUD).
After attending medical school in Kraków, Poland, where he grew up, and finishing his post-doc work in pharmacology in Warsaw, Bisaga moved to New York in 1993 to begin his US psychiatric residency. He went to Columbia in 1997, and has now been working with OUD patients, either in clinical studies or private practice, for more than 20 years.
Though Bisaga could have written separate books about OUD for physicians, families, and patients, he told Opioid Watch, he decided it would be better to put it all in one volume. “The physicians who have just started to treat these patients don’t fully understand what it’s like to be a parent or a patient,” he explained. “And parents need to know the same, to better see their loved ones through, and understand how they got to this point.”
The following is Part I of an edited transcript.
You write that opioid addiction is unlike any other form of drug dependency. What do you mean by that?
Even though there are certainly a lot of commonalities between all forms of addiction, whether it’s cocaine, alcohol, tobacco or opioid dependence, there are distinct differences when it comes to opioid dependence.
One thing, of course, is the lethality. This is the most lethal of all addictions. And the most lethal of all psychiatric disorders. Higher than major depression, bipolar disorder, anorexia.
Up to two percent of patients every year who use will die—one in 50—so it’s pretty high. So if you’re using for 10 years, your chance of dying is about one in five.
Therefore, when we think about opioid use disorder, priority number one should be to prevent premature death. And we have the tools to prevent it. This forces us to rethink the priorities of treatment.
You write: “I would argue that it is now unethical for professionals to refer OUD [opioid use disorder] patients to more than half of the treatment facilities in this country.” What do you mean by that?
Most of the treatment programs today are very traditional. The thinking about these programs was first established in the 1930s and 1940s. They primarily focus on behavioral change. On spiritual change. It does not include a medical intervention model. Maybe at the beginning of treatment, where you are detoxing, the doctor can help you relieve some of the withdrawal. But really that’s the very limited role of medical treatment.
Otherwise, it’s treatment by peers who’ve been through this themselves, and using medications is often seen as anathema. You’re not supposed to use any medications, particularly any that “alter your mind,” as it may impede the benefits of treatment. I believe the majority of addiction treatment programs still offer treatment that exclude medical interventions targeting opioid dependence.
Whereas we now know that the evidence shows really, really consistently that medical treatment is the one that is most effective in terms of preventing death.
If you have the choice, sending the patient to programs where you know that the chances of their staying alive is significantly less than with a medical management program, I think you have to think about the ethics of making this decision.
Is there still a place for the traditional approach?
Absolutely. The traditional model has a lot to offer. There are people who are very experienced working with this population, and can relate to this population, which is no small thing. Mutual help groups can be extremely useful and supportive, and show you that there are ways of dealing with cravings, urges. So clearly some sort of integration of the traditional methods with the medical model would be ideal. Some programs are already there. But it’s not happening fast enough considering the urgency of this epidemic and we need to force most of the programs to switch.
If we call it a “treatment program,” and they are paid for by medical insurance for delivering treatment, they should take advantage of the scientific developments that have taken place in the last 50 years. Standards should be no different than are accepted in any other branch of medicine. Nevertheless that has not been happening. People are dying because they don’t have access to treatment, or they do not have the most effective treatment offered to them.
So do we need better education, or should insurance be made contingent upon receiving medically-assisted treatment?
All of this. Because addictions were considered nonmedical, medical schools didn’t train providers. Hospitals removed addiction treatment from their services. So we don’t really have people trained in addiction. We have to restructure insurance so it will actually reimburse people for evidence-based treatment and refuse to pay for treatment that is known not to be effective.
What are the key insurance problems right now?
There are a few issues. At the most immediate level, for a long time, if you wanted to prescribe medications for addiction you needed preauthorization for it. Here, for the cheapest, most basic medications, there were barriers.
It’s changing right now. New York State, and I hope other states, are making regulations where insurers have to make at least one preparation of each medication for addiction available without preauthorization.
So if I give a patient a prescription today, he can go to the pharmacy without a problem. As opposed to waiting two days until I reach someone on the phone and go back and forth with them. Because if you wait with this disorder, there’s a chance that you’re not going to make it.
The other barrier, of course, is that there’s a dearth of programs that offer evidence-based, integrated, medical and behavioral treatment. So even if someone would like help, there is no program for insurance to pay for. Insurance tends to pay for the programs that are available. And those are frequently the programs that do not offer effective treatment.
How do we get people into medication-assisted treatment who don’t want it?
The number of people addicted to opioids is maybe two to three million. Probably not all of these patients are interested in getting help. Fine. We cherish individual freedom. We don’t impose, in a paternalistic way, rules on patients.
The problem is that there are a substantial number of patients who are interested in getting help and can’t.
Now their interest in getting help may wax and wane. One day you want to get better, another day you don’t. That’s the nature of the disease. It’s called ambivalence.
But the issue is: when they are ready to receive treatment, if there is no treatment available, obviously they can get discouraged and give up on the idea of treatment. Sadly, some of them will have a bad outcome before they are ready so seek help again.
What we know is that we have an epidemic of overdose deaths, most of them are probably accidental. Would all of those people who die have wanted treatment? Probably not all of them. But I don’t think it is just to plan treatment services based on the assumption that only 10 percent will want treatment. The capacity for treatment should be greater than the need. Right now, more than 50 percent of patients would not have a place to go for treatment, and many of those places that take patients do not offer effective treatment. Again, would that be acceptable for any other disorder?
Say someone goes to the emergency room with an overdose. The hospital stabilizes them. How do we persuade that person to enter treatment?
We have an intervention strategy to increase the chance that someone like that will accept treatment. We talk to patients and try to motivate them to enter treatment. It’s very well established.
Is that part of the emergency room procedure?
No. The problem is that most of the time you don’t have ER staff that is trained in those techniques. And secondly, even if the patient wanted treatment, there is no treatment available for them.
This is very different than the way we treat people with any other medical disorder. When you come with a heart attack, we don’t tell you, you should exercise more, eat better, avoid stress, and go home and don’t have another heart attack. We treat it very aggressively. We admit them to the hospital to establish what’s happening. We’ll implement very aggressive medical protocols, and then we put them into the chronic care model.
We know that for people who overdose this year, the chance of dying is extremely high if they don’t get treated. So basically if someone survives an overdose and you don’t make sure you do everything possible to hook this person up with treatment, many of these people will die.
You have a chance in the ER to do something to prevent it. And if this was any other medical disorder, you would feel legally, and ethically compelled to do that.
How bad are relapse rates for traditional treatment, and with medication-assisted treatment?
About 70 to 90 percent will relapse from traditional treatment within the first three months—definitely within six months. And many of them, especially these days, when such dangerous drugs are available, will have a lethal overdose.
So we know a large majority of people who do not receive the medical treatment—who only receive the short-term intervention and then they are told to change their lifestyle, go to the self-help groups, and try to stay away from drugs—those people will relapse.
The medical treatment when it’s done well can probably hold onto 50 percent of those patients at six months.
So you see the difference between 50 percent of people still in treatment doing well, versus maybe 80 percent of people in relapse – it’s highly, highly significant.
When treating cancer, we approve treatments that increase your survival rate by a week or two, or by a 5 percent chance, and those treatments are hailed as highly effective, get approved by FDA, and people will pay large amounts of money to have access to this treatment.
Here you have 20-30 percent difference, yet we still feel kind of ambivalent about whether this is the right way. It has to do with stigma. Nothing else.
[This the end of Part I of the interview. Part II continues here.]