Commentary

Nearly every parent gets excited about their child’s first smile, steps, and words. Developmental and behavioral screening helps to better track young children’s progress in areas like communication, motor, cognitive, and social/emotional skills. Approximately one in four or five children are at risk for a developmental/behavioral delay, which might indicate an emerging developmental disability or mental health disorder.

Regular screenings raise awareness of children’s development, which makes it easier for parents to expect and celebrate milestones. They encourage parents and doctors to avoid the common pitfall of taking a “wait and see” approach. Regular screenings might even help doctors more easily diagnose co-occurring conditions like autism, sleep disorders, iron deficiencies, hearing impairment, metabolic disorders, genetic disorders, in utero drug/alcohol exposure, or child maltreatment.

High-quality interventions for children aged 0-5 years can decrease rates of special education, substance abuse, criminality/incarceration, suicidal attempts, and unemployment or welfare dependency. The trick is to swiftly identify and refer at-risk and delayed children to the most effective resources in a family-centered manner.

Our new study, which has been published online in Developmental Medicine and Child Neurology, investigated early childhood screening practices across the United States and Scandinavia (Denmark, Norway, and Sweden), which lie relatively far apart on the spectrum of preventive care models (2018 Sep 23. doi: 10.1111/dmcn.14044).

Just like many other developed areas of the world, the United States and Scandinavia are increasingly using two accurate, parent-reported screening tools – the Ages & Stages Questionnaire (ASQ) and ASQ:Social-Emotional (ASQ:SE) – to measure developmental and behavioral skills in children aged 0-5 years. We found that routine and periodic ASQ and/or ASQ:SE screening is low cost, feasible, and increases early detection and referral rates, plus they connect at-risk children to early intervention programs at significantly younger ages.

Surprisingly, the United States and Scandinavia tend to use these same two screening questionnaires quite differently. U.S. pediatricians and family physicians commonly use the ASQ and/or ASQ:SE in clinic settings to swiftly identify developmental/behavioral red flags in children from general and at-risk populations (See video at end of article). Scandinavian studies more commonly report the use of the ASQ and ASQ:SE to track developmental/behavioral differences in children in an intervention/exposure group and how they compare with children in a control group over time. In other words, the United States uses these screens clinically, and Scandinavia mostly uses them for research purposes.

In Scandinavia, home visit nurses and general practitioners commonly administer more narrowly focused, “hands-on” screens during infancy. Different municipalities use different screens. Language-focused screening typically is not performed until ages 2.5-3 years in preschools or child health centers. That’s probably too late. Scandinavian countries, which boast bountiful and equitable early childhood resources, are not routinely using parent-centered screening tools that measure all of a child’s developmental domains, including social/emotional skills. One reason is probably that Danish and Swedish ASQ and ASQ:SE norming (standardization) and validation (reliability and accuracy) studies are lacking and because Norwegian norms are out-of-date. Therefore, they are primarily used just for research. Every decade, the “good” screening questionnaires have to be scientifically tweaked and improved as the characteristics of populations (like ethnicity, socioeconomic status, or percentage of new immigrants) and cultural norms (like rotary versus cell phones) change over time.

Here is a video Dr. Marks has developed showing how to integrate ASQ screening into your practice.

Dr. Marks is a pediatrician, clinical researcher, and coauthor of Developmental Screening in Your Community. Dr. Madsen Sjö is a certified pediatric neuropsychologist in Copenhagen. Dr. Marks and his family moved from the United States to Denmark in 2017. Email him at [email protected].

Nearly every parent gets excited about their child’s first smile, steps, and words. Developmental and behavioral screening helps to better track young children’s progress in areas like communication, motor, cognitive, and social/emotional skills. Approximately one in four or five children are at risk for a developmental/behavioral delay, which might indicate an emerging developmental disability or mental health disorder.

Regular screenings raise awareness of children’s development, which makes it easier for parents to expect and celebrate milestones. They encourage parents and doctors to avoid the common pitfall of taking a “wait and see” approach. Regular screenings might even help doctors more easily diagnose co-occurring conditions like autism, sleep disorders, iron deficiencies, hearing impairment, metabolic disorders, genetic disorders, in utero drug/alcohol exposure, or child maltreatment.

High-quality interventions for children aged 0-5 years can decrease rates of special education, substance abuse, criminality/incarceration, suicidal attempts, and unemployment or welfare dependency. The trick is to swiftly identify and refer at-risk and delayed children to the most effective resources in a family-centered manner.

Our new study, which has been published online in Developmental Medicine and Child Neurology, investigated early childhood screening practices across the United States and Scandinavia (Denmark, Norway, and Sweden), which lie relatively far apart on the spectrum of preventive care models (2018 Sep 23. doi: 10.1111/dmcn.14044).

Just like many other developed areas of the world, the United States and Scandinavia are increasingly using two accurate, parent-reported screening tools – the Ages & Stages Questionnaire (ASQ) and ASQ:Social-Emotional (ASQ:SE) – to measure developmental and behavioral skills in children aged 0-5 years. We found that routine and periodic ASQ and/or ASQ:SE screening is low cost, feasible, and increases early detection and referral rates, plus they connect at-risk children to early intervention programs at significantly younger ages.

Surprisingly, the United States and Scandinavia tend to use these same two screening questionnaires quite differently. U.S. pediatricians and family physicians commonly use the ASQ and/or ASQ:SE in clinic settings to swiftly identify developmental/behavioral red flags in children from general and at-risk populations (See video at end of article). Scandinavian studies more commonly report the use of the ASQ and ASQ:SE to track developmental/behavioral differences in children in an intervention/exposure group and how they compare with children in a control group over time. In other words, the United States uses these screens clinically, and Scandinavia mostly uses them for research purposes.

In Scandinavia, home visit nurses and general practitioners commonly administer more narrowly focused, “hands-on” screens during infancy. Different municipalities use different screens. Language-focused screening typically is not performed until ages 2.5-3 years in preschools or child health centers. That’s probably too late. Scandinavian countries, which boast bountiful and equitable early childhood resources, are not routinely using parent-centered screening tools that measure all of a child’s developmental domains, including social/emotional skills. One reason is probably that Danish and Swedish ASQ and ASQ:SE norming (standardization) and validation (reliability and accuracy) studies are lacking and because Norwegian norms are out-of-date. Therefore, they are primarily used just for research. Every decade, the “good” screening questionnaires have to be scientifically tweaked and improved as the characteristics of populations (like ethnicity, socioeconomic status, or percentage of new immigrants) and cultural norms (like rotary versus cell phones) change over time.

Here is a video Dr. Marks has developed showing how to integrate ASQ screening into your practice.

Dr. Marks is a pediatrician, clinical researcher, and coauthor of Developmental Screening in Your Community. Dr. Madsen Sjö is a certified pediatric neuropsychologist in Copenhagen. Dr. Marks and his family moved from the United States to Denmark in 2017. Email him at [email protected].

Nearly every parent gets excited about their child’s first smile, steps, and words. Developmental and behavioral screening helps to better track young children’s progress in areas like communication, motor, cognitive, and social/emotional skills. Approximately one in four or five children are at risk for a developmental/behavioral delay, which might indicate an emerging developmental disability or mental health disorder.

Regular screenings raise awareness of children’s development, which makes it easier for parents to expect and celebrate milestones. They encourage parents and doctors to avoid the common pitfall of taking a “wait and see” approach. Regular screenings might even help doctors more easily diagnose co-occurring conditions like autism, sleep disorders, iron deficiencies, hearing impairment, metabolic disorders, genetic disorders, in utero drug/alcohol exposure, or child maltreatment.

High-quality interventions for children aged 0-5 years can decrease rates of special education, substance abuse, criminality/incarceration, suicidal attempts, and unemployment or welfare dependency. The trick is to swiftly identify and refer at-risk and delayed children to the most effective resources in a family-centered manner.

Our new study, which has been published online in Developmental Medicine and Child Neurology, investigated early childhood screening practices across the United States and Scandinavia (Denmark, Norway, and Sweden), which lie relatively far apart on the spectrum of preventive care models (2018 Sep 23. doi: 10.1111/dmcn.14044).

Just like many other developed areas of the world, the United States and Scandinavia are increasingly using two accurate, parent-reported screening tools – the Ages & Stages Questionnaire (ASQ) and ASQ:Social-Emotional (ASQ:SE) – to measure developmental and behavioral skills in children aged 0-5 years. We found that routine and periodic ASQ and/or ASQ:SE screening is low cost, feasible, and increases early detection and referral rates, plus they connect at-risk children to early intervention programs at significantly younger ages.

Surprisingly, the United States and Scandinavia tend to use these same two screening questionnaires quite differently. U.S. pediatricians and family physicians commonly use the ASQ and/or ASQ:SE in clinic settings to swiftly identify developmental/behavioral red flags in children from general and at-risk populations (See video at end of article). Scandinavian studies more commonly report the use of the ASQ and ASQ:SE to track developmental/behavioral differences in children in an intervention/exposure group and how they compare with children in a control group over time. In other words, the United States uses these screens clinically, and Scandinavia mostly uses them for research purposes.

In Scandinavia, home visit nurses and general practitioners commonly administer more narrowly focused, “hands-on” screens during infancy. Different municipalities use different screens. Language-focused screening typically is not performed until ages 2.5-3 years in preschools or child health centers. That’s probably too late. Scandinavian countries, which boast bountiful and equitable early childhood resources, are not routinely using parent-centered screening tools that measure all of a child’s developmental domains, including social/emotional skills. One reason is probably that Danish and Swedish ASQ and ASQ:SE norming (standardization) and validation (reliability and accuracy) studies are lacking and because Norwegian norms are out-of-date. Therefore, they are primarily used just for research. Every decade, the “good” screening questionnaires have to be scientifically tweaked and improved as the characteristics of populations (like ethnicity, socioeconomic status, or percentage of new immigrants) and cultural norms (like rotary versus cell phones) change over time.

Here is a video Dr. Marks has developed showing how to integrate ASQ screening into your practice.

Dr. Marks is a pediatrician, clinical researcher, and coauthor of Developmental Screening in Your Community. Dr. Madsen Sjö is a certified pediatric neuropsychologist in Copenhagen. Dr. Marks and his family moved from the United States to Denmark in 2017. Email him at [email protected].

“The Campus Cure: A Parent’s Guide to Mental Health and Wellness for College Students” (Lanham, Md.: Rowman & Littlefield Publishers, 2018) is written as a first-aid guide for parents of young people struggling with the mental health issues facing college students today. The importance of parents working collaboratively with the student/patient and the health care team is stressed throughout; Dr. Marcia Morris draws upon the medical literature and more than 20 years’ experience as a psychiatrist at the University of Florida, Gainesville, to provide clear guidance on a key theme: The continued support and involvement of caring parents in a young adult’s life can be crucial to her college success.

The book is well organized with separate chapters containing easy-to-understand explanations of the causes and treatments of common problems (anxiety, depression, substance use, academic failure to thrive), pressures (loneliness, perfectionism, financial stress, and culture/sexuality/gender issues), and crises (suicide, sexual assault, eating disorders, psychosis) affecting students today. Helpful background information about medications, resources for obtaining help on campuses, and legal issues about confidentiality is provided where appropriate. Each section is brought to life with vignettes of typical patients seen in the college mental health setting. Questions that ask the reader how they would respond in the situation illustrated are used effectively and encourage the reader to think through the information presented and retain what they have learned. Helpful summary lists of “tips” close most chapters.

In her introduction, Dr. Morris stresses that this book is not just for parents but also for family and friends who may find themselves in the role of being the caring adult in a student’s life. She encourages parents to read the whole book, even those chapters they may not think will apply to their child, explaining how common difficulties are in this age group and how important it is to know how to respond when an issue may arise.

Although this is good advice, I suspect that many parents without specific concerns are unlikely to proactively choose to read this book. Concerned parents who do pick this volume up “just in case” will find specific strategies for effective and helpful communication with their child and with professionals as well as stories of reassuring good outcomes from parental involvement. Dr. Morris recommends that parents ask their child to obtain access for the parents to the student’s grades and grant permission for parents to communicate with mental health care providers and school administration. However, she does not offer much guidance for the parent of the child who never signs the required forms to allow access to this information – and is generally not communicative with the parents.

Parents of a teenager who receives treatment (even prior to college) certainly should be encouraged to read this book. I also would recommend this book for many others working with young adults (even if they are not in college settings) for example, health care professionals without mental health training, educators, psychotherapist trainees, and mentors. Along with parents, they will find “The Campus Cure” to be a great resource for understanding and dealing with the mental health challenges of young adulthood.

Dr. Holland is board certified in child/adolescent and adult psychiatry. She is based in Boca Raton, Fla., where she is an affiliate assistant professor at Florida Atlantic University’s Schmidt College of Medicine. Click here to listen to a recent MDedge Psychcast interview with Dr. Morris about the prevalence of binge drinking on college campuses – and steps psychiatrists and other therapists can take to mitigate risk.

“The Campus Cure: A Parent’s Guide to Mental Health and Wellness for College Students” (Lanham, Md.: Rowman & Littlefield Publishers, 2018) is written as a first-aid guide for parents of young people struggling with the mental health issues facing college students today. The importance of parents working collaboratively with the student/patient and the health care team is stressed throughout; Dr. Marcia Morris draws upon the medical literature and more than 20 years’ experience as a psychiatrist at the University of Florida, Gainesville, to provide clear guidance on a key theme: The continued support and involvement of caring parents in a young adult’s life can be crucial to her college success.

The book is well organized with separate chapters containing easy-to-understand explanations of the causes and treatments of common problems (anxiety, depression, substance use, academic failure to thrive), pressures (loneliness, perfectionism, financial stress, and culture/sexuality/gender issues), and crises (suicide, sexual assault, eating disorders, psychosis) affecting students today. Helpful background information about medications, resources for obtaining help on campuses, and legal issues about confidentiality is provided where appropriate. Each section is brought to life with vignettes of typical patients seen in the college mental health setting. Questions that ask the reader how they would respond in the situation illustrated are used effectively and encourage the reader to think through the information presented and retain what they have learned. Helpful summary lists of “tips” close most chapters.

In her introduction, Dr. Morris stresses that this book is not just for parents but also for family and friends who may find themselves in the role of being the caring adult in a student’s life. She encourages parents to read the whole book, even those chapters they may not think will apply to their child, explaining how common difficulties are in this age group and how important it is to know how to respond when an issue may arise.

Although this is good advice, I suspect that many parents without specific concerns are unlikely to proactively choose to read this book. Concerned parents who do pick this volume up “just in case” will find specific strategies for effective and helpful communication with their child and with professionals as well as stories of reassuring good outcomes from parental involvement. Dr. Morris recommends that parents ask their child to obtain access for the parents to the student’s grades and grant permission for parents to communicate with mental health care providers and school administration. However, she does not offer much guidance for the parent of the child who never signs the required forms to allow access to this information – and is generally not communicative with the parents.

Parents of a teenager who receives treatment (even prior to college) certainly should be encouraged to read this book. I also would recommend this book for many others working with young adults (even if they are not in college settings) for example, health care professionals without mental health training, educators, psychotherapist trainees, and mentors. Along with parents, they will find “The Campus Cure” to be a great resource for understanding and dealing with the mental health challenges of young adulthood.

Dr. Holland is board certified in child/adolescent and adult psychiatry. She is based in Boca Raton, Fla., where she is an affiliate assistant professor at Florida Atlantic University’s Schmidt College of Medicine. Click here to listen to a recent MDedge Psychcast interview with Dr. Morris about the prevalence of binge drinking on college campuses – and steps psychiatrists and other therapists can take to mitigate risk.

“The Campus Cure: A Parent’s Guide to Mental Health and Wellness for College Students” (Lanham, Md.: Rowman & Littlefield Publishers, 2018) is written as a first-aid guide for parents of young people struggling with the mental health issues facing college students today. The importance of parents working collaboratively with the student/patient and the health care team is stressed throughout; Dr. Marcia Morris draws upon the medical literature and more than 20 years’ experience as a psychiatrist at the University of Florida, Gainesville, to provide clear guidance on a key theme: The continued support and involvement of caring parents in a young adult’s life can be crucial to her college success.

The book is well organized with separate chapters containing easy-to-understand explanations of the causes and treatments of common problems (anxiety, depression, substance use, academic failure to thrive), pressures (loneliness, perfectionism, financial stress, and culture/sexuality/gender issues), and crises (suicide, sexual assault, eating disorders, psychosis) affecting students today. Helpful background information about medications, resources for obtaining help on campuses, and legal issues about confidentiality is provided where appropriate. Each section is brought to life with vignettes of typical patients seen in the college mental health setting. Questions that ask the reader how they would respond in the situation illustrated are used effectively and encourage the reader to think through the information presented and retain what they have learned. Helpful summary lists of “tips” close most chapters.

In her introduction, Dr. Morris stresses that this book is not just for parents but also for family and friends who may find themselves in the role of being the caring adult in a student’s life. She encourages parents to read the whole book, even those chapters they may not think will apply to their child, explaining how common difficulties are in this age group and how important it is to know how to respond when an issue may arise.

Although this is good advice, I suspect that many parents without specific concerns are unlikely to proactively choose to read this book. Concerned parents who do pick this volume up “just in case” will find specific strategies for effective and helpful communication with their child and with professionals as well as stories of reassuring good outcomes from parental involvement. Dr. Morris recommends that parents ask their child to obtain access for the parents to the student’s grades and grant permission for parents to communicate with mental health care providers and school administration. However, she does not offer much guidance for the parent of the child who never signs the required forms to allow access to this information – and is generally not communicative with the parents.

Parents of a teenager who receives treatment (even prior to college) certainly should be encouraged to read this book. I also would recommend this book for many others working with young adults (even if they are not in college settings) for example, health care professionals without mental health training, educators, psychotherapist trainees, and mentors. Along with parents, they will find “The Campus Cure” to be a great resource for understanding and dealing with the mental health challenges of young adulthood.

Dr. Holland is board certified in child/adolescent and adult psychiatry. She is based in Boca Raton, Fla., where she is an affiliate assistant professor at Florida Atlantic University’s Schmidt College of Medicine. Click here to listen to a recent MDedge Psychcast interview with Dr. Morris about the prevalence of binge drinking on college campuses – and steps psychiatrists and other therapists can take to mitigate risk.

The national opioid epidemic is one of the most important public health challenges facing the United States today. This crisis has resulted in death, disability, and increased infectious and other comorbid diseases.

sdominick/iStock/Getty Images

Public attention has been focused on the medical management of pain, patterns of opioid prescriptions, and use of heroin and fentanyl. But the opioid crisis is, in fact, part of a far larger drug epidemic. The foundation on which the opioid epidemic is built is recreational pharmacology – the widespread use of aggressively marketed chemicals that seductively superstimulate brain-reward producing alterations in consciousness and pleasure, often mislabeled “self-medication.”

Drugs of abuse are unique chemicals that stimulate their own taking by producing an intense reinforcement in the human brain, which tells users that they have done something monumentally good. Instead of preserving the species, this chemical stimulation of brain reward begins the process of retraining the brain and reward system to respond quickly to drugs of abuse and drug-promoting cues. Drugs of abuse do not come from one class or chemical structure, but, rather, from disparate chemical classes that have in common the stimulation of brain reward. This bad learning is accelerated to addiction when drugs of abuse are smoked, snorted, vaped, or injected, as these routes of administration produce rapidly rising and falling blood levels.

Thanks to the science of animal models, we understand drug self-administration and abstinence. However, in animals, we cannot approximate addiction beyond the mechanical because of the cultural complexity of human behavior. Most animal models are good at predicting what treatments will work for drug addiction in animals. They are less predictive when it comes to humans. Animal models are good for understanding withdrawal reversal and identifying self-administration reductions and even changes in place preference. Animal models have consistently shown that drugs of abuse raise the brain’s reward threshold and cause epigenetic changes, and that many of these changes are persistent, if not permanent. In animal models, clonidine or opioid detoxification followed by naltrexone is a cure for opioid use disorder. Again, in animal models, this protocol is tied to no relapses – just a cure. We know that this is not the case for humans suffering from opioid addiction, where relapses define the disorder.

A closer look at opioid overdoses

Opioid overdose deaths are skyrocketing in the United States. The number of deaths tied to opioid overdoses quadrupled between 1999 and 2015 (in this 15-year period, that is more than 500,000 deaths). Then, between 2015 and 2016, they further increased dramatically to more than 60,000 and in 2017 topped 72,000. This increase was driven partly by a sevenfold increase in overdose deaths involving synthetic opioids (excluding methadone): from 3,105 in 2013 to about 20,000 in 2016.

Illicitly manufactured fentanyl, a synthetic opioid 50-100 times more potent than morphine, is primarily responsible for this rapid increase. In addition, fentanyl analogs such as acetyl fentanyl, furanyl fentanyl, and carfentanil are being detected increasingly in overdose deaths and the illicit opioid drug supply. Drug overdose is the leading cause of accidental death in the United States, with opioids implicated in more than half of these deaths. Moreover, drug overdose is now the leading cause of death of all Americans under age 50. As if these data were not bad enough, recent analyses suggest that the number of opioid overdose deaths might be significantly undercounted. Without intervention, we would expect 235,000 opioid-related deaths (85,000 from prescription opioids and 150,000 from heroin) from 2016 to 2020; and 510,000 opioid-related deaths (170,000 from prescription opioids and 340,000 from heroin) from 2016 to 2025.¹ In these opioid overdose deaths, rarely is the opioid the only drug present. Data from the Florida Drug-Related Outcomes Surveillance & Tracking System show that, in that state, more than 90% of opioid overdose deaths in 2016 showed other drugs of abuse present at death, an average of 2 to 4 – but as many as 11.²

It is well-accepted that medicine – in particular the overprescribing of opioids for pain and downplaying the risks of prescription opioid use – has played a fundamental role in the exponential rise in addiction and overdose death. The prescribing of other controlled substances, especially stimulants and benzodiazepines, also is a factor in overdose deaths.

To say that the country has an opioid problem would be a simplistic understatement. It has been too easy to zero in on opioids while ignoring the ubiquity of polysubstance use by almost all individuals suffering from opioid and other substance use disorders and related drug problems, including overdose. Drug sellers are innovative, consistently adding new chemicals to the menu of available drugs. The user market keeps adding potential customers who already have trained their brains and dopamine systems to respond vigorously to drug-promoting cues and drugs. We are a nation of polydrug users without drug or brand loyalty, engaging in “recreational pharmacology.” Framing the national drug problem around opioids misses the bigger target. The future of the national drug problem is more drugs used by more drug users – not simply prescription misuse or even opioids but instead globally produced illegal synthetic drugs as is now common in Hong Kong and Southeast Asia. A focus exclusively on opioid use disorders might yield great progress in new treatment developments that are specific to opioids. But few people addicted to opioids do not also use many other drugs in other drug classes. The opioid treatments (for example, buprenorphine, methadone, naltrexone) are irrelevant to these other addictive and problem-generating drugs.

Finally, as a very recent report found, the national opioid epidemic has had profound second- and third-hand effects on those with opioid use disorders, their families, and communities, costing about $80 billion yearly in lost productivity, treatment (including emergency, medical, psychiatric, and addiction-specific care), and criminal justice involvement.¹ Worse yet, missing from current discussion is the simple fact that drug users in the United States spend $100 billion on drugs each year. The entire annual cost of all treatment – both public and private – for alcohol and other substance use disorders is $34 billion a year. Drug users could pay for all of the treatment in the country with one-third of the money they now spend on drugs.

How much do drug users themselves spend on addiction treatment? Close to zero. The costs of both treatment and prevention are almost all carried by nondrug users. While many drug policy discussions call for “more treatment,” as important as that objective is, overlooked is the fact that 95% of people with substance use disorders do not think they have a drug problem and do not want treatment. What actions are needed now?

Control drug supply

Illicit drug supply used to be centrally controlled and reasonably well understood by law enforcement. Today, the illegal supply of addicting chemicals is global, innovative, massive, and decentralized. More drugs, including opioids, are now manufactured and delivered to users in higher potency, at lower prices, and with greater convenience than ever before. At the same time, illegal drug suppliers are moving away from agriculturally produced drugs such as marijuana, cocaine, and heroin to purely synthetic drugs such as synthetic cannabis, methamphetamine, and fentanyl. These synthetics do not require growing fields that are difficult to conceal, nor do they require farmers, or complex, clandestine, and vulnerable modes of transportation.

Instead, these new drugs can be synthesized in small and mobile laboratories located in any part of the globe and delivered anonymously, often by mail, to the users’ addresses. In addition, there remains ample illegal access to the older addicting agricultural chemicals and access to the many addicting legal chemicals that are widely used in the practice of medicine (for example, prescription drugs, including opioids). These abundant and varied sources make addicting drugs widely available to millions of Americans. Strong supply reduction efforts are needed. We must use the Drug Enforcement Administration to increase the cost of doing business in the illegal drug supply chain, and decrease access to drugs by bolstering interdiction and reducing precursor access. We can work to screen packages for drugs sent by U.S. mail or other express services.

It is gratifying to see so many of the missing pieces identified in the classic report³ published in 2012 by Columbia University in New York. Health care providers and professionals-in-training are being taught addiction medicine principles and practices. The Surgeon General has helped mobilize the public response to this crisis, and rightly suggested⁴ that everyone learn how to use and carry naloxone. Researchers are refocused on more than supply reduction.⁵ In addition, the Substance Abuse and Mental Health Services Administration and the National Institute on Drug Abuse (NIDA) are working on delivery service improvements, developing nonopioid pain medications, and new treatments for addiction.

Increase access to naloxone

Increasing access to the opioid reversal medication is critical. Because of the surge in opioid overdose–related mortality, considerable resources have been devoted to emergency response and the widespread dissemination of the mu-opioid receptor antagonist naloxone.⁶

Naloxone should be readily available without prescription and at a price that makes access practical for emergency technicians and any concerned citizen. Administering naloxone should be analogous to CPR or cardioversion. They are similar, in that they are life-saving actions, but the target within the patient is the brain, rather than the heart. CPR education and cardioversion training efforts and access have been promoted well across the United States and can be done for naloxone.

Another comparison has been made between naloxone and giving an EpiPen to an allergic person in an anaphylaxis emergency or crisis. We need and want to rescue, resuscitate, and revive the overdosed patient and give the person another chance to make a change. We want to administer naloxone and get the patient evaluated and into long-term treatment. Now, rapid return to drug use is common after overdose reversal. We need to use overdose reversal as a path to treatment and see that it is sustained to long-term abstinence from drug use. The most recent report on the high cost of drug use correctly points out that none of the current treatment and policy proposals can reduce substantially the number of overdose deaths.¹ Among 11 interventions analyzed by those researchers, making naloxone more available resulted in the greatest number of addiction deaths prevented.


 

Learn from physician health model of care

An assessment is needed of the 5-year recovery outcomes of all interventions for substance use disorder, including treatments that use and do not use medications, and harm-reduction interventions such as naloxone, needle exchange, and safe injection sites. A few years ago, researchers reported on a sample of 904 physicians consecutively admitted to 16 state Physician Health Programs (PHPs) that was monitored for 5 years or longer.⁷

This study characterized the outcomes of this episode of care and explored the elements of those programs that could improve the care routinely given to physicians but not to other addicted populations. PHPs were abstinence based and required physicians to abstain from any use of alcohol or other drugs of abuse as assessed by frequent random tests typically lasting for 5 years. Random tests rapidly identified any return to substance use, leading to swift and significant consequences.

Remarkably, 78% of participants had no positive test for either alcohol or drugs over the 5-year period of intensive monitoring. At posttreatment follow-up, 72% of the physicians were continuing to practice medicine. A key to the PHPs’ success is the 5 years of close monitoring with immediate consequences for any use and rapid, vigorous intervention upon any relapse to alcohol or drugs.

The unique PHP care management included close links to the 12-step fellowships of Alcoholics Anonymous (AA), Narcotics Anonymous, and other intensive recovery support for the entire 5 years of care management. The PHPs used relatively brief residential and outpatient treatment programs. Given the remarkable long-term outcomes of the PHPs, this model of care management should inspire new approaches to integrated and sustained care management of addiction in health care generally. The 5-year recovery standard should be applied to all addiction treatments to judge their value.⁸

Re-energize prevention efforts

The country must integrate addiction care into all of health care in the model of other chronic disease management: from prevention to intervention, treatment, monitoring, and intervention for any relapse. For prevention, we must retarget the health goal for youth under age 21 of no use of alcohol, nicotine, marijuana, or other drugs. Substance use disorders, including opioid use disorders, can be traced to adolescent use of alcohol and other drugs. The younger the age of a person initiating the use of any addicting substance – and the more chronic that use – the greater the likelihood of subsequent substance use problems persisting, or reigniting, later in life.

This later addiction risk resulting from adolescent drug use is no surprise, given the unique vulnerability of the adolescent brain, a brain that is especially vulnerable to addicting chemicals and that is not fully developed until about age 25. Effective addiction prevention – for example, helping youth grow up drug free – can improve dramatically public health by reducing the lifetime prevalence of substance use disorders, including opioid addiction.

Youth prevention efforts today vary tremendously in message and scope. Often, prevention messages for youth are limited to specific drugs (for example, nonmedical use of prescription drugs or tobacco) to specific situations (e.g., drunk driving), or to specific amounts of drug use (for example, binge drinking) when all substance use among youth is linked and all drug use poses health risks during adolescence and beyond. Among youth aged 12-17, the use of any one of the three most widely used and available drugs – alcohol, nicotine, and marijuana – increases the likelihood of using the other two drugs, as well as other illicit drugs.⁹ Similarly, no use of alcohol, nicotine, or marijuana decreases the likelihood of using the others, or of using other illicit drugs.

A recent clinical report and policy statement issued by the American Academy of Pediatrics affirms that it is in the best interests of young patients to not use any substances.¹⁰ The screening recommendations issued by the AAP further encourage pediatricians and adolescent medicine physicians to help guide their patients to this fundamental and easily-understood health goal.

A new and better vision for addiction prevention must focus on the single, clear goal of no use of alcohol, nicotine, marijuana, or other drugs for health by youth under age 21.¹¹ Some good news for prevention is that, for the past 3 decades, there has been a slow but steadily increasing percentage of American high school seniors reporting abstinence from any use of alcohol, cigarettes, marijuana, and other illicit drugs.¹² In 2014, 25.5% of high school seniors reported lifetime abstinence, and fully 50% reported past-month abstinence from all substances. Those figures are dramatic, compared with abstinence rates during the nation’s peak years of youth drug use. In 1978, among high school seniors, 4.4% reported lifetime abstinence from any use of alcohol, cigarettes, marijuana, and other illicit drugs and 21% reported past-month abstinence. Notably, similar increasing rates of abstinence have been recorded among eighth- and 10th-graders. This encouraging and largely overlooked reality demonstrates that the no-use prevention goal for youth is both realistic and attainable.
 

Expand drug and alcohol courts

We need to rehabilitate the role of the criminal justice system in a public health–oriented policy to achieve two essential goals: 1) to improve supply reduction as described above, and 2) to reshape the criminal justice system as an engine of recovery as it is now for alcohol addiction.

The landmark report, “Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health,” called for a continuum of health care extending from prevention to early identification and treatment of substance use disorders and long-term health care management with the goal of sustained recovery.¹³ A growing number of pioneering programs within the criminal justice system (for example, Hawaii’s HOPE Probation, South Dakota’s 24/7 Sobriety Project, and drug courts) are using innovative monitoring strategies for individuals with substance use problems, including providing substance use disorder treatment, with results showing reduced substance use, reduced recidivism, and reduced incarceration.¹⁴

In HOPE, drug-involved offenders are subject to frequent random drug testing, rather than the typical drug testing done on standard probation, only at the time of scheduled meetings with probation officers. Failure to abstain from drugs or failure to show up for random drug testing always results in a brief jail sanction, usually 2-15 days, depending on the nature and severity of the offense. Upon placement in HOPE at a warning hearing, probationers are encouraged to succeed, and are fully informed of the length of the jail sanctions that will be imposed for each type of violation. They are assured of the certainty and speed with which the sanctions will be applied.

Sanctions are applied consistently and impartially to ensure fairness for all. Substance abuse treatment is available to all offenders who want it and to those who demonstrate a need for treatment through “behavioral triage.” Offenders who test positive for drugs two or more times in short order with jail sanctions are referred for a substance abuse assessment and instructed to follow any recommended treatment. For this reason, offenders in HOPE succeed in treatment – because they are the offenders in most need and are supported by the leverage provided by the court to help them complete treatment.

A randomized, controlled trial compared offenders assigned to HOPE Probation and a control group assigned to probation as usual. Compared with offenders on probation as usual, at 1-year follow-up, HOPE offenders were:

• 55% less likely to be arrested for a new crime.

• 72% less likely to test positive for illegal drugs.

• 61% less likely to skip appointments with their supervisory officer.

• 53% less likely to have their probation revoked.

There also is a growing potential to harness the latent but enormous strength of the families who have confronted and are continuing to confront addiction in a family member. Families and those with addictions can be engaged in alcohol or drug courts, which can act like the PHP for addicted individuals in the criminal justice system.
 

Implications for treatment

The diversion of medications that are prescribed and intended for patients in pain is just one part of the far larger drug use and overdose problem. An addicted person with a hijacked brain is not the same as a nonaddicted pain patient. Taking medication as prescribed for pain can produce physical dependence, but importantly, this is not addiction. The person who is using drugs – whether or not prescribed – to produce euphoria is a different person from the person in that same body who is abstinent and not using. Talking with a person in active addiction often is frustrating and futile. That addicted user’s brain wants to use drugs.

The PHP system of care management demonstrates that individuals with substance use disorders can refrain from any substance use for extended periods of time with a carrot and stick approach; permitting a physician to earn a livelihood as a physician is the carrot. In medication-assisted treatment (MAT), the carrot is provided by agonist drugs and the comfort-fit they provide in the brain. They protect the patient from anxiety, and reduce stress and craving responsivity. The stick is an environment that is intolerant of continued nonmedical or addicting drug use. This can be the family, an employer, the criminal justice system, or others in a position to insist on abstinence.

PHP care management shows the way to improve all treatment outcomes; however, an even larger lesson can be learned from the millions of Americans now in recovery from addiction to opioids and other drugs. The “evidence” of what recovery is and how it is achieved and sustained is available to everyone who knows or comes into contact with people in recovery. How did that near-miraculous transformation happen? Even more importantly, how is it sustained when relapse is so common in addiction? The millions of Americans in recovery are the inspiration for a new generation of improved addiction treatment.

Addiction reprioritizes the brain toward continued drug use first, rather than family, friends, health, job, or another important remnant of the addicted person’s past having any meaningful standing. It is often a question like that raised by the AA axiom that it is easy to change a cucumber (naive or new drug user) into a pickle (an addict), but turning a pickle into a cucumber is very difficult. Risk-benefit research has shown that drugs change the ability to accurately assess risks and benefits by prioritizing drug use over virtually everything else, including the interests of the drug users themselves.

Along with judgment deficits comes dishonesty – a hallmark of addiction. The person with addictions lies, minimizes, and denies drug use, thus keeping the addictive run going. That often is the heart of addiction. The point is that once the disease is in control of the addicted brain, those around that hijacked brain must intervene – and the goal of cutting down drug use or limiting it to exclude one or another drug is not useful. Rather, it perpetuates the addiction. Freedom from addiction, that modern chemical slavery, requires no use of alcohol and other drugs, including marijuana, and a return to healthy relationships, sleep, eating, exercise, etc.

Recovery is more than abstinence from all drug use; it includes character development and citizenship. The data supporting the essential goal of recovery are found in the people who are in recovery not in today’s scientific research, which generally is off-target on recovery. Just because recovering people are anonymous does not mean that they do not exist. They prove that recovery happens all the time. They show what recovery is, and how it is achieved and maintained. Current arguments over which MAT is the best in a 3-month study is too short-term for a lifetime disorder and it ignores the concept of recovery despite the millions of people who are living it. Their stories are the bedrock of our message.

Our core evidence, our inspiration, comes from asking the people in recovery from the deadly, chronic disease of addiction three questions: 1) What was your life like when using drugs? 2) What happened to get you to stop using drugs? and 3) What is your life like when not using any drugs?” Every American who knows someone in recovery can do this research for themselves. We have been doing that research for decades.

People in recovery all have sobriety dates. Few in MAT have sobriety dates. Recovery from addiction is not just not taking Vicodin but living the life of a drug-free, recovering person. How do they hold onto recovery, and prevent and deal with relapses and slips? MAT is a major achievement in addiction treatment, including agonist maintenance with buprenorphine and methadone, but it needs to build in the goal of sustained recovery and strong recovery support. That means building into MAT the 12-step fellowships and related recovery support, as is done every day by James H. Berry, DO, of the Chestnut Ridge Center at West Virginia University’s Comprehensive Opioid Addiction Treatment, or COAT, program.¹⁵

MAT is good. It needs to be targeted on recovery, which can include continued use of the medicines now widely used: methadone, buprenorphine, and naltrexone. But recovery cannot include continued nonmedical drug use, and it also must include character development – with honesty replacing the dishonesty that is at the heart of addiction.

Dr. Gold is the 17th Distinguished Alumni Professor at the University of Florida, Gainesville, professor of psychiatry (adjunct) at Washington University in St. Louis. Dr. DuPont is the first director of the National Institute on Drug Abuse and the second White House drug chief, founding president of the Institute for Behavior and Health in Rockville, Md., and author of “Chemical Slavery: Understanding Addiction and Stopping the Drug Epidemic” (Create Space Independent Publishing Platform), 2018.

References

1. Am J Public Health. 2018 Oct 108(10):1394-1400.

2. Florida Drug-Related Outcomes Surveillance & Tracking system (FROST)

3. Center on Addiction. Addiction Medicine: Closing the Gap Between Science and Practice. 2012 Jun.

4. Surgeon General’s Advisory on Naloxone and Opioid Overdose.

5. Mayo Clin Proc. 2018 Mar;93(3):269-72.

6. Ther Adv Drug Saf. 2015 Feb;6(1):20-31.

7. J Subst Abuse Treat. 2009 Mar;36(2):159-71.

8. J Subst Abuse Treat. 2015 Nov;58:1-5.

9. Prev Med. 2018 Aug;113:68-73.

10. Pediatrics. 2016 Jun;138(1). doi: 10.1542/peds.2016-1211.

11. Institute for Behavior and Health. (updated) 2018 Aug 29.

12. Pediatrics. 2018 Aug;142(2). doi: 10.1542/peds.2017-3498.

13. Office of the Surgeon General. 2016.

14. The ASAM Principles of Addiction Medicine. (6th ed.) (in press) Wolters Kluwer, 2018.

15. West Virginia Clinical and Translational Science Institute. 2017 Aug 21.

The national opioid epidemic is one of the most important public health challenges facing the United States today. This crisis has resulted in death, disability, and increased infectious and other comorbid diseases.

sdominick/iStock/Getty Images

Public attention has been focused on the medical management of pain, patterns of opioid prescriptions, and use of heroin and fentanyl. But the opioid crisis is, in fact, part of a far larger drug epidemic. The foundation on which the opioid epidemic is built is recreational pharmacology – the widespread use of aggressively marketed chemicals that seductively superstimulate brain-reward producing alterations in consciousness and pleasure, often mislabeled “self-medication.”

Drugs of abuse are unique chemicals that stimulate their own taking by producing an intense reinforcement in the human brain, which tells users that they have done something monumentally good. Instead of preserving the species, this chemical stimulation of brain reward begins the process of retraining the brain and reward system to respond quickly to drugs of abuse and drug-promoting cues. Drugs of abuse do not come from one class or chemical structure, but, rather, from disparate chemical classes that have in common the stimulation of brain reward. This bad learning is accelerated to addiction when drugs of abuse are smoked, snorted, vaped, or injected, as these routes of administration produce rapidly rising and falling blood levels.

Thanks to the science of animal models, we understand drug self-administration and abstinence. However, in animals, we cannot approximate addiction beyond the mechanical because of the cultural complexity of human behavior. Most animal models are good at predicting what treatments will work for drug addiction in animals. They are less predictive when it comes to humans. Animal models are good for understanding withdrawal reversal and identifying self-administration reductions and even changes in place preference. Animal models have consistently shown that drugs of abuse raise the brain’s reward threshold and cause epigenetic changes, and that many of these changes are persistent, if not permanent. In animal models, clonidine or opioid detoxification followed by naltrexone is a cure for opioid use disorder. Again, in animal models, this protocol is tied to no relapses – just a cure. We know that this is not the case for humans suffering from opioid addiction, where relapses define the disorder.

A closer look at opioid overdoses

Opioid overdose deaths are skyrocketing in the United States. The number of deaths tied to opioid overdoses quadrupled between 1999 and 2015 (in this 15-year period, that is more than 500,000 deaths). Then, between 2015 and 2016, they further increased dramatically to more than 60,000 and in 2017 topped 72,000. This increase was driven partly by a sevenfold increase in overdose deaths involving synthetic opioids (excluding methadone): from 3,105 in 2013 to about 20,000 in 2016.

Illicitly manufactured fentanyl, a synthetic opioid 50-100 times more potent than morphine, is primarily responsible for this rapid increase. In addition, fentanyl analogs such as acetyl fentanyl, furanyl fentanyl, and carfentanil are being detected increasingly in overdose deaths and the illicit opioid drug supply. Drug overdose is the leading cause of accidental death in the United States, with opioids implicated in more than half of these deaths. Moreover, drug overdose is now the leading cause of death of all Americans under age 50. As if these data were not bad enough, recent analyses suggest that the number of opioid overdose deaths might be significantly undercounted. Without intervention, we would expect 235,000 opioid-related deaths (85,000 from prescription opioids and 150,000 from heroin) from 2016 to 2020; and 510,000 opioid-related deaths (170,000 from prescription opioids and 340,000 from heroin) from 2016 to 2025.¹ In these opioid overdose deaths, rarely is the opioid the only drug present. Data from the Florida Drug-Related Outcomes Surveillance & Tracking System show that, in that state, more than 90% of opioid overdose deaths in 2016 showed other drugs of abuse present at death, an average of 2 to 4 – but as many as 11.²

It is well-accepted that medicine – in particular the overprescribing of opioids for pain and downplaying the risks of prescription opioid use – has played a fundamental role in the exponential rise in addiction and overdose death. The prescribing of other controlled substances, especially stimulants and benzodiazepines, also is a factor in overdose deaths.

To say that the country has an opioid problem would be a simplistic understatement. It has been too easy to zero in on opioids while ignoring the ubiquity of polysubstance use by almost all individuals suffering from opioid and other substance use disorders and related drug problems, including overdose. Drug sellers are innovative, consistently adding new chemicals to the menu of available drugs. The user market keeps adding potential customers who already have trained their brains and dopamine systems to respond vigorously to drug-promoting cues and drugs. We are a nation of polydrug users without drug or brand loyalty, engaging in “recreational pharmacology.” Framing the national drug problem around opioids misses the bigger target. The future of the national drug problem is more drugs used by more drug users – not simply prescription misuse or even opioids but instead globally produced illegal synthetic drugs as is now common in Hong Kong and Southeast Asia. A focus exclusively on opioid use disorders might yield great progress in new treatment developments that are specific to opioids. But few people addicted to opioids do not also use many other drugs in other drug classes. The opioid treatments (for example, buprenorphine, methadone, naltrexone) are irrelevant to these other addictive and problem-generating drugs.

Finally, as a very recent report found, the national opioid epidemic has had profound second- and third-hand effects on those with opioid use disorders, their families, and communities, costing about $80 billion yearly in lost productivity, treatment (including emergency, medical, psychiatric, and addiction-specific care), and criminal justice involvement.¹ Worse yet, missing from current discussion is the simple fact that drug users in the United States spend $100 billion on drugs each year. The entire annual cost of all treatment – both public and private – for alcohol and other substance use disorders is $34 billion a year. Drug users could pay for all of the treatment in the country with one-third of the money they now spend on drugs.

How much do drug users themselves spend on addiction treatment? Close to zero. The costs of both treatment and prevention are almost all carried by nondrug users. While many drug policy discussions call for “more treatment,” as important as that objective is, overlooked is the fact that 95% of people with substance use disorders do not think they have a drug problem and do not want treatment. What actions are needed now?

Control drug supply

Illicit drug supply used to be centrally controlled and reasonably well understood by law enforcement. Today, the illegal supply of addicting chemicals is global, innovative, massive, and decentralized. More drugs, including opioids, are now manufactured and delivered to users in higher potency, at lower prices, and with greater convenience than ever before. At the same time, illegal drug suppliers are moving away from agriculturally produced drugs such as marijuana, cocaine, and heroin to purely synthetic drugs such as synthetic cannabis, methamphetamine, and fentanyl. These synthetics do not require growing fields that are difficult to conceal, nor do they require farmers, or complex, clandestine, and vulnerable modes of transportation.

Instead, these new drugs can be synthesized in small and mobile laboratories located in any part of the globe and delivered anonymously, often by mail, to the users’ addresses. In addition, there remains ample illegal access to the older addicting agricultural chemicals and access to the many addicting legal chemicals that are widely used in the practice of medicine (for example, prescription drugs, including opioids). These abundant and varied sources make addicting drugs widely available to millions of Americans. Strong supply reduction efforts are needed. We must use the Drug Enforcement Administration to increase the cost of doing business in the illegal drug supply chain, and decrease access to drugs by bolstering interdiction and reducing precursor access. We can work to screen packages for drugs sent by U.S. mail or other express services.

It is gratifying to see so many of the missing pieces identified in the classic report³ published in 2012 by Columbia University in New York. Health care providers and professionals-in-training are being taught addiction medicine principles and practices. The Surgeon General has helped mobilize the public response to this crisis, and rightly suggested⁴ that everyone learn how to use and carry naloxone. Researchers are refocused on more than supply reduction.⁵ In addition, the Substance Abuse and Mental Health Services Administration and the National Institute on Drug Abuse (NIDA) are working on delivery service improvements, developing nonopioid pain medications, and new treatments for addiction.

Increase access to naloxone

Increasing access to the opioid reversal medication is critical. Because of the surge in opioid overdose–related mortality, considerable resources have been devoted to emergency response and the widespread dissemination of the mu-opioid receptor antagonist naloxone.⁶

Naloxone should be readily available without prescription and at a price that makes access practical for emergency technicians and any concerned citizen. Administering naloxone should be analogous to CPR or cardioversion. They are similar, in that they are life-saving actions, but the target within the patient is the brain, rather than the heart. CPR education and cardioversion training efforts and access have been promoted well across the United States and can be done for naloxone.

Another comparison has been made between naloxone and giving an EpiPen to an allergic person in an anaphylaxis emergency or crisis. We need and want to rescue, resuscitate, and revive the overdosed patient and give the person another chance to make a change. We want to administer naloxone and get the patient evaluated and into long-term treatment. Now, rapid return to drug use is common after overdose reversal. We need to use overdose reversal as a path to treatment and see that it is sustained to long-term abstinence from drug use. The most recent report on the high cost of drug use correctly points out that none of the current treatment and policy proposals can reduce substantially the number of overdose deaths.¹ Among 11 interventions analyzed by those researchers, making naloxone more available resulted in the greatest number of addiction deaths prevented.


 

Learn from physician health model of care

An assessment is needed of the 5-year recovery outcomes of all interventions for substance use disorder, including treatments that use and do not use medications, and harm-reduction interventions such as naloxone, needle exchange, and safe injection sites. A few years ago, researchers reported on a sample of 904 physicians consecutively admitted to 16 state Physician Health Programs (PHPs) that was monitored for 5 years or longer.⁷

This study characterized the outcomes of this episode of care and explored the elements of those programs that could improve the care routinely given to physicians but not to other addicted populations. PHPs were abstinence based and required physicians to abstain from any use of alcohol or other drugs of abuse as assessed by frequent random tests typically lasting for 5 years. Random tests rapidly identified any return to substance use, leading to swift and significant consequences.

Remarkably, 78% of participants had no positive test for either alcohol or drugs over the 5-year period of intensive monitoring. At posttreatment follow-up, 72% of the physicians were continuing to practice medicine. A key to the PHPs’ success is the 5 years of close monitoring with immediate consequences for any use and rapid, vigorous intervention upon any relapse to alcohol or drugs.

The unique PHP care management included close links to the 12-step fellowships of Alcoholics Anonymous (AA), Narcotics Anonymous, and other intensive recovery support for the entire 5 years of care management. The PHPs used relatively brief residential and outpatient treatment programs. Given the remarkable long-term outcomes of the PHPs, this model of care management should inspire new approaches to integrated and sustained care management of addiction in health care generally. The 5-year recovery standard should be applied to all addiction treatments to judge their value.⁸

Re-energize prevention efforts

The country must integrate addiction care into all of health care in the model of other chronic disease management: from prevention to intervention, treatment, monitoring, and intervention for any relapse. For prevention, we must retarget the health goal for youth under age 21 of no use of alcohol, nicotine, marijuana, or other drugs. Substance use disorders, including opioid use disorders, can be traced to adolescent use of alcohol and other drugs. The younger the age of a person initiating the use of any addicting substance – and the more chronic that use – the greater the likelihood of subsequent substance use problems persisting, or reigniting, later in life.

This later addiction risk resulting from adolescent drug use is no surprise, given the unique vulnerability of the adolescent brain, a brain that is especially vulnerable to addicting chemicals and that is not fully developed until about age 25. Effective addiction prevention – for example, helping youth grow up drug free – can improve dramatically public health by reducing the lifetime prevalence of substance use disorders, including opioid addiction.

Youth prevention efforts today vary tremendously in message and scope. Often, prevention messages for youth are limited to specific drugs (for example, nonmedical use of prescription drugs or tobacco) to specific situations (e.g., drunk driving), or to specific amounts of drug use (for example, binge drinking) when all substance use among youth is linked and all drug use poses health risks during adolescence and beyond. Among youth aged 12-17, the use of any one of the three most widely used and available drugs – alcohol, nicotine, and marijuana – increases the likelihood of using the other two drugs, as well as other illicit drugs.⁹ Similarly, no use of alcohol, nicotine, or marijuana decreases the likelihood of using the others, or of using other illicit drugs.

A recent clinical report and policy statement issued by the American Academy of Pediatrics affirms that it is in the best interests of young patients to not use any substances.¹⁰ The screening recommendations issued by the AAP further encourage pediatricians and adolescent medicine physicians to help guide their patients to this fundamental and easily-understood health goal.

A new and better vision for addiction prevention must focus on the single, clear goal of no use of alcohol, nicotine, marijuana, or other drugs for health by youth under age 21.¹¹ Some good news for prevention is that, for the past 3 decades, there has been a slow but steadily increasing percentage of American high school seniors reporting abstinence from any use of alcohol, cigarettes, marijuana, and other illicit drugs.¹² In 2014, 25.5% of high school seniors reported lifetime abstinence, and fully 50% reported past-month abstinence from all substances. Those figures are dramatic, compared with abstinence rates during the nation’s peak years of youth drug use. In 1978, among high school seniors, 4.4% reported lifetime abstinence from any use of alcohol, cigarettes, marijuana, and other illicit drugs and 21% reported past-month abstinence. Notably, similar increasing rates of abstinence have been recorded among eighth- and 10th-graders. This encouraging and largely overlooked reality demonstrates that the no-use prevention goal for youth is both realistic and attainable.
 

Expand drug and alcohol courts

We need to rehabilitate the role of the criminal justice system in a public health–oriented policy to achieve two essential goals: 1) to improve supply reduction as described above, and 2) to reshape the criminal justice system as an engine of recovery as it is now for alcohol addiction.

The landmark report, “Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health,” called for a continuum of health care extending from prevention to early identification and treatment of substance use disorders and long-term health care management with the goal of sustained recovery.¹³ A growing number of pioneering programs within the criminal justice system (for example, Hawaii’s HOPE Probation, South Dakota’s 24/7 Sobriety Project, and drug courts) are using innovative monitoring strategies for individuals with substance use problems, including providing substance use disorder treatment, with results showing reduced substance use, reduced recidivism, and reduced incarceration.¹⁴

In HOPE, drug-involved offenders are subject to frequent random drug testing, rather than the typical drug testing done on standard probation, only at the time of scheduled meetings with probation officers. Failure to abstain from drugs or failure to show up for random drug testing always results in a brief jail sanction, usually 2-15 days, depending on the nature and severity of the offense. Upon placement in HOPE at a warning hearing, probationers are encouraged to succeed, and are fully informed of the length of the jail sanctions that will be imposed for each type of violation. They are assured of the certainty and speed with which the sanctions will be applied.

Sanctions are applied consistently and impartially to ensure fairness for all. Substance abuse treatment is available to all offenders who want it and to those who demonstrate a need for treatment through “behavioral triage.” Offenders who test positive for drugs two or more times in short order with jail sanctions are referred for a substance abuse assessment and instructed to follow any recommended treatment. For this reason, offenders in HOPE succeed in treatment – because they are the offenders in most need and are supported by the leverage provided by the court to help them complete treatment.

A randomized, controlled trial compared offenders assigned to HOPE Probation and a control group assigned to probation as usual. Compared with offenders on probation as usual, at 1-year follow-up, HOPE offenders were:

• 55% less likely to be arrested for a new crime.

• 72% less likely to test positive for illegal drugs.

• 61% less likely to skip appointments with their supervisory officer.

• 53% less likely to have their probation revoked.

There also is a growing potential to harness the latent but enormous strength of the families who have confronted and are continuing to confront addiction in a family member. Families and those with addictions can be engaged in alcohol or drug courts, which can act like the PHP for addicted individuals in the criminal justice system.
 

Implications for treatment

The diversion of medications that are prescribed and intended for patients in pain is just one part of the far larger drug use and overdose problem. An addicted person with a hijacked brain is not the same as a nonaddicted pain patient. Taking medication as prescribed for pain can produce physical dependence, but importantly, this is not addiction. The person who is using drugs – whether or not prescribed – to produce euphoria is a different person from the person in that same body who is abstinent and not using. Talking with a person in active addiction often is frustrating and futile. That addicted user’s brain wants to use drugs.

The PHP system of care management demonstrates that individuals with substance use disorders can refrain from any substance use for extended periods of time with a carrot and stick approach; permitting a physician to earn a livelihood as a physician is the carrot. In medication-assisted treatment (MAT), the carrot is provided by agonist drugs and the comfort-fit they provide in the brain. They protect the patient from anxiety, and reduce stress and craving responsivity. The stick is an environment that is intolerant of continued nonmedical or addicting drug use. This can be the family, an employer, the criminal justice system, or others in a position to insist on abstinence.

PHP care management shows the way to improve all treatment outcomes; however, an even larger lesson can be learned from the millions of Americans now in recovery from addiction to opioids and other drugs. The “evidence” of what recovery is and how it is achieved and sustained is available to everyone who knows or comes into contact with people in recovery. How did that near-miraculous transformation happen? Even more importantly, how is it sustained when relapse is so common in addiction? The millions of Americans in recovery are the inspiration for a new generation of improved addiction treatment.

Addiction reprioritizes the brain toward continued drug use first, rather than family, friends, health, job, or another important remnant of the addicted person’s past having any meaningful standing. It is often a question like that raised by the AA axiom that it is easy to change a cucumber (naive or new drug user) into a pickle (an addict), but turning a pickle into a cucumber is very difficult. Risk-benefit research has shown that drugs change the ability to accurately assess risks and benefits by prioritizing drug use over virtually everything else, including the interests of the drug users themselves.

Along with judgment deficits comes dishonesty – a hallmark of addiction. The person with addictions lies, minimizes, and denies drug use, thus keeping the addictive run going. That often is the heart of addiction. The point is that once the disease is in control of the addicted brain, those around that hijacked brain must intervene – and the goal of cutting down drug use or limiting it to exclude one or another drug is not useful. Rather, it perpetuates the addiction. Freedom from addiction, that modern chemical slavery, requires no use of alcohol and other drugs, including marijuana, and a return to healthy relationships, sleep, eating, exercise, etc.

Recovery is more than abstinence from all drug use; it includes character development and citizenship. The data supporting the essential goal of recovery are found in the people who are in recovery not in today’s scientific research, which generally is off-target on recovery. Just because recovering people are anonymous does not mean that they do not exist. They prove that recovery happens all the time. They show what recovery is, and how it is achieved and maintained. Current arguments over which MAT is the best in a 3-month study is too short-term for a lifetime disorder and it ignores the concept of recovery despite the millions of people who are living it. Their stories are the bedrock of our message.

Our core evidence, our inspiration, comes from asking the people in recovery from the deadly, chronic disease of addiction three questions: 1) What was your life like when using drugs? 2) What happened to get you to stop using drugs? and 3) What is your life like when not using any drugs?” Every American who knows someone in recovery can do this research for themselves. We have been doing that research for decades.

People in recovery all have sobriety dates. Few in MAT have sobriety dates. Recovery from addiction is not just not taking Vicodin but living the life of a drug-free, recovering person. How do they hold onto recovery, and prevent and deal with relapses and slips? MAT is a major achievement in addiction treatment, including agonist maintenance with buprenorphine and methadone, but it needs to build in the goal of sustained recovery and strong recovery support. That means building into MAT the 12-step fellowships and related recovery support, as is done every day by James H. Berry, DO, of the Chestnut Ridge Center at West Virginia University’s Comprehensive Opioid Addiction Treatment, or COAT, program.¹⁵

MAT is good. It needs to be targeted on recovery, which can include continued use of the medicines now widely used: methadone, buprenorphine, and naltrexone. But recovery cannot include continued nonmedical drug use, and it also must include character development – with honesty replacing the dishonesty that is at the heart of addiction.

Dr. Gold is the 17th Distinguished Alumni Professor at the University of Florida, Gainesville, professor of psychiatry (adjunct) at Washington University in St. Louis. Dr. DuPont is the first director of the National Institute on Drug Abuse and the second White House drug chief, founding president of the Institute for Behavior and Health in Rockville, Md., and author of “Chemical Slavery: Understanding Addiction and Stopping the Drug Epidemic” (Create Space Independent Publishing Platform), 2018.

References

1. Am J Public Health. 2018 Oct 108(10):1394-1400.

2. Florida Drug-Related Outcomes Surveillance & Tracking system (FROST)

3. Center on Addiction. Addiction Medicine: Closing the Gap Between Science and Practice. 2012 Jun.

4. Surgeon General’s Advisory on Naloxone and Opioid Overdose.

5. Mayo Clin Proc. 2018 Mar;93(3):269-72.

6. Ther Adv Drug Saf. 2015 Feb;6(1):20-31.

7. J Subst Abuse Treat. 2009 Mar;36(2):159-71.

8. J Subst Abuse Treat. 2015 Nov;58:1-5.

9. Prev Med. 2018 Aug;113:68-73.

10. Pediatrics. 2016 Jun;138(1). doi: 10.1542/peds.2016-1211.

11. Institute for Behavior and Health. (updated) 2018 Aug 29.

12. Pediatrics. 2018 Aug;142(2). doi: 10.1542/peds.2017-3498.

13. Office of the Surgeon General. 2016.

14. The ASAM Principles of Addiction Medicine. (6th ed.) (in press) Wolters Kluwer, 2018.

15. West Virginia Clinical and Translational Science Institute. 2017 Aug 21.

The national opioid epidemic is one of the most important public health challenges facing the United States today. This crisis has resulted in death, disability, and increased infectious and other comorbid diseases.

sdominick/iStock/Getty Images

Public attention has been focused on the medical management of pain, patterns of opioid prescriptions, and use of heroin and fentanyl. But the opioid crisis is, in fact, part of a far larger drug epidemic. The foundation on which the opioid epidemic is built is recreational pharmacology – the widespread use of aggressively marketed chemicals that seductively superstimulate brain-reward producing alterations in consciousness and pleasure, often mislabeled “self-medication.”

Drugs of abuse are unique chemicals that stimulate their own taking by producing an intense reinforcement in the human brain, which tells users that they have done something monumentally good. Instead of preserving the species, this chemical stimulation of brain reward begins the process of retraining the brain and reward system to respond quickly to drugs of abuse and drug-promoting cues. Drugs of abuse do not come from one class or chemical structure, but, rather, from disparate chemical classes that have in common the stimulation of brain reward. This bad learning is accelerated to addiction when drugs of abuse are smoked, snorted, vaped, or injected, as these routes of administration produce rapidly rising and falling blood levels.

Thanks to the science of animal models, we understand drug self-administration and abstinence. However, in animals, we cannot approximate addiction beyond the mechanical because of the cultural complexity of human behavior. Most animal models are good at predicting what treatments will work for drug addiction in animals. They are less predictive when it comes to humans. Animal models are good for understanding withdrawal reversal and identifying self-administration reductions and even changes in place preference. Animal models have consistently shown that drugs of abuse raise the brain’s reward threshold and cause epigenetic changes, and that many of these changes are persistent, if not permanent. In animal models, clonidine or opioid detoxification followed by naltrexone is a cure for opioid use disorder. Again, in animal models, this protocol is tied to no relapses – just a cure. We know that this is not the case for humans suffering from opioid addiction, where relapses define the disorder.

A closer look at opioid overdoses

Opioid overdose deaths are skyrocketing in the United States. The number of deaths tied to opioid overdoses quadrupled between 1999 and 2015 (in this 15-year period, that is more than 500,000 deaths). Then, between 2015 and 2016, they further increased dramatically to more than 60,000 and in 2017 topped 72,000. This increase was driven partly by a sevenfold increase in overdose deaths involving synthetic opioids (excluding methadone): from 3,105 in 2013 to about 20,000 in 2016.

Illicitly manufactured fentanyl, a synthetic opioid 50-100 times more potent than morphine, is primarily responsible for this rapid increase. In addition, fentanyl analogs such as acetyl fentanyl, furanyl fentanyl, and carfentanil are being detected increasingly in overdose deaths and the illicit opioid drug supply. Drug overdose is the leading cause of accidental death in the United States, with opioids implicated in more than half of these deaths. Moreover, drug overdose is now the leading cause of death of all Americans under age 50. As if these data were not bad enough, recent analyses suggest that the number of opioid overdose deaths might be significantly undercounted. Without intervention, we would expect 235,000 opioid-related deaths (85,000 from prescription opioids and 150,000 from heroin) from 2016 to 2020; and 510,000 opioid-related deaths (170,000 from prescription opioids and 340,000 from heroin) from 2016 to 2025.¹ In these opioid overdose deaths, rarely is the opioid the only drug present. Data from the Florida Drug-Related Outcomes Surveillance & Tracking System show that, in that state, more than 90% of opioid overdose deaths in 2016 showed other drugs of abuse present at death, an average of 2 to 4 – but as many as 11.²

It is well-accepted that medicine – in particular the overprescribing of opioids for pain and downplaying the risks of prescription opioid use – has played a fundamental role in the exponential rise in addiction and overdose death. The prescribing of other controlled substances, especially stimulants and benzodiazepines, also is a factor in overdose deaths.

To say that the country has an opioid problem would be a simplistic understatement. It has been too easy to zero in on opioids while ignoring the ubiquity of polysubstance use by almost all individuals suffering from opioid and other substance use disorders and related drug problems, including overdose. Drug sellers are innovative, consistently adding new chemicals to the menu of available drugs. The user market keeps adding potential customers who already have trained their brains and dopamine systems to respond vigorously to drug-promoting cues and drugs. We are a nation of polydrug users without drug or brand loyalty, engaging in “recreational pharmacology.” Framing the national drug problem around opioids misses the bigger target. The future of the national drug problem is more drugs used by more drug users – not simply prescription misuse or even opioids but instead globally produced illegal synthetic drugs as is now common in Hong Kong and Southeast Asia. A focus exclusively on opioid use disorders might yield great progress in new treatment developments that are specific to opioids. But few people addicted to opioids do not also use many other drugs in other drug classes. The opioid treatments (for example, buprenorphine, methadone, naltrexone) are irrelevant to these other addictive and problem-generating drugs.

Finally, as a very recent report found, the national opioid epidemic has had profound second- and third-hand effects on those with opioid use disorders, their families, and communities, costing about $80 billion yearly in lost productivity, treatment (including emergency, medical, psychiatric, and addiction-specific care), and criminal justice involvement.¹ Worse yet, missing from current discussion is the simple fact that drug users in the United States spend $100 billion on drugs each year. The entire annual cost of all treatment – both public and private – for alcohol and other substance use disorders is $34 billion a year. Drug users could pay for all of the treatment in the country with one-third of the money they now spend on drugs.

How much do drug users themselves spend on addiction treatment? Close to zero. The costs of both treatment and prevention are almost all carried by nondrug users. While many drug policy discussions call for “more treatment,” as important as that objective is, overlooked is the fact that 95% of people with substance use disorders do not think they have a drug problem and do not want treatment. What actions are needed now?

Control drug supply

Illicit drug supply used to be centrally controlled and reasonably well understood by law enforcement. Today, the illegal supply of addicting chemicals is global, innovative, massive, and decentralized. More drugs, including opioids, are now manufactured and delivered to users in higher potency, at lower prices, and with greater convenience than ever before. At the same time, illegal drug suppliers are moving away from agriculturally produced drugs such as marijuana, cocaine, and heroin to purely synthetic drugs such as synthetic cannabis, methamphetamine, and fentanyl. These synthetics do not require growing fields that are difficult to conceal, nor do they require farmers, or complex, clandestine, and vulnerable modes of transportation.

Instead, these new drugs can be synthesized in small and mobile laboratories located in any part of the globe and delivered anonymously, often by mail, to the users’ addresses. In addition, there remains ample illegal access to the older addicting agricultural chemicals and access to the many addicting legal chemicals that are widely used in the practice of medicine (for example, prescription drugs, including opioids). These abundant and varied sources make addicting drugs widely available to millions of Americans. Strong supply reduction efforts are needed. We must use the Drug Enforcement Administration to increase the cost of doing business in the illegal drug supply chain, and decrease access to drugs by bolstering interdiction and reducing precursor access. We can work to screen packages for drugs sent by U.S. mail or other express services.

It is gratifying to see so many of the missing pieces identified in the classic report³ published in 2012 by Columbia University in New York. Health care providers and professionals-in-training are being taught addiction medicine principles and practices. The Surgeon General has helped mobilize the public response to this crisis, and rightly suggested⁴ that everyone learn how to use and carry naloxone. Researchers are refocused on more than supply reduction.⁵ In addition, the Substance Abuse and Mental Health Services Administration and the National Institute on Drug Abuse (NIDA) are working on delivery service improvements, developing nonopioid pain medications, and new treatments for addiction.

Increase access to naloxone

Increasing access to the opioid reversal medication is critical. Because of the surge in opioid overdose–related mortality, considerable resources have been devoted to emergency response and the widespread dissemination of the mu-opioid receptor antagonist naloxone.⁶

Naloxone should be readily available without prescription and at a price that makes access practical for emergency technicians and any concerned citizen. Administering naloxone should be analogous to CPR or cardioversion. They are similar, in that they are life-saving actions, but the target within the patient is the brain, rather than the heart. CPR education and cardioversion training efforts and access have been promoted well across the United States and can be done for naloxone.

Another comparison has been made between naloxone and giving an EpiPen to an allergic person in an anaphylaxis emergency or crisis. We need and want to rescue, resuscitate, and revive the overdosed patient and give the person another chance to make a change. We want to administer naloxone and get the patient evaluated and into long-term treatment. Now, rapid return to drug use is common after overdose reversal. We need to use overdose reversal as a path to treatment and see that it is sustained to long-term abstinence from drug use. The most recent report on the high cost of drug use correctly points out that none of the current treatment and policy proposals can reduce substantially the number of overdose deaths.¹ Among 11 interventions analyzed by those researchers, making naloxone more available resulted in the greatest number of addiction deaths prevented.


 

Learn from physician health model of care

An assessment is needed of the 5-year recovery outcomes of all interventions for substance use disorder, including treatments that use and do not use medications, and harm-reduction interventions such as naloxone, needle exchange, and safe injection sites. A few years ago, researchers reported on a sample of 904 physicians consecutively admitted to 16 state Physician Health Programs (PHPs) that was monitored for 5 years or longer.⁷

This study characterized the outcomes of this episode of care and explored the elements of those programs that could improve the care routinely given to physicians but not to other addicted populations. PHPs were abstinence based and required physicians to abstain from any use of alcohol or other drugs of abuse as assessed by frequent random tests typically lasting for 5 years. Random tests rapidly identified any return to substance use, leading to swift and significant consequences.

Remarkably, 78% of participants had no positive test for either alcohol or drugs over the 5-year period of intensive monitoring. At posttreatment follow-up, 72% of the physicians were continuing to practice medicine. A key to the PHPs’ success is the 5 years of close monitoring with immediate consequences for any use and rapid, vigorous intervention upon any relapse to alcohol or drugs.

The unique PHP care management included close links to the 12-step fellowships of Alcoholics Anonymous (AA), Narcotics Anonymous, and other intensive recovery support for the entire 5 years of care management. The PHPs used relatively brief residential and outpatient treatment programs. Given the remarkable long-term outcomes of the PHPs, this model of care management should inspire new approaches to integrated and sustained care management of addiction in health care generally. The 5-year recovery standard should be applied to all addiction treatments to judge their value.⁸

Re-energize prevention efforts

The country must integrate addiction care into all of health care in the model of other chronic disease management: from prevention to intervention, treatment, monitoring, and intervention for any relapse. For prevention, we must retarget the health goal for youth under age 21 of no use of alcohol, nicotine, marijuana, or other drugs. Substance use disorders, including opioid use disorders, can be traced to adolescent use of alcohol and other drugs. The younger the age of a person initiating the use of any addicting substance – and the more chronic that use – the greater the likelihood of subsequent substance use problems persisting, or reigniting, later in life.

This later addiction risk resulting from adolescent drug use is no surprise, given the unique vulnerability of the adolescent brain, a brain that is especially vulnerable to addicting chemicals and that is not fully developed until about age 25. Effective addiction prevention – for example, helping youth grow up drug free – can improve dramatically public health by reducing the lifetime prevalence of substance use disorders, including opioid addiction.

Youth prevention efforts today vary tremendously in message and scope. Often, prevention messages for youth are limited to specific drugs (for example, nonmedical use of prescription drugs or tobacco) to specific situations (e.g., drunk driving), or to specific amounts of drug use (for example, binge drinking) when all substance use among youth is linked and all drug use poses health risks during adolescence and beyond. Among youth aged 12-17, the use of any one of the three most widely used and available drugs – alcohol, nicotine, and marijuana – increases the likelihood of using the other two drugs, as well as other illicit drugs.⁹ Similarly, no use of alcohol, nicotine, or marijuana decreases the likelihood of using the others, or of using other illicit drugs.

A recent clinical report and policy statement issued by the American Academy of Pediatrics affirms that it is in the best interests of young patients to not use any substances.¹⁰ The screening recommendations issued by the AAP further encourage pediatricians and adolescent medicine physicians to help guide their patients to this fundamental and easily-understood health goal.

A new and better vision for addiction prevention must focus on the single, clear goal of no use of alcohol, nicotine, marijuana, or other drugs for health by youth under age 21.¹¹ Some good news for prevention is that, for the past 3 decades, there has been a slow but steadily increasing percentage of American high school seniors reporting abstinence from any use of alcohol, cigarettes, marijuana, and other illicit drugs.¹² In 2014, 25.5% of high school seniors reported lifetime abstinence, and fully 50% reported past-month abstinence from all substances. Those figures are dramatic, compared with abstinence rates during the nation’s peak years of youth drug use. In 1978, among high school seniors, 4.4% reported lifetime abstinence from any use of alcohol, cigarettes, marijuana, and other illicit drugs and 21% reported past-month abstinence. Notably, similar increasing rates of abstinence have been recorded among eighth- and 10th-graders. This encouraging and largely overlooked reality demonstrates that the no-use prevention goal for youth is both realistic and attainable.
 

Expand drug and alcohol courts

We need to rehabilitate the role of the criminal justice system in a public health–oriented policy to achieve two essential goals: 1) to improve supply reduction as described above, and 2) to reshape the criminal justice system as an engine of recovery as it is now for alcohol addiction.

The landmark report, “Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health,” called for a continuum of health care extending from prevention to early identification and treatment of substance use disorders and long-term health care management with the goal of sustained recovery.¹³ A growing number of pioneering programs within the criminal justice system (for example, Hawaii’s HOPE Probation, South Dakota’s 24/7 Sobriety Project, and drug courts) are using innovative monitoring strategies for individuals with substance use problems, including providing substance use disorder treatment, with results showing reduced substance use, reduced recidivism, and reduced incarceration.¹⁴

In HOPE, drug-involved offenders are subject to frequent random drug testing, rather than the typical drug testing done on standard probation, only at the time of scheduled meetings with probation officers. Failure to abstain from drugs or failure to show up for random drug testing always results in a brief jail sanction, usually 2-15 days, depending on the nature and severity of the offense. Upon placement in HOPE at a warning hearing, probationers are encouraged to succeed, and are fully informed of the length of the jail sanctions that will be imposed for each type of violation. They are assured of the certainty and speed with which the sanctions will be applied.

Sanctions are applied consistently and impartially to ensure fairness for all. Substance abuse treatment is available to all offenders who want it and to those who demonstrate a need for treatment through “behavioral triage.” Offenders who test positive for drugs two or more times in short order with jail sanctions are referred for a substance abuse assessment and instructed to follow any recommended treatment. For this reason, offenders in HOPE succeed in treatment – because they are the offenders in most need and are supported by the leverage provided by the court to help them complete treatment.

A randomized, controlled trial compared offenders assigned to HOPE Probation and a control group assigned to probation as usual. Compared with offenders on probation as usual, at 1-year follow-up, HOPE offenders were:

• 55% less likely to be arrested for a new crime.

• 72% less likely to test positive for illegal drugs.

• 61% less likely to skip appointments with their supervisory officer.

• 53% less likely to have their probation revoked.

There also is a growing potential to harness the latent but enormous strength of the families who have confronted and are continuing to confront addiction in a family member. Families and those with addictions can be engaged in alcohol or drug courts, which can act like the PHP for addicted individuals in the criminal justice system.
 

Implications for treatment

The diversion of medications that are prescribed and intended for patients in pain is just one part of the far larger drug use and overdose problem. An addicted person with a hijacked brain is not the same as a nonaddicted pain patient. Taking medication as prescribed for pain can produce physical dependence, but importantly, this is not addiction. The person who is using drugs – whether or not prescribed – to produce euphoria is a different person from the person in that same body who is abstinent and not using. Talking with a person in active addiction often is frustrating and futile. That addicted user’s brain wants to use drugs.

The PHP system of care management demonstrates that individuals with substance use disorders can refrain from any substance use for extended periods of time with a carrot and stick approach; permitting a physician to earn a livelihood as a physician is the carrot. In medication-assisted treatment (MAT), the carrot is provided by agonist drugs and the comfort-fit they provide in the brain. They protect the patient from anxiety, and reduce stress and craving responsivity. The stick is an environment that is intolerant of continued nonmedical or addicting drug use. This can be the family, an employer, the criminal justice system, or others in a position to insist on abstinence.

PHP care management shows the way to improve all treatment outcomes; however, an even larger lesson can be learned from the millions of Americans now in recovery from addiction to opioids and other drugs. The “evidence” of what recovery is and how it is achieved and sustained is available to everyone who knows or comes into contact with people in recovery. How did that near-miraculous transformation happen? Even more importantly, how is it sustained when relapse is so common in addiction? The millions of Americans in recovery are the inspiration for a new generation of improved addiction treatment.

Addiction reprioritizes the brain toward continued drug use first, rather than family, friends, health, job, or another important remnant of the addicted person’s past having any meaningful standing. It is often a question like that raised by the AA axiom that it is easy to change a cucumber (naive or new drug user) into a pickle (an addict), but turning a pickle into a cucumber is very difficult. Risk-benefit research has shown that drugs change the ability to accurately assess risks and benefits by prioritizing drug use over virtually everything else, including the interests of the drug users themselves.

Along with judgment deficits comes dishonesty – a hallmark of addiction. The person with addictions lies, minimizes, and denies drug use, thus keeping the addictive run going. That often is the heart of addiction. The point is that once the disease is in control of the addicted brain, those around that hijacked brain must intervene – and the goal of cutting down drug use or limiting it to exclude one or another drug is not useful. Rather, it perpetuates the addiction. Freedom from addiction, that modern chemical slavery, requires no use of alcohol and other drugs, including marijuana, and a return to healthy relationships, sleep, eating, exercise, etc.

Recovery is more than abstinence from all drug use; it includes character development and citizenship. The data supporting the essential goal of recovery are found in the people who are in recovery not in today’s scientific research, which generally is off-target on recovery. Just because recovering people are anonymous does not mean that they do not exist. They prove that recovery happens all the time. They show what recovery is, and how it is achieved and maintained. Current arguments over which MAT is the best in a 3-month study is too short-term for a lifetime disorder and it ignores the concept of recovery despite the millions of people who are living it. Their stories are the bedrock of our message.

Our core evidence, our inspiration, comes from asking the people in recovery from the deadly, chronic disease of addiction three questions: 1) What was your life like when using drugs? 2) What happened to get you to stop using drugs? and 3) What is your life like when not using any drugs?” Every American who knows someone in recovery can do this research for themselves. We have been doing that research for decades.

People in recovery all have sobriety dates. Few in MAT have sobriety dates. Recovery from addiction is not just not taking Vicodin but living the life of a drug-free, recovering person. How do they hold onto recovery, and prevent and deal with relapses and slips? MAT is a major achievement in addiction treatment, including agonist maintenance with buprenorphine and methadone, but it needs to build in the goal of sustained recovery and strong recovery support. That means building into MAT the 12-step fellowships and related recovery support, as is done every day by James H. Berry, DO, of the Chestnut Ridge Center at West Virginia University’s Comprehensive Opioid Addiction Treatment, or COAT, program.¹⁵

MAT is good. It needs to be targeted on recovery, which can include continued use of the medicines now widely used: methadone, buprenorphine, and naltrexone. But recovery cannot include continued nonmedical drug use, and it also must include character development – with honesty replacing the dishonesty that is at the heart of addiction.

Dr. Gold is the 17th Distinguished Alumni Professor at the University of Florida, Gainesville, professor of psychiatry (adjunct) at Washington University in St. Louis. Dr. DuPont is the first director of the National Institute on Drug Abuse and the second White House drug chief, founding president of the Institute for Behavior and Health in Rockville, Md., and author of “Chemical Slavery: Understanding Addiction and Stopping the Drug Epidemic” (Create Space Independent Publishing Platform), 2018.

References

1. Am J Public Health. 2018 Oct 108(10):1394-1400.

2. Florida Drug-Related Outcomes Surveillance & Tracking system (FROST)

3. Center on Addiction. Addiction Medicine: Closing the Gap Between Science and Practice. 2012 Jun.

4. Surgeon General’s Advisory on Naloxone and Opioid Overdose.

5. Mayo Clin Proc. 2018 Mar;93(3):269-72.

6. Ther Adv Drug Saf. 2015 Feb;6(1):20-31.

7. J Subst Abuse Treat. 2009 Mar;36(2):159-71.

8. J Subst Abuse Treat. 2015 Nov;58:1-5.

9. Prev Med. 2018 Aug;113:68-73.

10. Pediatrics. 2016 Jun;138(1). doi: 10.1542/peds.2016-1211.

11. Institute for Behavior and Health. (updated) 2018 Aug 29.

12. Pediatrics. 2018 Aug;142(2). doi: 10.1542/peds.2017-3498.

13. Office of the Surgeon General. 2016.

14. The ASAM Principles of Addiction Medicine. (6th ed.) (in press) Wolters Kluwer, 2018.

15. West Virginia Clinical and Translational Science Institute. 2017 Aug 21.

Any given weekend where the sun is shining in the United States, you can jump in your car and see children competing on the soccer field. Soccer, known as football in other countries, is one of the most played sports in the US with over 25 million children participating every year. Despite Americans’ mass participation in youth soccer, this level of enthusiasm hasn’t necessarily translated into soccer being one of our most watched sports. On an international level, soccer is not only a sport but a way of life, and it is often described as “the beautiful game”, as visions of Pelé, Kaká, Messi, Ronaldo, and others can invoke emotional responses in the hearts of so many people across the world.

Over the course of the past 20 years, the enthusiasm for soccer in the US has grown significantly as defined not only by the number of youth players on the field but also now by the increased number of professional teams, energetic supporters in the stands, and fans watching on their televisions at home. This exponential growth started with the success of our US Soccer National Teams in the 1990s, including the 1994 World Cup held in the US, and became cemented into the culture of American sports with the birth, development, and subsequent growth of Major League Soccer (MLS) across the country. Despite the recent disappointment of the US Men’s National Team not making the 2018 World Cup, Americans should remain excited that our US Women’s National Team is prepared to be a contender in the 2019 World Cup, our US Men’s National Team will certainly make a significant push to compete in the 2022 World Cup, and the US is again ready to re-energize Americans’ interest in soccer by hosting a collaborative bid for the Men’s 2026 World Cup!

Now that I have hopefully energized all of our readers about the current and future impact of soccer within the US, I am personally excited about being an active member of the soccer medicine community through my roles as the Chief Medical Officer of the Orlando City Soccer Club, including Orlando City Lions MLS team and Orlando Pride National Women’s Soccer League (NWSL) team, and a Team Physician for US Soccer. What most people don’t realize in the sports medicine community and beyond is that our MLS and US soccer medical teams have been working tirelessly for the last 20 years to not only provide top-notch medical care within our country but to create one of the best medical structures in the world.

Over the last several years, I have learned that our soccer medical community is fortunate to have strength in numbers. In fact, our international colleagues provide a collaborative team to help push the limits on medical innovation so that we constantly reflect upon the quality of care that we are providing for the ultimate improvement of the medical care for all of our players. I recently returned from a trip to Barcelona for the Isokinetic Medical Group Football, known as soccer in the US, Medicine Outcomes Meeting where over 3000 participants from almost 100 countries around the world attended. After previous involvement in Major League Baseball and the National Football League, and since my integration into the soccer medicine community several years ago, I have been amazed and challenged by the complexity of pathology that we see in soccer players and the attention to detail that is required to successfully transition a soccer player back to the field while also preventing a subsequent injury. In fact, soccer players require a unique combination of skill, fitness, performance, nutrition, and sustainability to be successful at the highest level of soccer. As a sports medicine community in the US, we have come so far but yet still have so much left to learn. I’m certainly excited that we will be able to build and share this knowledge base with not only my fellow Americans but also our international colleagues abroad. Who knows, after the 2026 World Cup, the further growth and solidification of soccer and soccer medicine in the US might enable me to change the title for my editorial with no resulting confusion: “Global Football Medicine for a Global Game”.

Any given weekend where the sun is shining in the United States, you can jump in your car and see children competing on the soccer field. Soccer, known as football in other countries, is one of the most played sports in the US with over 25 million children participating every year. Despite Americans’ mass participation in youth soccer, this level of enthusiasm hasn’t necessarily translated into soccer being one of our most watched sports. On an international level, soccer is not only a sport but a way of life, and it is often described as “the beautiful game”, as visions of Pelé, Kaká, Messi, Ronaldo, and others can invoke emotional responses in the hearts of so many people across the world.

Over the course of the past 20 years, the enthusiasm for soccer in the US has grown significantly as defined not only by the number of youth players on the field but also now by the increased number of professional teams, energetic supporters in the stands, and fans watching on their televisions at home. This exponential growth started with the success of our US Soccer National Teams in the 1990s, including the 1994 World Cup held in the US, and became cemented into the culture of American sports with the birth, development, and subsequent growth of Major League Soccer (MLS) across the country. Despite the recent disappointment of the US Men’s National Team not making the 2018 World Cup, Americans should remain excited that our US Women’s National Team is prepared to be a contender in the 2019 World Cup, our US Men’s National Team will certainly make a significant push to compete in the 2022 World Cup, and the US is again ready to re-energize Americans’ interest in soccer by hosting a collaborative bid for the Men’s 2026 World Cup!

Now that I have hopefully energized all of our readers about the current and future impact of soccer within the US, I am personally excited about being an active member of the soccer medicine community through my roles as the Chief Medical Officer of the Orlando City Soccer Club, including Orlando City Lions MLS team and Orlando Pride National Women’s Soccer League (NWSL) team, and a Team Physician for US Soccer. What most people don’t realize in the sports medicine community and beyond is that our MLS and US soccer medical teams have been working tirelessly for the last 20 years to not only provide top-notch medical care within our country but to create one of the best medical structures in the world.

Over the last several years, I have learned that our soccer medical community is fortunate to have strength in numbers. In fact, our international colleagues provide a collaborative team to help push the limits on medical innovation so that we constantly reflect upon the quality of care that we are providing for the ultimate improvement of the medical care for all of our players. I recently returned from a trip to Barcelona for the Isokinetic Medical Group Football, known as soccer in the US, Medicine Outcomes Meeting where over 3000 participants from almost 100 countries around the world attended. After previous involvement in Major League Baseball and the National Football League, and since my integration into the soccer medicine community several years ago, I have been amazed and challenged by the complexity of pathology that we see in soccer players and the attention to detail that is required to successfully transition a soccer player back to the field while also preventing a subsequent injury. In fact, soccer players require a unique combination of skill, fitness, performance, nutrition, and sustainability to be successful at the highest level of soccer. As a sports medicine community in the US, we have come so far but yet still have so much left to learn. I’m certainly excited that we will be able to build and share this knowledge base with not only my fellow Americans but also our international colleagues abroad. Who knows, after the 2026 World Cup, the further growth and solidification of soccer and soccer medicine in the US might enable me to change the title for my editorial with no resulting confusion: “Global Football Medicine for a Global Game”.

Any given weekend where the sun is shining in the United States, you can jump in your car and see children competing on the soccer field. Soccer, known as football in other countries, is one of the most played sports in the US with over 25 million children participating every year. Despite Americans’ mass participation in youth soccer, this level of enthusiasm hasn’t necessarily translated into soccer being one of our most watched sports. On an international level, soccer is not only a sport but a way of life, and it is often described as “the beautiful game”, as visions of Pelé, Kaká, Messi, Ronaldo, and others can invoke emotional responses in the hearts of so many people across the world.

Over the course of the past 20 years, the enthusiasm for soccer in the US has grown significantly as defined not only by the number of youth players on the field but also now by the increased number of professional teams, energetic supporters in the stands, and fans watching on their televisions at home. This exponential growth started with the success of our US Soccer National Teams in the 1990s, including the 1994 World Cup held in the US, and became cemented into the culture of American sports with the birth, development, and subsequent growth of Major League Soccer (MLS) across the country. Despite the recent disappointment of the US Men’s National Team not making the 2018 World Cup, Americans should remain excited that our US Women’s National Team is prepared to be a contender in the 2019 World Cup, our US Men’s National Team will certainly make a significant push to compete in the 2022 World Cup, and the US is again ready to re-energize Americans’ interest in soccer by hosting a collaborative bid for the Men’s 2026 World Cup!

Now that I have hopefully energized all of our readers about the current and future impact of soccer within the US, I am personally excited about being an active member of the soccer medicine community through my roles as the Chief Medical Officer of the Orlando City Soccer Club, including Orlando City Lions MLS team and Orlando Pride National Women’s Soccer League (NWSL) team, and a Team Physician for US Soccer. What most people don’t realize in the sports medicine community and beyond is that our MLS and US soccer medical teams have been working tirelessly for the last 20 years to not only provide top-notch medical care within our country but to create one of the best medical structures in the world.

Over the last several years, I have learned that our soccer medical community is fortunate to have strength in numbers. In fact, our international colleagues provide a collaborative team to help push the limits on medical innovation so that we constantly reflect upon the quality of care that we are providing for the ultimate improvement of the medical care for all of our players. I recently returned from a trip to Barcelona for the Isokinetic Medical Group Football, known as soccer in the US, Medicine Outcomes Meeting where over 3000 participants from almost 100 countries around the world attended. After previous involvement in Major League Baseball and the National Football League, and since my integration into the soccer medicine community several years ago, I have been amazed and challenged by the complexity of pathology that we see in soccer players and the attention to detail that is required to successfully transition a soccer player back to the field while also preventing a subsequent injury. In fact, soccer players require a unique combination of skill, fitness, performance, nutrition, and sustainability to be successful at the highest level of soccer. As a sports medicine community in the US, we have come so far but yet still have so much left to learn. I’m certainly excited that we will be able to build and share this knowledge base with not only my fellow Americans but also our international colleagues abroad. Who knows, after the 2026 World Cup, the further growth and solidification of soccer and soccer medicine in the US might enable me to change the title for my editorial with no resulting confusion: “Global Football Medicine for a Global Game”.

About a year ago, I had a patient come in who didn’t like me.

It seemed like a normal visit. My secretary had him fill out the usual forms and copied his insurance cards, and I took him back to my office. We do this many times, every day.

He came back to my office, and I asked him what brought him to my care.

Instead of starting his medical history, though, he immediately gave me a long list of complaints. He didn’t like my appearance. Or my secretary. Or my forms. Or us asking if he’d had any previous tests. Or the parking at my office. Or the phone system. Or a coffee stain in my building’s elevator carpeting.

A whole list of stuff, none actually related to his reason for coming in. I let him rant for a minute, thinking maybe he’d get to the point, but he just kept getting angrier and bringing up more grievances.

I finally interrupted him and said, “Sir, if you’re unhappy with me, you are welcome to end the appointment and leave now.” He told me he wasn’t going to pay for the visit (not that I would have charged him for it) and stomped out. My secretary shredded his info. There’s always other stuff that needs my attention, so I busied myself with that until the next appointment arrived.

Twenty years ago this probably would have really upset me. But today? Not at all.

Like most other doctors, I want to help people. I enjoy doing that. It’s why I’m here. But I’ve also learned that there are some people I’ll never be able to work with under any circumstances. Some will just never like me as a physician, my casual appearance, or small practice.

People like this guy happen a few times a year. Experience teaches that you can’t be everyone’s doctor, can’t make everyone happy, and can’t have them all like you. If they don’t, that’s part of life. You can’t predict interpersonal chemistry and worrying about such things isn’t good for your blood pressure. You can’t change others.

Ironically, the same gentleman called recently, saying he needed to get in with me now. My secretary called him back, reminded him of what happened last year and suggested he go elsewhere.

His response? “I didn’t like your office then and still don’t.”

I’m okay with that. You can’t please everyone. Sometimes it’s not even worth trying.

 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

About a year ago, I had a patient come in who didn’t like me.

It seemed like a normal visit. My secretary had him fill out the usual forms and copied his insurance cards, and I took him back to my office. We do this many times, every day.

He came back to my office, and I asked him what brought him to my care.

Instead of starting his medical history, though, he immediately gave me a long list of complaints. He didn’t like my appearance. Or my secretary. Or my forms. Or us asking if he’d had any previous tests. Or the parking at my office. Or the phone system. Or a coffee stain in my building’s elevator carpeting.

A whole list of stuff, none actually related to his reason for coming in. I let him rant for a minute, thinking maybe he’d get to the point, but he just kept getting angrier and bringing up more grievances.

I finally interrupted him and said, “Sir, if you’re unhappy with me, you are welcome to end the appointment and leave now.” He told me he wasn’t going to pay for the visit (not that I would have charged him for it) and stomped out. My secretary shredded his info. There’s always other stuff that needs my attention, so I busied myself with that until the next appointment arrived.

Twenty years ago this probably would have really upset me. But today? Not at all.

Like most other doctors, I want to help people. I enjoy doing that. It’s why I’m here. But I’ve also learned that there are some people I’ll never be able to work with under any circumstances. Some will just never like me as a physician, my casual appearance, or small practice.

People like this guy happen a few times a year. Experience teaches that you can’t be everyone’s doctor, can’t make everyone happy, and can’t have them all like you. If they don’t, that’s part of life. You can’t predict interpersonal chemistry and worrying about such things isn’t good for your blood pressure. You can’t change others.

Ironically, the same gentleman called recently, saying he needed to get in with me now. My secretary called him back, reminded him of what happened last year and suggested he go elsewhere.

His response? “I didn’t like your office then and still don’t.”

I’m okay with that. You can’t please everyone. Sometimes it’s not even worth trying.

 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

About a year ago, I had a patient come in who didn’t like me.

It seemed like a normal visit. My secretary had him fill out the usual forms and copied his insurance cards, and I took him back to my office. We do this many times, every day.

He came back to my office, and I asked him what brought him to my care.

Instead of starting his medical history, though, he immediately gave me a long list of complaints. He didn’t like my appearance. Or my secretary. Or my forms. Or us asking if he’d had any previous tests. Or the parking at my office. Or the phone system. Or a coffee stain in my building’s elevator carpeting.

A whole list of stuff, none actually related to his reason for coming in. I let him rant for a minute, thinking maybe he’d get to the point, but he just kept getting angrier and bringing up more grievances.

I finally interrupted him and said, “Sir, if you’re unhappy with me, you are welcome to end the appointment and leave now.” He told me he wasn’t going to pay for the visit (not that I would have charged him for it) and stomped out. My secretary shredded his info. There’s always other stuff that needs my attention, so I busied myself with that until the next appointment arrived.

Twenty years ago this probably would have really upset me. But today? Not at all.

Like most other doctors, I want to help people. I enjoy doing that. It’s why I’m here. But I’ve also learned that there are some people I’ll never be able to work with under any circumstances. Some will just never like me as a physician, my casual appearance, or small practice.

People like this guy happen a few times a year. Experience teaches that you can’t be everyone’s doctor, can’t make everyone happy, and can’t have them all like you. If they don’t, that’s part of life. You can’t predict interpersonal chemistry and worrying about such things isn’t good for your blood pressure. You can’t change others.

Ironically, the same gentleman called recently, saying he needed to get in with me now. My secretary called him back, reminded him of what happened last year and suggested he go elsewhere.

His response? “I didn’t like your office then and still don’t.”

I’m okay with that. You can’t please everyone. Sometimes it’s not even worth trying.

 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

If the hospital or clinic where you work is anything like my medical center, the looming deadline of October 1 is anything but a contemplative occasion. There are encounters to close, budgets to prepare, a flurry of e-mails—either pleading or threatening—to complete consults, mandatory training to finish, and on and on with protean tasks in the parlance of bureaucracy. For many it is the nadir of the mundane, mindless drudgery we slog through all year in pursuit of those transcendent moments when we feel morally certain we have made things better for a real human being.

What is the origin and rationale for the federal New Year beginning on October 1? In 1974, Congress passed the Congressional Budget and Impoundment Act. The act shifted the beginning of the fiscal year—for our purposes the date of the federal New Year—from the first of July to October 1. Shifting the end of the fiscal year 3 months later enabled Congress to have additional time to study and prepare to receive the annual budget from the executive office and productively engage in the subsequent negotiations regarding federal spending priorities.¹

For all of us who practice in a federal health care system, our New Year is fast approaching and will indeed be past when most of you read this editorial. While January 1 may be the date for parades and football for the rest of the country, the federal government is not alone in selecting a different day on which to begin the New Year. In fact, were we to look at most of the world, we would find a variety of dates chosen for reasons both symbolic and functional to be the end of an annum. Let’s look at a few of them to see whether we can glean any hints about how we might sublimate what often seem to be meaningless demands into something more personal and profound.

Currently, we are in the last quarter of the Chinese New Year of the earth dog, which began on February 16^, using a lunar calendar. In the modern era China has adopted January 1 as the official New Year, but the traditional Chinese festival remains among the most popular holidays in China—and for good reason. Historically, the New Year in China was a period of turning away from work to focus on the honoring of family both living and dead, those in heaven and on earth joining in one timeless community. The family home was often thoroughly cleaned to purge any residual bad luck from the prior cycle and to welcome the good fortune sought for the coming year.²

Several weeks before the writing of this column, the Jewish people celebrated Rosh Hashanah (literally, “head of the year” in Hebrew), one of the holiest days of the Jewish liturgical calendar. It is a commemoration of both creation and judgment. Rosh Hashanah ushers in a period of introspection and repentance, of taking responsibility for past actions, and of committing to do better in the future.

There are some common themes in all these celebrations, religious or secular, and among the most prominent is preparation. Too often, preparing in federal service is a word associated with resentment and apprehension. The US Department of Veterans Affairs prepares for the next investigation, the US Public Health Service for the next inspection, and the military, sadly, for the next war. Our thoughts are perforce focused on funding and finances: Will the president and Congress agree on a timely and sufficient allocation of resources for all of us to do our work well and without excessive worry and wear?

With the exception of the most powerful among us, these negotiations are far beyond our ken or dominion, and the new fiscal year becomes yet another imposed burden. I suggest that we all take back some of that power and purpose, not literally but psychologically. No, I am not advocating either sedition or a new Hallmark holiday with “Happy Federal New Year” cards and parties. Instead I am inviting all of us to consider how we can reset as we do with our computers.

Management experts tell us that cleaning our desk can have positive mental and even physical health benefits. I am not there, but I am willing to try to be more organized if you are. Combat veteran and psychologist Dr. Brett Moore offers “tips to police your workspace” as a means to fight against stress.³ Organizing your desk is a way to unclutter your mind so it can regain the attitudinal agility that is key to resilience.

Another New Year’s theme is remembering as a way of consolidating lessons learned and rededicating yourself to continue personal and professional growth in the months ahead. Invent your own rituals to commemorate another year of working for federal health care, even if that custom is to mark your calendar another year closer to retirement! Fall is beautiful in many parts of the country: Go outside for a few minutes a couple of times a week. Find somewhere quiet to sit and look around at the leaves turning and reflect. Reflection is literally, “return of light or sound from a surface.” It does not have to be formal meditation but simply mindfully looking back on the year to see what fruitful images and ideas return to you.

Reflection and preparation prime us for the third theme, which is a rekindling of motivation to be better and the commitment to do things differently, however that is expressed in the unique struggles and rewards of each individual’s career. New Year’s resolutions have become a trite cliché for stores to advertise exercise clothing and the Internet to feature fad diets. The ancient history of resolutions reveals their more spiritual nature as a celebration of the renewal of life.⁴

Virtue ethics tells us to look to walk in the steps of those we admire to know how to stay on the higher moral road: Who in your unit or clinic or office inspires you to aspire? There are a multitude of opportunities to recreate your work personae to be more like those you would emulate, the colleagues who are often able to solve the “impossible” problem, to stand up to the bully, and to find the ethical values in even the most ridiculous or demoralizing rule. Songwriter and performer Bob Dylan was right when he wrote, “You’re gonna have to serve somebody, yes indeed.”⁵ But no matter how oppressive we experience that mastery, we must hold tight and recognize that these forces are external.

No one can stop us from the small acts of compassion toward ourselves and one another that keep us free. Pick up the phone or walk over to see someone you know or used to work with and ask how they are doing. Volunteer for a new committee or service project to feel as though your work is more than your job. Repair a torn relationship or mend a departmental fence so you leave work with less emotional baggage than you carried in with you that morning. The next time you want to say something sarcastic or critical, challenge yourself to be silent instead or say something kind or affirming. As a priest I knew once told me, when someone cuts in front of you on the road, instead of raging “bless them before you start cursing.”

After you read this column, take a few minutes to ask yourself how you can cast off the shadows that gather around us from the media and government and find a new way of letting sunlight into your work life. Happy Fiscal Year 2019 from the Editor-in-Chief.

If the hospital or clinic where you work is anything like my medical center, the looming deadline of October 1 is anything but a contemplative occasion. There are encounters to close, budgets to prepare, a flurry of e-mails—either pleading or threatening—to complete consults, mandatory training to finish, and on and on with protean tasks in the parlance of bureaucracy. For many it is the nadir of the mundane, mindless drudgery we slog through all year in pursuit of those transcendent moments when we feel morally certain we have made things better for a real human being.

What is the origin and rationale for the federal New Year beginning on October 1? In 1974, Congress passed the Congressional Budget and Impoundment Act. The act shifted the beginning of the fiscal year—for our purposes the date of the federal New Year—from the first of July to October 1. Shifting the end of the fiscal year 3 months later enabled Congress to have additional time to study and prepare to receive the annual budget from the executive office and productively engage in the subsequent negotiations regarding federal spending priorities.¹

For all of us who practice in a federal health care system, our New Year is fast approaching and will indeed be past when most of you read this editorial. While January 1 may be the date for parades and football for the rest of the country, the federal government is not alone in selecting a different day on which to begin the New Year. In fact, were we to look at most of the world, we would find a variety of dates chosen for reasons both symbolic and functional to be the end of an annum. Let’s look at a few of them to see whether we can glean any hints about how we might sublimate what often seem to be meaningless demands into something more personal and profound.

Currently, we are in the last quarter of the Chinese New Year of the earth dog, which began on February 16^, using a lunar calendar. In the modern era China has adopted January 1 as the official New Year, but the traditional Chinese festival remains among the most popular holidays in China—and for good reason. Historically, the New Year in China was a period of turning away from work to focus on the honoring of family both living and dead, those in heaven and on earth joining in one timeless community. The family home was often thoroughly cleaned to purge any residual bad luck from the prior cycle and to welcome the good fortune sought for the coming year.²

Several weeks before the writing of this column, the Jewish people celebrated Rosh Hashanah (literally, “head of the year” in Hebrew), one of the holiest days of the Jewish liturgical calendar. It is a commemoration of both creation and judgment. Rosh Hashanah ushers in a period of introspection and repentance, of taking responsibility for past actions, and of committing to do better in the future.

There are some common themes in all these celebrations, religious or secular, and among the most prominent is preparation. Too often, preparing in federal service is a word associated with resentment and apprehension. The US Department of Veterans Affairs prepares for the next investigation, the US Public Health Service for the next inspection, and the military, sadly, for the next war. Our thoughts are perforce focused on funding and finances: Will the president and Congress agree on a timely and sufficient allocation of resources for all of us to do our work well and without excessive worry and wear?

With the exception of the most powerful among us, these negotiations are far beyond our ken or dominion, and the new fiscal year becomes yet another imposed burden. I suggest that we all take back some of that power and purpose, not literally but psychologically. No, I am not advocating either sedition or a new Hallmark holiday with “Happy Federal New Year” cards and parties. Instead I am inviting all of us to consider how we can reset as we do with our computers.

Management experts tell us that cleaning our desk can have positive mental and even physical health benefits. I am not there, but I am willing to try to be more organized if you are. Combat veteran and psychologist Dr. Brett Moore offers “tips to police your workspace” as a means to fight against stress.³ Organizing your desk is a way to unclutter your mind so it can regain the attitudinal agility that is key to resilience.

Another New Year’s theme is remembering as a way of consolidating lessons learned and rededicating yourself to continue personal and professional growth in the months ahead. Invent your own rituals to commemorate another year of working for federal health care, even if that custom is to mark your calendar another year closer to retirement! Fall is beautiful in many parts of the country: Go outside for a few minutes a couple of times a week. Find somewhere quiet to sit and look around at the leaves turning and reflect. Reflection is literally, “return of light or sound from a surface.” It does not have to be formal meditation but simply mindfully looking back on the year to see what fruitful images and ideas return to you.

Reflection and preparation prime us for the third theme, which is a rekindling of motivation to be better and the commitment to do things differently, however that is expressed in the unique struggles and rewards of each individual’s career. New Year’s resolutions have become a trite cliché for stores to advertise exercise clothing and the Internet to feature fad diets. The ancient history of resolutions reveals their more spiritual nature as a celebration of the renewal of life.⁴

Virtue ethics tells us to look to walk in the steps of those we admire to know how to stay on the higher moral road: Who in your unit or clinic or office inspires you to aspire? There are a multitude of opportunities to recreate your work personae to be more like those you would emulate, the colleagues who are often able to solve the “impossible” problem, to stand up to the bully, and to find the ethical values in even the most ridiculous or demoralizing rule. Songwriter and performer Bob Dylan was right when he wrote, “You’re gonna have to serve somebody, yes indeed.”⁵ But no matter how oppressive we experience that mastery, we must hold tight and recognize that these forces are external.

No one can stop us from the small acts of compassion toward ourselves and one another that keep us free. Pick up the phone or walk over to see someone you know or used to work with and ask how they are doing. Volunteer for a new committee or service project to feel as though your work is more than your job. Repair a torn relationship or mend a departmental fence so you leave work with less emotional baggage than you carried in with you that morning. The next time you want to say something sarcastic or critical, challenge yourself to be silent instead or say something kind or affirming. As a priest I knew once told me, when someone cuts in front of you on the road, instead of raging “bless them before you start cursing.”

After you read this column, take a few minutes to ask yourself how you can cast off the shadows that gather around us from the media and government and find a new way of letting sunlight into your work life. Happy Fiscal Year 2019 from the Editor-in-Chief.

If the hospital or clinic where you work is anything like my medical center, the looming deadline of October 1 is anything but a contemplative occasion. There are encounters to close, budgets to prepare, a flurry of e-mails—either pleading or threatening—to complete consults, mandatory training to finish, and on and on with protean tasks in the parlance of bureaucracy. For many it is the nadir of the mundane, mindless drudgery we slog through all year in pursuit of those transcendent moments when we feel morally certain we have made things better for a real human being.

What is the origin and rationale for the federal New Year beginning on October 1? In 1974, Congress passed the Congressional Budget and Impoundment Act. The act shifted the beginning of the fiscal year—for our purposes the date of the federal New Year—from the first of July to October 1. Shifting the end of the fiscal year 3 months later enabled Congress to have additional time to study and prepare to receive the annual budget from the executive office and productively engage in the subsequent negotiations regarding federal spending priorities.¹

For all of us who practice in a federal health care system, our New Year is fast approaching and will indeed be past when most of you read this editorial. While January 1 may be the date for parades and football for the rest of the country, the federal government is not alone in selecting a different day on which to begin the New Year. In fact, were we to look at most of the world, we would find a variety of dates chosen for reasons both symbolic and functional to be the end of an annum. Let’s look at a few of them to see whether we can glean any hints about how we might sublimate what often seem to be meaningless demands into something more personal and profound.

Currently, we are in the last quarter of the Chinese New Year of the earth dog, which began on February 16^, using a lunar calendar. In the modern era China has adopted January 1 as the official New Year, but the traditional Chinese festival remains among the most popular holidays in China—and for good reason. Historically, the New Year in China was a period of turning away from work to focus on the honoring of family both living and dead, those in heaven and on earth joining in one timeless community. The family home was often thoroughly cleaned to purge any residual bad luck from the prior cycle and to welcome the good fortune sought for the coming year.²

Several weeks before the writing of this column, the Jewish people celebrated Rosh Hashanah (literally, “head of the year” in Hebrew), one of the holiest days of the Jewish liturgical calendar. It is a commemoration of both creation and judgment. Rosh Hashanah ushers in a period of introspection and repentance, of taking responsibility for past actions, and of committing to do better in the future.

There are some common themes in all these celebrations, religious or secular, and among the most prominent is preparation. Too often, preparing in federal service is a word associated with resentment and apprehension. The US Department of Veterans Affairs prepares for the next investigation, the US Public Health Service for the next inspection, and the military, sadly, for the next war. Our thoughts are perforce focused on funding and finances: Will the president and Congress agree on a timely and sufficient allocation of resources for all of us to do our work well and without excessive worry and wear?

With the exception of the most powerful among us, these negotiations are far beyond our ken or dominion, and the new fiscal year becomes yet another imposed burden. I suggest that we all take back some of that power and purpose, not literally but psychologically. No, I am not advocating either sedition or a new Hallmark holiday with “Happy Federal New Year” cards and parties. Instead I am inviting all of us to consider how we can reset as we do with our computers.

Management experts tell us that cleaning our desk can have positive mental and even physical health benefits. I am not there, but I am willing to try to be more organized if you are. Combat veteran and psychologist Dr. Brett Moore offers “tips to police your workspace” as a means to fight against stress.³ Organizing your desk is a way to unclutter your mind so it can regain the attitudinal agility that is key to resilience.

Another New Year’s theme is remembering as a way of consolidating lessons learned and rededicating yourself to continue personal and professional growth in the months ahead. Invent your own rituals to commemorate another year of working for federal health care, even if that custom is to mark your calendar another year closer to retirement! Fall is beautiful in many parts of the country: Go outside for a few minutes a couple of times a week. Find somewhere quiet to sit and look around at the leaves turning and reflect. Reflection is literally, “return of light or sound from a surface.” It does not have to be formal meditation but simply mindfully looking back on the year to see what fruitful images and ideas return to you.

Reflection and preparation prime us for the third theme, which is a rekindling of motivation to be better and the commitment to do things differently, however that is expressed in the unique struggles and rewards of each individual’s career. New Year’s resolutions have become a trite cliché for stores to advertise exercise clothing and the Internet to feature fad diets. The ancient history of resolutions reveals their more spiritual nature as a celebration of the renewal of life.⁴

Virtue ethics tells us to look to walk in the steps of those we admire to know how to stay on the higher moral road: Who in your unit or clinic or office inspires you to aspire? There are a multitude of opportunities to recreate your work personae to be more like those you would emulate, the colleagues who are often able to solve the “impossible” problem, to stand up to the bully, and to find the ethical values in even the most ridiculous or demoralizing rule. Songwriter and performer Bob Dylan was right when he wrote, “You’re gonna have to serve somebody, yes indeed.”⁵ But no matter how oppressive we experience that mastery, we must hold tight and recognize that these forces are external.

No one can stop us from the small acts of compassion toward ourselves and one another that keep us free. Pick up the phone or walk over to see someone you know or used to work with and ask how they are doing. Volunteer for a new committee or service project to feel as though your work is more than your job. Repair a torn relationship or mend a departmental fence so you leave work with less emotional baggage than you carried in with you that morning. The next time you want to say something sarcastic or critical, challenge yourself to be silent instead or say something kind or affirming. As a priest I knew once told me, when someone cuts in front of you on the road, instead of raging “bless them before you start cursing.”

After you read this column, take a few minutes to ask yourself how you can cast off the shadows that gather around us from the media and government and find a new way of letting sunlight into your work life. Happy Fiscal Year 2019 from the Editor-in-Chief.

Rising waters forced hundreds of people, mainly in the Carolinas, to call for emergency rescues, and some people were forced to abandon their cars because of flooding. One man reportedly died by electrocution while trying to hook up a generator. Another man died after going out to check the status of hunting dogs, according to media reports. And in one of the most heart-wrenching tragedies, a mother and her infant were killed when a tree fell on their home.

Watching the TV reports and listening to the news of Hurricane Florence’s devastating impact on so many millions of people has been shocking. The death toll from this catastrophic weather event as of this writing stands at 39. Besides the current and future physical problems and illnesses left in Florence’s wake, the extent of property damage and loss must be overwhelming for the survivors.

I worry about the extent of the emotional toll left behind by Florence, just as Hurricane Maria did last year in Puerto Rico. The storm and its subsequent damage to the individual psyche – including the loss of identity and the fracturing of social structures and networks – almost certainly will lead to posttraumatic stress disorder, depression, and utter despair for many survivors.

While monitoring Florence’s impact, I thought about Hurricane Sandy, which upended me personally when it hit New York in 2012. As I’ve written previously, Sandy’s impact left me without power, running water, or toilet facilities. Almost 3 days of this uncertainty shook me from my comfort zone and truly affected my emotions. Before day 3, I left my home and drove (yes, I could still use my car; the roads were clear and my garage was not flooded) to my older son’s home – where I had a great support system and was able to continue to live a relatively normal life while watching the storm’s developments on TV. To this day, many areas of New York, New Jersey, and Connecticut that were hit by Sandy have not fully recovered.

Back to the human tragedy still unfolding for the survivors of Florence: I believe – and the data suggest – that early intervention and treatment of PTSD leads to better outcomes and should be addressed sooner than later. There is no specific medicinal “magic bullet” for PTSD, although some medications may help as well as treat a depressive component of the disorder and other medications may assist in improving sleep and disruptive sleep patterns. It’s been shown, time and again, that cognitive-behavioral therapy, various types of prolonged exposure therapy, and eye movement desensitization therapies work best. The most updated federal guidelines from the Department of Veterans Affairs and the Department of Defense, coauthored by Lori L. Davis, MD, of the University of Alabama at Birmingham, reinforce those treatments.

I also believe that, in situations in which masses of people are affected or potentially affected by PTSD, another first line of care that should be added is supportive, educational, interactive group therapy. In other words, it is possible that a cognitive-behavioral group therapy (CBGT) approach would reach many more people, make psychiatric intervention acceptable, and help the survivors of Florence. A recent study by researchers at the University of Massachusetts Boston that examined the role of “decentering” as part of CBGT for patients with specific anxiety disorders, for example, social anxiety disorder, might provide some hints. Decentering involves learning to observe thoughts and feelings as objective events in the mind rather than identifying with them personally. Aaron T. Beck, MD, and others hypothesized decentering as a mechanism of change in CBT.

In the UMass study, researchers recruited 81 people with a principal diagnosis of social anxiety disorder based on the Anxiety Disorders Interview Scheduled for DSM-IV. Other inclusion criteria for the study included stability on medications for 3 months or 1 month on benzodiazepines (Behav Ther. 2018 Sep;49[5]:809-12). Sixty-three of participants had 12 sessions of CBGT. The researchers found that people who received the CBGT experienced an increase in decentering. An increase in decentering, in turn, predicted improvement on most outcome measures.

Just as primary care physicians and surgeons know how to address serious physical health issues related natural and man-made disasters, psychiatrists must quickly know how to address the mental health aspects of care. Group therapy has the greatest potential to help more people and perhaps treat – and even prevent not only PTSD but many anxiety disorders as well.
 

Dr. London, a psychiatrist who practices in New York, developed and ran a short-term psychotherapy program for 20 years at NYU Langone Medical Center and has been writing columns for 35 years. His new book about helping people feel better fast is expected to be published in fall 2018. He has no disclosures.

Rising waters forced hundreds of people, mainly in the Carolinas, to call for emergency rescues, and some people were forced to abandon their cars because of flooding. One man reportedly died by electrocution while trying to hook up a generator. Another man died after going out to check the status of hunting dogs, according to media reports. And in one of the most heart-wrenching tragedies, a mother and her infant were killed when a tree fell on their home.

Watching the TV reports and listening to the news of Hurricane Florence’s devastating impact on so many millions of people has been shocking. The death toll from this catastrophic weather event as of this writing stands at 39. Besides the current and future physical problems and illnesses left in Florence’s wake, the extent of property damage and loss must be overwhelming for the survivors.

I worry about the extent of the emotional toll left behind by Florence, just as Hurricane Maria did last year in Puerto Rico. The storm and its subsequent damage to the individual psyche – including the loss of identity and the fracturing of social structures and networks – almost certainly will lead to posttraumatic stress disorder, depression, and utter despair for many survivors.

While monitoring Florence’s impact, I thought about Hurricane Sandy, which upended me personally when it hit New York in 2012. As I’ve written previously, Sandy’s impact left me without power, running water, or toilet facilities. Almost 3 days of this uncertainty shook me from my comfort zone and truly affected my emotions. Before day 3, I left my home and drove (yes, I could still use my car; the roads were clear and my garage was not flooded) to my older son’s home – where I had a great support system and was able to continue to live a relatively normal life while watching the storm’s developments on TV. To this day, many areas of New York, New Jersey, and Connecticut that were hit by Sandy have not fully recovered.

Back to the human tragedy still unfolding for the survivors of Florence: I believe – and the data suggest – that early intervention and treatment of PTSD leads to better outcomes and should be addressed sooner than later. There is no specific medicinal “magic bullet” for PTSD, although some medications may help as well as treat a depressive component of the disorder and other medications may assist in improving sleep and disruptive sleep patterns. It’s been shown, time and again, that cognitive-behavioral therapy, various types of prolonged exposure therapy, and eye movement desensitization therapies work best. The most updated federal guidelines from the Department of Veterans Affairs and the Department of Defense, coauthored by Lori L. Davis, MD, of the University of Alabama at Birmingham, reinforce those treatments.

I also believe that, in situations in which masses of people are affected or potentially affected by PTSD, another first line of care that should be added is supportive, educational, interactive group therapy. In other words, it is possible that a cognitive-behavioral group therapy (CBGT) approach would reach many more people, make psychiatric intervention acceptable, and help the survivors of Florence. A recent study by researchers at the University of Massachusetts Boston that examined the role of “decentering” as part of CBGT for patients with specific anxiety disorders, for example, social anxiety disorder, might provide some hints. Decentering involves learning to observe thoughts and feelings as objective events in the mind rather than identifying with them personally. Aaron T. Beck, MD, and others hypothesized decentering as a mechanism of change in CBT.

In the UMass study, researchers recruited 81 people with a principal diagnosis of social anxiety disorder based on the Anxiety Disorders Interview Scheduled for DSM-IV. Other inclusion criteria for the study included stability on medications for 3 months or 1 month on benzodiazepines (Behav Ther. 2018 Sep;49[5]:809-12). Sixty-three of participants had 12 sessions of CBGT. The researchers found that people who received the CBGT experienced an increase in decentering. An increase in decentering, in turn, predicted improvement on most outcome measures.

Just as primary care physicians and surgeons know how to address serious physical health issues related natural and man-made disasters, psychiatrists must quickly know how to address the mental health aspects of care. Group therapy has the greatest potential to help more people and perhaps treat – and even prevent not only PTSD but many anxiety disorders as well.
 

Dr. London, a psychiatrist who practices in New York, developed and ran a short-term psychotherapy program for 20 years at NYU Langone Medical Center and has been writing columns for 35 years. His new book about helping people feel better fast is expected to be published in fall 2018. He has no disclosures.

Rising waters forced hundreds of people, mainly in the Carolinas, to call for emergency rescues, and some people were forced to abandon their cars because of flooding. One man reportedly died by electrocution while trying to hook up a generator. Another man died after going out to check the status of hunting dogs, according to media reports. And in one of the most heart-wrenching tragedies, a mother and her infant were killed when a tree fell on their home.

Watching the TV reports and listening to the news of Hurricane Florence’s devastating impact on so many millions of people has been shocking. The death toll from this catastrophic weather event as of this writing stands at 39. Besides the current and future physical problems and illnesses left in Florence’s wake, the extent of property damage and loss must be overwhelming for the survivors.

I worry about the extent of the emotional toll left behind by Florence, just as Hurricane Maria did last year in Puerto Rico. The storm and its subsequent damage to the individual psyche – including the loss of identity and the fracturing of social structures and networks – almost certainly will lead to posttraumatic stress disorder, depression, and utter despair for many survivors.

While monitoring Florence’s impact, I thought about Hurricane Sandy, which upended me personally when it hit New York in 2012. As I’ve written previously, Sandy’s impact left me without power, running water, or toilet facilities. Almost 3 days of this uncertainty shook me from my comfort zone and truly affected my emotions. Before day 3, I left my home and drove (yes, I could still use my car; the roads were clear and my garage was not flooded) to my older son’s home – where I had a great support system and was able to continue to live a relatively normal life while watching the storm’s developments on TV. To this day, many areas of New York, New Jersey, and Connecticut that were hit by Sandy have not fully recovered.

Back to the human tragedy still unfolding for the survivors of Florence: I believe – and the data suggest – that early intervention and treatment of PTSD leads to better outcomes and should be addressed sooner than later. There is no specific medicinal “magic bullet” for PTSD, although some medications may help as well as treat a depressive component of the disorder and other medications may assist in improving sleep and disruptive sleep patterns. It’s been shown, time and again, that cognitive-behavioral therapy, various types of prolonged exposure therapy, and eye movement desensitization therapies work best. The most updated federal guidelines from the Department of Veterans Affairs and the Department of Defense, coauthored by Lori L. Davis, MD, of the University of Alabama at Birmingham, reinforce those treatments.

I also believe that, in situations in which masses of people are affected or potentially affected by PTSD, another first line of care that should be added is supportive, educational, interactive group therapy. In other words, it is possible that a cognitive-behavioral group therapy (CBGT) approach would reach many more people, make psychiatric intervention acceptable, and help the survivors of Florence. A recent study by researchers at the University of Massachusetts Boston that examined the role of “decentering” as part of CBGT for patients with specific anxiety disorders, for example, social anxiety disorder, might provide some hints. Decentering involves learning to observe thoughts and feelings as objective events in the mind rather than identifying with them personally. Aaron T. Beck, MD, and others hypothesized decentering as a mechanism of change in CBT.

In the UMass study, researchers recruited 81 people with a principal diagnosis of social anxiety disorder based on the Anxiety Disorders Interview Scheduled for DSM-IV. Other inclusion criteria for the study included stability on medications for 3 months or 1 month on benzodiazepines (Behav Ther. 2018 Sep;49[5]:809-12). Sixty-three of participants had 12 sessions of CBGT. The researchers found that people who received the CBGT experienced an increase in decentering. An increase in decentering, in turn, predicted improvement on most outcome measures.

Just as primary care physicians and surgeons know how to address serious physical health issues related natural and man-made disasters, psychiatrists must quickly know how to address the mental health aspects of care. Group therapy has the greatest potential to help more people and perhaps treat – and even prevent not only PTSD but many anxiety disorders as well.
 

Dr. London, a psychiatrist who practices in New York, developed and ran a short-term psychotherapy program for 20 years at NYU Langone Medical Center and has been writing columns for 35 years. His new book about helping people feel better fast is expected to be published in fall 2018. He has no disclosures.

I’m not sure why I read the “Letter from the President” in the American Academy of Pediatrics’ AAP News every month. I guess it is out of curiosity about how far the guild to which I belong is drifting from where I think it should be going.

Getty Images

In her August 2018 letter, Colleen A. Kraft, MD, lays out the challenges pediatricians will be facing in the next several decades as the “era of health care consumerism” engulfs us, a change that she suggests will mean “redefining the patient/provider relationship.” As an example, she observes that millennial parents who want “personalized care when and where they want it” have become our “new target market.” Dr. Kraft goes on to suggest that telemedicine may provide a way to reconcile the millennials’ two seemingly incompatible demands. However, she notes that only “15% of pediatricians report using telehealth technologies to provide patient care.” Dr. Kraft recommends that to survive the rising waters of health consumerism more of us should consider climbing onto the telemedicine ship.

There is no question that millennials are aging into the childbearing and child-rearing phases of their lives. They have become the major consumers of pediatric services. Is Dr. Kraft correct that we must change how we practice pediatrics to accommodate the I-want-it-now-delivered-to-my-inbox mentality of the millennials? If we fail to adjust, will we be committing financial suicide?

She makes a valid point. If your practice isn’t providing evening and weekend hours, if your patients’ calls aren’t being answered in a timely manner, and if your receptionists are more about deflecting calls than helping patients get their questions answered, you are running the risk of choking off your income stream to an unsustainable trickle.

But how far should we chase that “target market” made up of people who believe that they can receive personalized care without putting a wrinkle in their device-driven lives? It may be that they have never experienced the benefits of real personalized service from the same person encounter after encounter. I’m convinced that if you provide quality care that is reasonably available, enough patients will stick with you to make your practice sustainable. You will lose some impatient patients to walk-in-quick-care operations, but if you are giving good personalized care, many will return to the quality you are offering. But if you aren’t willing to consider improving your availability, even being the most personable provider in town isn’t going to keep you afloat.

Now to the claim that telemedicine may hold the answer to surviving consumerism. I think we must move cautiously. The fact that only 15% of us aren’t climbing on board doesn’t mean we are all Luddites. It is very likely that many of us are still feeling the sting of investing large amounts of money and time to computerize our health records and seeing little benefit. Telemedicine means lots of things to lots of people. It won’t hurt to keep an open mind and listen as technology evolves. But if you had it to do all over again, wouldn’t you have taken more time and given more thought into signing on for your electronic medical records system?

Finally, let’s remember millennials will be followed by another generation. Although some “experts” suggest that the post-millennials will be just more of the same, I’m not so sure. Millennials and their expectations have become fodder for comedians, even from within their own cohort. The post-millennials may surprise us and provide a refreshing breath of retro and a market that is much easier to reconcile with the realities of good patient care.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

I’m not sure why I read the “Letter from the President” in the American Academy of Pediatrics’ AAP News every month. I guess it is out of curiosity about how far the guild to which I belong is drifting from where I think it should be going.

Getty Images

In her August 2018 letter, Colleen A. Kraft, MD, lays out the challenges pediatricians will be facing in the next several decades as the “era of health care consumerism” engulfs us, a change that she suggests will mean “redefining the patient/provider relationship.” As an example, she observes that millennial parents who want “personalized care when and where they want it” have become our “new target market.” Dr. Kraft goes on to suggest that telemedicine may provide a way to reconcile the millennials’ two seemingly incompatible demands. However, she notes that only “15% of pediatricians report using telehealth technologies to provide patient care.” Dr. Kraft recommends that to survive the rising waters of health consumerism more of us should consider climbing onto the telemedicine ship.

There is no question that millennials are aging into the childbearing and child-rearing phases of their lives. They have become the major consumers of pediatric services. Is Dr. Kraft correct that we must change how we practice pediatrics to accommodate the I-want-it-now-delivered-to-my-inbox mentality of the millennials? If we fail to adjust, will we be committing financial suicide?

She makes a valid point. If your practice isn’t providing evening and weekend hours, if your patients’ calls aren’t being answered in a timely manner, and if your receptionists are more about deflecting calls than helping patients get their questions answered, you are running the risk of choking off your income stream to an unsustainable trickle.

But how far should we chase that “target market” made up of people who believe that they can receive personalized care without putting a wrinkle in their device-driven lives? It may be that they have never experienced the benefits of real personalized service from the same person encounter after encounter. I’m convinced that if you provide quality care that is reasonably available, enough patients will stick with you to make your practice sustainable. You will lose some impatient patients to walk-in-quick-care operations, but if you are giving good personalized care, many will return to the quality you are offering. But if you aren’t willing to consider improving your availability, even being the most personable provider in town isn’t going to keep you afloat.

Now to the claim that telemedicine may hold the answer to surviving consumerism. I think we must move cautiously. The fact that only 15% of us aren’t climbing on board doesn’t mean we are all Luddites. It is very likely that many of us are still feeling the sting of investing large amounts of money and time to computerize our health records and seeing little benefit. Telemedicine means lots of things to lots of people. It won’t hurt to keep an open mind and listen as technology evolves. But if you had it to do all over again, wouldn’t you have taken more time and given more thought into signing on for your electronic medical records system?

Finally, let’s remember millennials will be followed by another generation. Although some “experts” suggest that the post-millennials will be just more of the same, I’m not so sure. Millennials and their expectations have become fodder for comedians, even from within their own cohort. The post-millennials may surprise us and provide a refreshing breath of retro and a market that is much easier to reconcile with the realities of good patient care.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

I’m not sure why I read the “Letter from the President” in the American Academy of Pediatrics’ AAP News every month. I guess it is out of curiosity about how far the guild to which I belong is drifting from where I think it should be going.

Getty Images

In her August 2018 letter, Colleen A. Kraft, MD, lays out the challenges pediatricians will be facing in the next several decades as the “era of health care consumerism” engulfs us, a change that she suggests will mean “redefining the patient/provider relationship.” As an example, she observes that millennial parents who want “personalized care when and where they want it” have become our “new target market.” Dr. Kraft goes on to suggest that telemedicine may provide a way to reconcile the millennials’ two seemingly incompatible demands. However, she notes that only “15% of pediatricians report using telehealth technologies to provide patient care.” Dr. Kraft recommends that to survive the rising waters of health consumerism more of us should consider climbing onto the telemedicine ship.

There is no question that millennials are aging into the childbearing and child-rearing phases of their lives. They have become the major consumers of pediatric services. Is Dr. Kraft correct that we must change how we practice pediatrics to accommodate the I-want-it-now-delivered-to-my-inbox mentality of the millennials? If we fail to adjust, will we be committing financial suicide?

She makes a valid point. If your practice isn’t providing evening and weekend hours, if your patients’ calls aren’t being answered in a timely manner, and if your receptionists are more about deflecting calls than helping patients get their questions answered, you are running the risk of choking off your income stream to an unsustainable trickle.

But how far should we chase that “target market” made up of people who believe that they can receive personalized care without putting a wrinkle in their device-driven lives? It may be that they have never experienced the benefits of real personalized service from the same person encounter after encounter. I’m convinced that if you provide quality care that is reasonably available, enough patients will stick with you to make your practice sustainable. You will lose some impatient patients to walk-in-quick-care operations, but if you are giving good personalized care, many will return to the quality you are offering. But if you aren’t willing to consider improving your availability, even being the most personable provider in town isn’t going to keep you afloat.

Now to the claim that telemedicine may hold the answer to surviving consumerism. I think we must move cautiously. The fact that only 15% of us aren’t climbing on board doesn’t mean we are all Luddites. It is very likely that many of us are still feeling the sting of investing large amounts of money and time to computerize our health records and seeing little benefit. Telemedicine means lots of things to lots of people. It won’t hurt to keep an open mind and listen as technology evolves. But if you had it to do all over again, wouldn’t you have taken more time and given more thought into signing on for your electronic medical records system?

Finally, let’s remember millennials will be followed by another generation. Although some “experts” suggest that the post-millennials will be just more of the same, I’m not so sure. Millennials and their expectations have become fodder for comedians, even from within their own cohort. The post-millennials may surprise us and provide a refreshing breath of retro and a market that is much easier to reconcile with the realities of good patient care.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

“Breast Milk From Bottle May Not Be As Beneficial As Feeding Directly From The Breast, Researchers Say.” This was the headline on the AAP Daily Briefing that was sent to American Academy of Pediatrics members on Sept 25, 2018.

©Jaimie Duplass/Fotolia.com

I suspect that this finding doesn’t surprise you. I can imagine a dozen factors that could make bottled breast milk less advantageous for a baby than milk received directly from the mother’s breast. Antibodies might adhere to the glass surface. A few degrees above or below body temperature could interfere with gastric emptying. Or a temptation to focus on the level in the bottle and inadvertently overfeed could inflate the baby’s body mass index at 3 months, as was found in the study published online in the September 2018 issue of Pediatrics (“Infant Feeding and Weight Gain: Separating Breast Milk From Breastfeeding and Formula From Food”).

I agree that the title of the actual paper is rather dry; it’s a scientific research paper. But the distillation chosen by the folks at AAP Daily Briefing seems ill advised. They were not alone. CCN-Health chose “Breastfeeding better for babies’ weight gain than pumping, new study says” (Michael Nedelman, Sept. 24, 2018). HealthDay News headlined its story with “Milk straight from breast best for baby’s weight” (Sept. 24, 2018).

The articles themselves were well balanced and accurately described this research based on more than 2,500 Canadian mother-infant dyads. But not everyone – including mothers who are struggling with or considering breastfeeding – reads beyond the headlines. How many realize that “better for babies’ weight gain” means a slower weight gain? For the mother who has found that, for a variety of reasons, pumping is the only way she can provide her baby the benefits of breast milk, what these headlines suggest is another blow to her already fragile sense of self-worth.

This research article is excellent and should be read by all of us who counsel young families. It suggests that one of the contributors to our epidemic of childhood obesity may be that bottle-feeding discourages the infant’s own self-regulation skills. It should prompt us to ask every parent who is bottle-feeding his or her baby – regardless of what is in the bottle – exactly how they decide how much to put in the bottle and how long a feeding takes. Even if we are comfortable with the infant’s weight gain, we should caution parents to be more aware of the baby’s cues that he or she has had enough. Not every baby provides cues that are obvious, and parents may need our coaching in deciding how much to feed. This research paper also suggests that as long as breastfeeding was continued, introduction of solids as early as 5 months was not associated with an unhealthy BMI trajectory.

Unfortunately, the reporting of this research article is another example of the hazards of the explosive growth of the Internet. There really is no reason to keep the results of well-crafted research from the lay public, particularly if they are explained in common sense language. However, this places a burden of responsibility on the editors of websites to consider the damage that can be done by a poorly chosen headline.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

“Breast Milk From Bottle May Not Be As Beneficial As Feeding Directly From The Breast, Researchers Say.” This was the headline on the AAP Daily Briefing that was sent to American Academy of Pediatrics members on Sept 25, 2018.

©Jaimie Duplass/Fotolia.com

I suspect that this finding doesn’t surprise you. I can imagine a dozen factors that could make bottled breast milk less advantageous for a baby than milk received directly from the mother’s breast. Antibodies might adhere to the glass surface. A few degrees above or below body temperature could interfere with gastric emptying. Or a temptation to focus on the level in the bottle and inadvertently overfeed could inflate the baby’s body mass index at 3 months, as was found in the study published online in the September 2018 issue of Pediatrics (“Infant Feeding and Weight Gain: Separating Breast Milk From Breastfeeding and Formula From Food”).

I agree that the title of the actual paper is rather dry; it’s a scientific research paper. But the distillation chosen by the folks at AAP Daily Briefing seems ill advised. They were not alone. CCN-Health chose “Breastfeeding better for babies’ weight gain than pumping, new study says” (Michael Nedelman, Sept. 24, 2018). HealthDay News headlined its story with “Milk straight from breast best for baby’s weight” (Sept. 24, 2018).

The articles themselves were well balanced and accurately described this research based on more than 2,500 Canadian mother-infant dyads. But not everyone – including mothers who are struggling with or considering breastfeeding – reads beyond the headlines. How many realize that “better for babies’ weight gain” means a slower weight gain? For the mother who has found that, for a variety of reasons, pumping is the only way she can provide her baby the benefits of breast milk, what these headlines suggest is another blow to her already fragile sense of self-worth.

This research article is excellent and should be read by all of us who counsel young families. It suggests that one of the contributors to our epidemic of childhood obesity may be that bottle-feeding discourages the infant’s own self-regulation skills. It should prompt us to ask every parent who is bottle-feeding his or her baby – regardless of what is in the bottle – exactly how they decide how much to put in the bottle and how long a feeding takes. Even if we are comfortable with the infant’s weight gain, we should caution parents to be more aware of the baby’s cues that he or she has had enough. Not every baby provides cues that are obvious, and parents may need our coaching in deciding how much to feed. This research paper also suggests that as long as breastfeeding was continued, introduction of solids as early as 5 months was not associated with an unhealthy BMI trajectory.

Unfortunately, the reporting of this research article is another example of the hazards of the explosive growth of the Internet. There really is no reason to keep the results of well-crafted research from the lay public, particularly if they are explained in common sense language. However, this places a burden of responsibility on the editors of websites to consider the damage that can be done by a poorly chosen headline.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

“Breast Milk From Bottle May Not Be As Beneficial As Feeding Directly From The Breast, Researchers Say.” This was the headline on the AAP Daily Briefing that was sent to American Academy of Pediatrics members on Sept 25, 2018.

©Jaimie Duplass/Fotolia.com

I suspect that this finding doesn’t surprise you. I can imagine a dozen factors that could make bottled breast milk less advantageous for a baby than milk received directly from the mother’s breast. Antibodies might adhere to the glass surface. A few degrees above or below body temperature could interfere with gastric emptying. Or a temptation to focus on the level in the bottle and inadvertently overfeed could inflate the baby’s body mass index at 3 months, as was found in the study published online in the September 2018 issue of Pediatrics (“Infant Feeding and Weight Gain: Separating Breast Milk From Breastfeeding and Formula From Food”).

I agree that the title of the actual paper is rather dry; it’s a scientific research paper. But the distillation chosen by the folks at AAP Daily Briefing seems ill advised. They were not alone. CCN-Health chose “Breastfeeding better for babies’ weight gain than pumping, new study says” (Michael Nedelman, Sept. 24, 2018). HealthDay News headlined its story with “Milk straight from breast best for baby’s weight” (Sept. 24, 2018).

The articles themselves were well balanced and accurately described this research based on more than 2,500 Canadian mother-infant dyads. But not everyone – including mothers who are struggling with or considering breastfeeding – reads beyond the headlines. How many realize that “better for babies’ weight gain” means a slower weight gain? For the mother who has found that, for a variety of reasons, pumping is the only way she can provide her baby the benefits of breast milk, what these headlines suggest is another blow to her already fragile sense of self-worth.

This research article is excellent and should be read by all of us who counsel young families. It suggests that one of the contributors to our epidemic of childhood obesity may be that bottle-feeding discourages the infant’s own self-regulation skills. It should prompt us to ask every parent who is bottle-feeding his or her baby – regardless of what is in the bottle – exactly how they decide how much to put in the bottle and how long a feeding takes. Even if we are comfortable with the infant’s weight gain, we should caution parents to be more aware of the baby’s cues that he or she has had enough. Not every baby provides cues that are obvious, and parents may need our coaching in deciding how much to feed. This research paper also suggests that as long as breastfeeding was continued, introduction of solids as early as 5 months was not associated with an unhealthy BMI trajectory.

Unfortunately, the reporting of this research article is another example of the hazards of the explosive growth of the Internet. There really is no reason to keep the results of well-crafted research from the lay public, particularly if they are explained in common sense language. However, this places a burden of responsibility on the editors of websites to consider the damage that can be done by a poorly chosen headline.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at [email protected].

The other day, I saw my health care provider for a routine appointment—and indeed, it seemed that I saw him, rather than the other way around. After having my vital signs measured by the medical assistant, I was led into the exam room. To my surprise, the provider (I will not divulge whether he was a physician, PA, or NP) was already there, sitting in front of his computer. He glanced up to say hello, but did not stand up, shake my hand, or maintain any level of eye contact. He did swear under his breath several times—something about his hatred of electronic medical records (EMRs)—while he asked me questions, hammering away on his laptop in time with my responses. After confirming that I was there for a prescription refill, he picked up his laptop and walked out of the room. A few minutes later, he popped back in to say, “Gee, I guess I should listen to your heart.” He placed the stethoscope on my chest over my shirt for a fraction of a second and was gone again. When I got to the pharmacy, I discovered he had called in the wrong prescription.

When Harvard professor Clayton M. Christensen coined the phrase disruptive technology, I’m not sure he imagined quite this level of impact! The time focused on a computer or device, rather than on the patient, has become so disproportionate that Dr. Abraham Verghese coined the term iPatient—a result of what he calls the chart-as-surrogate-for-the-patient approach.¹

While I hope my experience is not a regular occurrence in health care today, I’m well aware that the addition of e-this and e-that (computers, tablets, smartphones) at the bedside has clinicians multitasking more and more. Sure, performing more than one task at a time can be time-saving. But it can also lead to preoccupation and medical errors—at a time when medical errors are the third leading cause of death in the United States.²

We, as clinicians and as a larger society, are fascinated by speed. We want information faster than ever: medical information, lab results, etc. Our devices, stimulating and exhilarating as they are, have created a new society. Tell me you have not noticed the zombie-like motions of our colleagues walking in an electronic trance, pecking away at their preferred device! (OK, I am guilty of this, as well.)

Furthermore—and counterintuitively—efficiency in the clinic has been decimated by technology. In the “old days,” we could see patients roughly every 15 minutes, and many were double-booked. No problem; we merely dictated a note while walking from room to room, turned in our tapes at the end of the day, and signed a stack of notes two days later. Now, documentation alone takes at least 15 minutes, because it’s not just the note; it’s also the charges and the visit summary that is supposed to (but never does) go home with the patient.

So, if you want to see patients, if you want to generate revenue, if you want to keep the corporate slave drivers at bay, you either skimp on patient care or you document on your own time. One colleague lamented to me that, by implementing cost-saving measures to eliminate medical transcription ($2-$3/h outsourced to India), administrators and EMRs have reduced clinicians to the role of “Doc-retary.”

The diversion of attention, coupled with pressure to “perform,” is at the heart of the problem. Lately, every clinician I have spoken to seems to feel burdened by an influx of demands to see more patients in abbreviated visits while maintaining detailed records and documenting everything. It is no wonder that more than 75% of respondents in a study on physician distress met the criteria for burnout.³ I worry that NPs and PAs are not far behind. In a 2018 study, more than half (55.6%) of PAs rated “spending too many hours at work” as an important contributor to stress, and about 29% had previously quit a job due to stress.⁴

Continue to: If my own editorials are anything to judge by...

If my own editorials are anything to judge by, the joys and (welcome) challenges of the job are increasingly rare. I’ve discussed the “lost art” of the physical examination (November 2010); lamented the “death of altruism” (April 2016); and listed the pros and cons (mostly cons) of social media use (December 2017). Is careful listening to the patient the next thing to go?

We know intuitively that careful listening leads to better diagnosis and fewer errors. In fact, Balogh and colleagues identified patient engagement as one of four major cultural movements in health care (the others are patient safety, professionalism, and collaboration) that health care organizations need to foster in order to improve diagnosis and reduce errors.⁵ To my mind, that means finding ways to bring back the interpersonal relationship between clinician and patient and finding ways to remove the barriers that electronics can build.

I know exam room computing and EMRs are here to stay—and even, I suspect, likely to increase. But it is still possible, in my opinion, to incorporate patients into the interaction between clinician and computer. It is also possible, with the use of scribes, to have a third party transcribe your thoughts and actions as you interact directly with the patient. The last clinic I worked at operated this way, and it was liberating to be able to spend my time doing what I love best: interacting with my patients.

For those of you saying, “Yes, but my practice won’t hire scribes,” there is good advice out there on how to improve your interaction with patients in the Digital Age. In 2016, Frankel introduced the mnemonic POISED to enhance patient encounters while incorporating technologic devices:

Prepare. Review the patient’s medical records before you enter the exam room.

Continue to: Prepare

Orient. Let the patient know what you are doing or plan to do, and explain the use of the computer or scribe.

Information gathering. Although clinician-centric, this process should involve a two-way conversation between the clinician and patient.

Share. Use audiovisual sources (ie, your computer screen) to share information—for example, test results—with the patient.

Educate. Similarly, the computer can be a useful tool for educating the patient, as can low-tech materials like pictures and/or models.

Continue to: Debrief

Debrief. Review what has been said and make sure the patient has a chance to ask questions.⁶

The use of computers, EMRs, and other gadgets carries many potential consequences—but when used appropriately, these devices can be valuable tools for clinicians to interact with patients, stimulate engagement, and enrich patient-centered relationships. Do you agree? Please share with me your ideas on how we can better use the technology being placed before us at [email protected].

The other day, I saw my health care provider for a routine appointment—and indeed, it seemed that I saw him, rather than the other way around. After having my vital signs measured by the medical assistant, I was led into the exam room. To my surprise, the provider (I will not divulge whether he was a physician, PA, or NP) was already there, sitting in front of his computer. He glanced up to say hello, but did not stand up, shake my hand, or maintain any level of eye contact. He did swear under his breath several times—something about his hatred of electronic medical records (EMRs)—while he asked me questions, hammering away on his laptop in time with my responses. After confirming that I was there for a prescription refill, he picked up his laptop and walked out of the room. A few minutes later, he popped back in to say, “Gee, I guess I should listen to your heart.” He placed the stethoscope on my chest over my shirt for a fraction of a second and was gone again. When I got to the pharmacy, I discovered he had called in the wrong prescription.

When Harvard professor Clayton M. Christensen coined the phrase disruptive technology, I’m not sure he imagined quite this level of impact! The time focused on a computer or device, rather than on the patient, has become so disproportionate that Dr. Abraham Verghese coined the term iPatient—a result of what he calls the chart-as-surrogate-for-the-patient approach.¹

While I hope my experience is not a regular occurrence in health care today, I’m well aware that the addition of e-this and e-that (computers, tablets, smartphones) at the bedside has clinicians multitasking more and more. Sure, performing more than one task at a time can be time-saving. But it can also lead to preoccupation and medical errors—at a time when medical errors are the third leading cause of death in the United States.²

We, as clinicians and as a larger society, are fascinated by speed. We want information faster than ever: medical information, lab results, etc. Our devices, stimulating and exhilarating as they are, have created a new society. Tell me you have not noticed the zombie-like motions of our colleagues walking in an electronic trance, pecking away at their preferred device! (OK, I am guilty of this, as well.)

Furthermore—and counterintuitively—efficiency in the clinic has been decimated by technology. In the “old days,” we could see patients roughly every 15 minutes, and many were double-booked. No problem; we merely dictated a note while walking from room to room, turned in our tapes at the end of the day, and signed a stack of notes two days later. Now, documentation alone takes at least 15 minutes, because it’s not just the note; it’s also the charges and the visit summary that is supposed to (but never does) go home with the patient.

So, if you want to see patients, if you want to generate revenue, if you want to keep the corporate slave drivers at bay, you either skimp on patient care or you document on your own time. One colleague lamented to me that, by implementing cost-saving measures to eliminate medical transcription ($2-$3/h outsourced to India), administrators and EMRs have reduced clinicians to the role of “Doc-retary.”

The diversion of attention, coupled with pressure to “perform,” is at the heart of the problem. Lately, every clinician I have spoken to seems to feel burdened by an influx of demands to see more patients in abbreviated visits while maintaining detailed records and documenting everything. It is no wonder that more than 75% of respondents in a study on physician distress met the criteria for burnout.³ I worry that NPs and PAs are not far behind. In a 2018 study, more than half (55.6%) of PAs rated “spending too many hours at work” as an important contributor to stress, and about 29% had previously quit a job due to stress.⁴

Continue to: If my own editorials are anything to judge by...

If my own editorials are anything to judge by, the joys and (welcome) challenges of the job are increasingly rare. I’ve discussed the “lost art” of the physical examination (November 2010); lamented the “death of altruism” (April 2016); and listed the pros and cons (mostly cons) of social media use (December 2017). Is careful listening to the patient the next thing to go?

We know intuitively that careful listening leads to better diagnosis and fewer errors. In fact, Balogh and colleagues identified patient engagement as one of four major cultural movements in health care (the others are patient safety, professionalism, and collaboration) that health care organizations need to foster in order to improve diagnosis and reduce errors.⁵ To my mind, that means finding ways to bring back the interpersonal relationship between clinician and patient and finding ways to remove the barriers that electronics can build.

I know exam room computing and EMRs are here to stay—and even, I suspect, likely to increase. But it is still possible, in my opinion, to incorporate patients into the interaction between clinician and computer. It is also possible, with the use of scribes, to have a third party transcribe your thoughts and actions as you interact directly with the patient. The last clinic I worked at operated this way, and it was liberating to be able to spend my time doing what I love best: interacting with my patients.

For those of you saying, “Yes, but my practice won’t hire scribes,” there is good advice out there on how to improve your interaction with patients in the Digital Age. In 2016, Frankel introduced the mnemonic POISED to enhance patient encounters while incorporating technologic devices:

Prepare. Review the patient’s medical records before you enter the exam room.

Continue to: Prepare

Orient. Let the patient know what you are doing or plan to do, and explain the use of the computer or scribe.

Information gathering. Although clinician-centric, this process should involve a two-way conversation between the clinician and patient.

Share. Use audiovisual sources (ie, your computer screen) to share information—for example, test results—with the patient.

Educate. Similarly, the computer can be a useful tool for educating the patient, as can low-tech materials like pictures and/or models.

Continue to: Debrief

Debrief. Review what has been said and make sure the patient has a chance to ask questions.⁶

The use of computers, EMRs, and other gadgets carries many potential consequences—but when used appropriately, these devices can be valuable tools for clinicians to interact with patients, stimulate engagement, and enrich patient-centered relationships. Do you agree? Please share with me your ideas on how we can better use the technology being placed before us at [email protected].

The other day, I saw my health care provider for a routine appointment—and indeed, it seemed that I saw him, rather than the other way around. After having my vital signs measured by the medical assistant, I was led into the exam room. To my surprise, the provider (I will not divulge whether he was a physician, PA, or NP) was already there, sitting in front of his computer. He glanced up to say hello, but did not stand up, shake my hand, or maintain any level of eye contact. He did swear under his breath several times—something about his hatred of electronic medical records (EMRs)—while he asked me questions, hammering away on his laptop in time with my responses. After confirming that I was there for a prescription refill, he picked up his laptop and walked out of the room. A few minutes later, he popped back in to say, “Gee, I guess I should listen to your heart.” He placed the stethoscope on my chest over my shirt for a fraction of a second and was gone again. When I got to the pharmacy, I discovered he had called in the wrong prescription.

When Harvard professor Clayton M. Christensen coined the phrase disruptive technology, I’m not sure he imagined quite this level of impact! The time focused on a computer or device, rather than on the patient, has become so disproportionate that Dr. Abraham Verghese coined the term iPatient—a result of what he calls the chart-as-surrogate-for-the-patient approach.¹

While I hope my experience is not a regular occurrence in health care today, I’m well aware that the addition of e-this and e-that (computers, tablets, smartphones) at the bedside has clinicians multitasking more and more. Sure, performing more than one task at a time can be time-saving. But it can also lead to preoccupation and medical errors—at a time when medical errors are the third leading cause of death in the United States.²

We, as clinicians and as a larger society, are fascinated by speed. We want information faster than ever: medical information, lab results, etc. Our devices, stimulating and exhilarating as they are, have created a new society. Tell me you have not noticed the zombie-like motions of our colleagues walking in an electronic trance, pecking away at their preferred device! (OK, I am guilty of this, as well.)

Furthermore—and counterintuitively—efficiency in the clinic has been decimated by technology. In the “old days,” we could see patients roughly every 15 minutes, and many were double-booked. No problem; we merely dictated a note while walking from room to room, turned in our tapes at the end of the day, and signed a stack of notes two days later. Now, documentation alone takes at least 15 minutes, because it’s not just the note; it’s also the charges and the visit summary that is supposed to (but never does) go home with the patient.

So, if you want to see patients, if you want to generate revenue, if you want to keep the corporate slave drivers at bay, you either skimp on patient care or you document on your own time. One colleague lamented to me that, by implementing cost-saving measures to eliminate medical transcription ($2-$3/h outsourced to India), administrators and EMRs have reduced clinicians to the role of “Doc-retary.”

The diversion of attention, coupled with pressure to “perform,” is at the heart of the problem. Lately, every clinician I have spoken to seems to feel burdened by an influx of demands to see more patients in abbreviated visits while maintaining detailed records and documenting everything. It is no wonder that more than 75% of respondents in a study on physician distress met the criteria for burnout.³ I worry that NPs and PAs are not far behind. In a 2018 study, more than half (55.6%) of PAs rated “spending too many hours at work” as an important contributor to stress, and about 29% had previously quit a job due to stress.⁴

Continue to: If my own editorials are anything to judge by...

If my own editorials are anything to judge by, the joys and (welcome) challenges of the job are increasingly rare. I’ve discussed the “lost art” of the physical examination (November 2010); lamented the “death of altruism” (April 2016); and listed the pros and cons (mostly cons) of social media use (December 2017). Is careful listening to the patient the next thing to go?

We know intuitively that careful listening leads to better diagnosis and fewer errors. In fact, Balogh and colleagues identified patient engagement as one of four major cultural movements in health care (the others are patient safety, professionalism, and collaboration) that health care organizations need to foster in order to improve diagnosis and reduce errors.⁵ To my mind, that means finding ways to bring back the interpersonal relationship between clinician and patient and finding ways to remove the barriers that electronics can build.

I know exam room computing and EMRs are here to stay—and even, I suspect, likely to increase. But it is still possible, in my opinion, to incorporate patients into the interaction between clinician and computer. It is also possible, with the use of scribes, to have a third party transcribe your thoughts and actions as you interact directly with the patient. The last clinic I worked at operated this way, and it was liberating to be able to spend my time doing what I love best: interacting with my patients.

For those of you saying, “Yes, but my practice won’t hire scribes,” there is good advice out there on how to improve your interaction with patients in the Digital Age. In 2016, Frankel introduced the mnemonic POISED to enhance patient encounters while incorporating technologic devices:

Prepare. Review the patient’s medical records before you enter the exam room.

Continue to: Prepare

Orient. Let the patient know what you are doing or plan to do, and explain the use of the computer or scribe.

Information gathering. Although clinician-centric, this process should involve a two-way conversation between the clinician and patient.

Share. Use audiovisual sources (ie, your computer screen) to share information—for example, test results—with the patient.

Educate. Similarly, the computer can be a useful tool for educating the patient, as can low-tech materials like pictures and/or models.

Continue to: Debrief

Debrief. Review what has been said and make sure the patient has a chance to ask questions.⁶

The use of computers, EMRs, and other gadgets carries many potential consequences—but when used appropriately, these devices can be valuable tools for clinicians to interact with patients, stimulate engagement, and enrich patient-centered relationships. Do you agree? Please share with me your ideas on how we can better use the technology being placed before us at [email protected].