Integrative Medicine for Vulnerable Populations: A Clinical Guide to Working with Chronic and Comorbid Medical Disease, Mental Illness, and Addiction [1st ed. 2020] 978-3-030-21610-8, 978-3-030-21611-5

Table of contents :
Front Matter ....Pages i-xi
Front Matter ....Pages 1-2
Fundamental Concepts of Integrative Medicine (Julia Hodgson, Kevin Moore, Trisha Acri, Glenn Jordan Treisman)....Pages 3-13
Models of Integrative Practice (Julia Hodgson, Kevin Moore, Trisha Acri, Glenn Jordan Treisman)....Pages 15-22
Requisite Practices of Integrative Medicine (Julia Hodgson, Kevin Moore, Trisha Acri, Glenn Jordan Treisman)....Pages 23-33
Front Matter ....Pages 35-35
Understanding the Disease of Addiction (Julia Hodgson, Kevin Moore, Trisha Acri, Glenn Jordan Treisman)....Pages 37-53
The Four Facets of Patient Conceptualization (Julia Hodgson, Kevin Moore, Trisha Acri, Glenn Jordan Treisman)....Pages 55-78
Diagnostic Decision-Making Processes (Julia Hodgson, Kevin Moore, Trisha Acri, Glenn Jordan Treisman)....Pages 79-85
Front Matter ....Pages 87-87
Behavioral and Psychological Interventions for Addiction (Julia Hodgson, Kevin Moore, Trisha Acri, Glenn Jordan Treisman)....Pages 89-107
Adjunctive Pharmacotherapy for Opioid Addictions (Julia Hodgson, Kevin Moore, Trisha Acri, Glenn Jordan Treisman)....Pages 109-129
Contemplating Integrative Medicine Skills with a Case Example (Julia Hodgson, Kevin Moore, Trisha Acri, Glenn Jordan Treisman)....Pages 131-148
Front Matter ....Pages 149-149
Setting Up an Integrative Medicine Team (Julia Hodgson, Kevin Moore, Trisha Acri, Glenn Jordan Treisman)....Pages 151-159
An Integrative Training Model (Julia Hodgson, Kevin Moore, Trisha Acri, Glenn Jordan Treisman)....Pages 161-168
Applying Coordinated Treatment Skills to a Case Example (Julia Hodgson, Kevin Moore, Trisha Acri, Glenn Jordan Treisman)....Pages 169-177
A Sample Guide to Treatment for Patients (Julia Hodgson, Kevin Moore, Trisha Acri, Glenn Jordan Treisman)....Pages 179-190
Conclusion (Julia Hodgson, Kevin Moore, Trisha Acri, Glenn Jordan Treisman)....Pages 191-192
Back Matter ....Pages 193-198

Citation preview

Integrative Medicine for Vulnerable Populations A Clinical Guide to Working with Chronic and Comorbid Medical Disease, Mental Illness, and Addiction Julia Hodgson PsyD, MEd Kevin Moore PsyD Trisha Acri MD Glenn Jordan Treisman MD, PhD

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Integrative Medicine for Vulnerable Populations

Julia Hodgson • Kevin Moore  Trisha Acri • Glenn Jordan Treisman

Integrative Medicine for Vulnerable Populations A Clinical Guide to Working with Chronic and Comorbid Medical Disease, Mental Illness, and Addiction

Julia Hodgson Sharon Hill, PA USA

Kevin Moore Philadelphia, PA USA

Trisha Acri Philadelphia, PA USA

Glenn Jordan Treisman Baltimore, MD USA

ISBN 978-3-030-21610-8    ISBN 978-3-030-21611-5 (eBook) https://doi.org/10.1007/978-3-030-21611-5 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Preface

This book addresses the failures of the healthcare system to address vulnerable patients with multiple, chronic, comorbid conditions. These patients are frequently unresponsive to the methods and approaches used to treat other patients with conditions that are less complicated. This book is intended to be a guide for all allied healthcare professionals to working with these vulnerable patients. Because of the financial and delivery model of healthcare in the United States, which emphasizes specific services provided with maximum efficiency in specialized settings, the larger goals for care for this population of patients are frequently lost. We will emphasize a holistic evaluation which looks at the whole patient, will discuss comprehensive formulations that describe the interacting problems that afflict the patient including elements that are barriers to effective treatment of active medical problems and barriers to recovery, and will describe integrated treatment plans that focus on all the treatment needs of the patient. This may simply sound like good care, but with the current emphasis on “problemfocused visits,” short medical visits, limited access to psychotherapeutic interventions, and evolution of elements of care located at different sites, healthcare is often fragmented. Some primary care settings and some community mental health centers have developed models to try to address this problem. Large physician groups often have clinicians within their practice who are the group expert on a particular problem, or primary care is brought into traditional systems focused exclusively on mental health and/or substance abuse treatment. However, for the patients we are discussing, these attempts remain inadequate as evidenced by the large population of chronically ill and inadequately responding patients who are described throughout the medical literature. They are often referred to as “high-cost utilizers,” “inadequate responders,” and “treatment refractory” in publications and administrative settings. The implication is often that the patients are uncooperative or that their conditions are beyond the reach of the medical system. Because integrative medical practice is successful with these patients, we will describe an alternative model to provide care that focuses on rehabilitation for chronic conditions, comprehensive provision of care, and, most importantly, understanding of the psychological elements that have been barriers to effective care. Our model depends on developing an expertise in evaluation of patients that includes a psychological formulation as well as a physical one and a treatment plan that addresses both sets of problems in an integrated way. This book is for interested healthcare professionals, administrators, policy stakeholders, and interested patients and patient advocates. Readers need not have any formal education in medicine, psychology, or allied health but only some life experience with the deficiencies of the current healthcare system. We will discuss the kind of patients who would benefit from integrative care, the elements of providing integrative care, the barriers to integrative care, the model we have developed that has been successful in providing integrative care, and patient examples of the various ways that integrative care improved lives. v

Today in the United States, healthcare can be seen as a spectrum between a traditional medicine and a new model of “population health.” Traditional medicine focuses on the individual patient who develops a specific illness to be cured and then sees a doctor and gets the cure. The population healthcare idea emphasizes mental and physical hygiene, population and prevention of disease, as well as algorithmic series of interventions defined by problem type. Both of these models fail our population of patients. Our patients have a cascade of problems that develop over a lifetime and often include an aversive set of developmental events, a set of maladaptive learned behaviors that have been reinforced, a vulnerable temperament, psychiatric illnesses that impair function and coping, and chronic medical conditions that produce symptoms that cannot be “cured.” To take one example, HIV infection produces a state of chronic inflammation that causes or worsens depression. Depression also impairs adherence to HIV medications and produces a sense of stigma. This further disenfranchises people from medical care. Clinicians find depressed patients time-consuming and hard to treat, and HIV clinicians may have no training in recognizing and treating depression. This very simple example shows the need for a complex understanding of the nature of the conditions we treat and a comprehensive approach to treatment. The traditional medicine model has yet to provide an actual cure for HIV, so a more complex model is needed. The population health model emphasizes prevention and return on healthcare investment. This approach misses the fact that healthcare problems have consequences beyond the individual suffering from them and that while a treatment may be very expensive initially, over time, those same treatments become less expensive and more efficient. In the example of hepatitis C treatment, traditional medicine has provided a cure, but in some instances, a person is reinfected. It is often argued that retreatment is too expensive without recognizing the fact that in order to get reinfected, the person engaged in a behavior that transmitted the infection and, if not retreated, that same behavior will infect others that will need additional costly treatment. The “blaming” of patients is clear when we compare the reinfection to someone reinfected with malaria, tuberculosis, or cholera, where retreatment would be the obvious choice. The healthcare system failed to treat the underlying conditions that caused the behaviors that got the person infected with hepatitis C in the first place. We know how people get hepatitis C, and the behaviors that cause the infection are usually manifestations of other medical problems, such as depression, addiction, cognitive impairment, and temperamental vulnerabilities. In an integrative medicine setting, patients are assessed for the risk factor that got them infected, and the treatment for those vulnerabilities is addressed as part of their routine treatment for hepatitis C. One of the most disruptive problems we face is that the person who can adequately evaluate the psychological conditions that produce risk behaviors for infection with hepatitis C may be in a clinic in another building or maybe even another area of the city. Mental health services are “carved out,” paid for differently, and inadequately reimbursed. This means that the person providing hepatitis C care must navigate the process of trying to find evaluation and treatment for a patient with constantly changing parameters of insurance, restrictive authorization policies, and artificial barriers to treatment. An integrative approach overcomes these barriers. We will discuss more extensively the structural elements of integrative care that include co-location, shared charts, formal and informal communications, collaborative case formulation, and treatment planning. This book addresses the major misadventures in our healthcare system over the last two decades, including the opioid epidemic and the epidemic of disability in the United States, the failure to decrease HIV transmission, the increasing misuse of our emergency rooms, as well

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Preface

as many others. Each of these problems has its roots in oversimplification of problems to provide a quick algorithm-­based fix with inadequate evaluation and planning for complicated medical problems. The opioid epidemic, which has been widely blamed on the pharmaceutical industry, is actually the product of trying to treat pain as a symptom using “pain killers” rather than distinguishing between chronic pain and acute pain, then carefully investigating the causes of chronic pain, and, if the underlying cause cannot be remedied, helping patients to minimize pain and adapt successfully to their condition, an approach with demonstrated effectiveness. Even the response to the realization that we have an epidemic has been shortsighted. By simply restricting the prescribing of opioids to patients already dependent on these drugs, the death rates have actually increased as these patients have turned to more dangerous drugs. The effective programs of integrated care for these patients exist with demonstrated successful outcomes, and while these programs are neither fast nor cheap, they are far less expensive than the current problem and the results of the way it is being addressed. Our book will begin by defining integrated care, discussing the types of patients who benefit from this approach and some of the models of care, including financing, barriers to acceptance, and advocacy for patients. The second section will discuss the structural elements of integrated care, including the building of a team approach, issues of leadership, and role definition, and our experiences in overcoming some of the problems with using our approach. We will also discuss the importance of integrative care in education and training. In the remaining sections, we will discuss the major complicating features of the patients seen in integrative care settings, including a description of the kinds of problems, a model for formulation of patient cases, and successful approaches to treatment of these problems. Finally, we will discuss some of the real-world applications where integrative care provides better outcomes for treatment, including addictions, medically complex patients, and chronic pain patients. In short, this book is for anyone who has felt ineffective, useless, frustrated, or struggled with poor outcomes as either a patient or a clinician. This book clarifies that “high-cost utilizers” are people with complex problems that have been inadequately addressed. This book redefines “difficult patients” into understandable and treatable people who suffer from psychological disorders, demoralization and frustration with their experiences, or who have simply been misguided by the elements of a consumerist model of healthcare in which there is a quick fix for all problems and the customer is always right.

Sharon Hill, PA, USA  Julia Hodgson, PsyD, MEd Philadelphia, PA, USA  Kevin Moore, PsyD Philadelphia, PA, USA  Trisha Acri, MD Baltimore, MD, USA  Glenn J. Treisman, MD, PhD

Preface

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Acknowledgments

As a team, we would like to thank each patient we have served for teaching us what is shared in this book. We would particularly like to thank the patient that we called Sara for her enthusiasm and generosity in sharing her story in this book. Julia Hodgson, Kevin Moore, Trisha Acri, and Glenn J. Treisman I am grateful to my coauthors who trained me in integrative medicine and now treat me as a colleague; your shared wisdom and endless support of my developing career have been invaluable. I would like to thank my family for ingraining in me a desire to help make the world better and my partner, Dr. Matt Zakreski, for being my tireless champion. I would like to dedicate this work to my uncle and godfather, Sten Eric Hodgson, II, who we lost to AIDS at far too young an age and who has inspired my life’s work in countless ways. Julia Hodgson I would like to thank my family, my friends, and my coauthors, and especially, I’d like to dedicate this book to my father, the late Benjamin Luther Moore, PhD, for instilling in me a passion to combine professional and community service. Kevin Moore I would like to acknowledge my family, colleagues, and coauthors for all their support. I would also like to thank the patients who have taught me so much and make this all worthwhile. Trisha Acri I would like to acknowledge the help provided to me by Mr. Thomas Moses, who tirelessly makes it possible for me to do so many things. I would also like to thank and acknowledge my father, Dr. Edward Treisman, who taught me to never give up on patients; my brother, Dr. Jonathan Treisman, who taught me it is possible for a doctor to know everything; and my wife, Dr. Joyce King, who is the best doctor I know, who helps with and is the inspiration for the work I do. Glenn J. Treisman

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Contents

Part I Foundational Concepts of Integrative Medicine 1 Fundamental Concepts of Integrative Medicine�����������������������������������������   3 2 Models of Integrative Practice�������������������������������������������������������������������������  15 3 Requisite Practices of Integrative Medicine�������������������������������������������������  23 Part II Conceptualization and Diagnosis in Integrative Medicine 4 Understanding the Disease of Addiction �����������������������������������������������������  37 5 The Four Facets of Patient Conceptualization���������������������������������������������  55 6 Diagnostic Decision-­Making Processes �������������������������������������������������������  79 Part III Treatment Within an Integrative Medicine Model 7 Behavioral and Psychological Interventions for Addiction�������������������������������������������������������������������������������������������������������  89 8 Adjunctive Pharmacotherapy for Opioid Addictions ������������������������������� 109 9 Contemplating Integrative Medicine Skills with a Case Example��������������������������������������������������������������������������������������������������������������� 131 Part IV Logistical Considerations of Integrative Care 10 Setting Up an Integrative Medicine Team����������������������������������������������������� 151 11 An Integrative Training Model����������������������������������������������������������������������� 161 12 Applying Coordinated Treatment Skills to a Case Example ��������������������������������������������������������������������������������������������� 169 13 A Sample Guide to Treatment for Patients��������������������������������������������������� 179 14 Conclusion����������������������������������������������������������������������������������������������������������� 191 Index ����������������������������������������������������������������������������������������������������������������������������� 193

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PART I

Foundational Concepts of Integrative Medicine

Terminology around integration is varied, using terms like integrated care, holistic care, integration, and, our preference, integrative medicine. These terms are interchangeable and, for the purpose of this text, we use the term integrative medicine to refer to this concept of bringing together medical and psychological care of a patient. Integrative medicine is a model of medical care in which all elements of healthcare are provided to the patient in a coordinated way that is based on a comprehensive evaluation, a shared diagnostic formulation, and a team-based treatment plan that is flexible, communicated to all of the caregivers, and open to revision as the treatment proceeds to illuminate more of the nature of the patient and their illness. The goal of integrative care is rehabilitative and focuses on improving functioning. The Agency for Healthcare Research and Quality (AHRQ) has defined standards seen by professionals across this burgeoning field as the gold standard of integration of medical and behavioral health interventions. In their consensus document, the Lexicon for Behavioral Health and Primary Care Integration: Concepts and Definitions Developed by Expert Consensus, definitions and explorations of the concepts of integration are laid out in a foundational framework that guides our work. At its most basic, the Lexicon defines integrated care as: A practice team of primary care and behavioral health clinicians working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization. [1]

The next few chapters are devoted to discussing the principles of integrative medicine, the target populations, different models of integration, and the mindset necessary to implement such a system of treating patients. Early training and setting up a cohesive and comprehensive team is an intentional and thoughtful process. Patients are at the center of a treatment program, but they must be surrounded by a cohesive and communicating team of providers who make every decision with their well-being in mind.

Reference 1. Peek CJ, The National Integration Academy Council. Lexicon for behavioral health and primary care integration: concepts and definitions developed by expert consensus, AHRQ Publication No.13-IP001-EF. Rockville: Agency for Healthcare Research and Quality; 2013. Available at: http://integrationacademy.ahrq.gov/sites/default/files/Lexicon.pdf.

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Fundamental Concepts of Integrative Medicine Julia Hodgson, Kevin Moore, Trisha Acri, and Glenn Jordan Treisman

Striving to provide the best possible clinical care requires active and thorough consideration of multiple diagnostic possibilities including the complex interplay between biological, psychological, and developmental processes. Integrated medical care requires that all providers caring for the patients have a common understanding of the problems, a common set of treatment goals, and access to the clinical plan for achieving those goals. To maximally care for people with chronic conditions, patients are best managed over many years by a multidisciplinary team with expertise in a variety of healthcare issues and the sophistication to address clinical, organizational, financial, and philosophical complexity. The most ambitious clinicians of every stripe have slowly been coalescing what these best practices look like over the past few decades. These best practices are variously named something along the lines of integrative/integrated medicine/healthcare or individualized/patient-centered care/medical home. There have now been more than 80 randomized clinical trials of integrative medicine versus standard of care, and every single trial shows the superiority of integrative medicine [1]. Because clinical phenomena need to be simplified in order to be quantified and clinical trials are measured by quantified scoring, randomized clinical trials underreport the curative effects of integrative medicine because they miss the clinical complexities best addressed by integrative medicine. The current model for the provision of clinical care, despite the numerous problems, usually does deliver good care for singular problems. It has evolved over years to accommodate the numerous agendas of those who pay for care, those who need care, and those who deliver care. On the whole, the current healthcare model succeeds for conditions like broken bones, cholecystitis, pneumonia, strep throat, and the like. There are, however, a subgroup of patients with complex conditions that cross medical disciplines and exacerbate each other and sustain comorbidity and chronicity. This subpopulation of © Springer Nature Switzerland AG 2020 J. Hodgson et al., Integrative Medicine for Vulnerable Populations, https://doi.org/10.1007/978-3-030-21611-5_1

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patients requires a different approach and may actually worsen with the traditional approach of medical care. They develop patterns of medical care utilization that do not result in improvement but often become costly and burdensome. The reaction of medical administrators to the remarkable waste of resources expended uselessly on these patients has been to try to limit access. This effort is misdirected and further compounds the problem. The first step in the care of this subgroup of patients is to acknowledge that they are sick and not just difficult, and the second step is to develop a better model of care for them. The target for our approach is to provide effective care for these patients, improving their quality of life and function and decreasing the cost of caring for them overall. For the purpose of this book, integrative medicine is defined as a patient-­ centered, multidisciplinary approach to diagnosis, comprehensive treatment planning, and coordination of care delivery. The role of the treatment team in this model is complex; it includes expert evaluation and treatment prescription as well as clear communication with the patient and the agencies involved, advocacy, and ongoing efforts to develop a more comprehensive understanding of the case.

Goals of Integrative Medicine Medical practice boils down to trying to accomplish three goals for its patients: function, quality of life, and longevity. This book will expand upon methodology, interventions, complex conceptualizations, and other techniques that make up integrative medicine. However, all practice ultimately comes back to these three goals. In order to take care of their health concerns, patients need to be able to function in their lives. This means that patients must make appointments, navigate insurance and finances, juggle medications, and handle everything else that they might need to do to manage their health. Independence is the maximum state of health, but rehabilitation means helping people where they are at and helping motivate them to do incrementally more than they had previously done. When what needs to be done is more than the patient can handle, the team deploys resources to maximize the patient’s quality of life and function. An integrative medicine team is a civil society’s best service to provide for the vulnerable and underserved. Typically, patients will neglect needed healthcare because of a lack of the resources needed to attend or pay for visits with providers. Untreated dental cavities lead to increased inflammation which leads to increased coronary artery disease which leads to heart attacks, coronary artery stents, and coronary artery bypass surgery. Ignoring a problem exacerbates it and complicates it, leading to even higher costs and demands for service in the long run. Patients who are able to have their concerns treated when they attend the doctor are more successful in committing to and maintaining a healthy lifestyle; these visits are rewarding and positive overall. The experience that many vulnerable and complex patients encounter, one of frustration and compounding concerns with each doctor’s visit and insurance bill, feel punished by the healthcare system and

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are less motivated to commit to their health. Making interactions with the healthcare system rewarding rather than aversive encourages patients to adhere to treatment and maintain significant relationships with their providers, thus maintaining their ability to receive care and better their quality of life. Integrative medicine teams focus on functioning in patients’ lives because this is what leads to the behaviors and the adherence to medical care that ultimately increases quality of life. A person whose pain is under control, whose depression is subsiding, and whose hepatitis C is being cured will not only be healthier, but he/she will feel better too. Without the looming presence of these sorts of conditions, patients are more able to engage in other aspects of their lives, like work, volunteering, and school as well as building up relationships with their partners, children, and other social supports. The integrative medicine team is able to intervene in a way that alleviates some of the burden and allows the patient to build up a meaningful life for themselves. One of the goals of this model is long-term intervention and sustained care; integrative medicine patients are cared for continuously, consistently, and long-term. Unlike care where the “panel” of doctors caring for patients is constantly changing and therefore patients face a new doctor frequently, the collaborative and coordinated nature of integrative medicine allows the patient to be protected from losing their treatment if there are changes in providers within the team. Because there are still multiple members of the team who will know the patient, care is ongoing and able to shift more seamlessly when staffing changes occur. Furthermore, because the team is treating the patient holistically, the same team will manage changes or concerns as they arise instead of the patient bouncing from specialist to specialist to attempt to receive care. In this way, integrative medicine is uniquely able to provide longterm consistent care for patients, despite what ailments may arise. The patient in an integrative medicine practice not only increases their functioning and quality of life but is able to do so in a sustained and long-­ term way with continuous and consistent care by the entire team.

Who Needs Integrative Medicine? Most patients do well with the current medical system which has evolved to be successful in most cases. During an attack of appendicitis, a patient comes to the emergency department, gets a diagnosis, is admitted, has surgery, and goes home. The system selects the most appropriate plan for the patient through a series of gated triage steps, and single problems require little coordinated input from more than one discipline. Many people are able to navigate going to separate doctors, therapists, and specialists for annual checkups and follow-ups and to handle simple problems or maintenance. These patients are not the targets of integrative medicine. The targets of integrative medicine are more complicated; they are the sliver of the population that have chronic and comorbid conditions. The ideal candidates for integrative medicine are those with some combination, two out of three at least, of complex medical, psychological, and addiction issues.

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A different patient might come to the emergency room with a complaint of abdominal pain but also be addicted to opioids and in withdrawal; for this patient, the appendicitis might get missed or the addiction might not get addressed. Each additional level of comorbidity increases the need for a coordinated approach that involves complicated decision-making. Increased complexity requires more communication between different types of clinicians. The target population of integrative medicine is those patients with severe, chronic, and complex health problems; not only are these the patients who need the most support from coordinating providers, but they also need the most help navigating the healthcare system. The more the patient’s comorbidities differ in kind, such as behavioral problems, mental illness, psychological issues, and medical issues, the more integrated medicine is needed. Most patients with coexisting hypertension and diabetes can get these problems addressed in the usual medical setting. The explanations are disease-oriented and the treatments are medication. Add in obesity and the importance of behavior change becomes critical. This complexity moves treatment beyond the realm of medication-­ based treatment and requires input from behavioral health, psychology, and/or social work. The addition of psychological evaluations, behavioral interventions, and mapping the course of therapy for comorbidity requires a team of communicating clinicians for success. Patients may not understand or accept the need for the disciplines beyond the traditional medical doctor giving them a pill, and this confusion on the part of the patient leads to resistance against more effective interventions and, consequently, to poorer outcomes. However, consider the difference between integrative medicine and specialty referral care in the treatment of a patient with chronic back pain. A neurologist managing a patient with chronic back pain might obtain an MRI, increase the patient’s pain medications, and refer the patient to a surgical specialist; this could provide some information or temporary relief, but is a very narrow view of what might be going on for this patient. In contrast, as long as there are no serious signs or radiologic findings indicating need for urgent surgical intervention, a primary care physician and a psychologist in an integrative medicine team might be able to discern that the patient has had increased stresses in her home life, as well as depression and anxiety that make the pain less manageable. Psychotherapy, physical therapy, and a home exercise program might lead the patient to decrease his/her use of pain medication and improve his/her quality of life. Often, the patients who most need and benefit from integrated care are those in need of psychological and behavioral interventions in addition to medical care.

Super-Utilizers and Fractured Healthcare Chronic health conditions create organizational confusion due to the variety of clinical needs and the demands of the health insurance and healthcare referral systems. As any cancer patient can explain, attending multiple appointments and taking multiple medications can tax the most diligent

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planner. After correct diagnoses are established, typically multiple interventions are recommended by the treatment team and are most effective when engaged in concert. While patient responsibility and adherence is always paramount, even the patient who is well versed in the medical system often requires assistance navigating diverse healthcare systems. If you have ever attempted to read the fine print of a health insurance plan, it comes as no surprise that attempting to understand and attain insurance benefits causes great confusion to most people. Imagine trying to navigate this while simultaneously managing chronic and comorbid conditions, like an opioid addiction and a recent prostate cancer diagnosis; these are the patients who need the sophisticated level of support that integrative medicine can provide. An analysis of the distribution of healthcare resources in the United States reveals that the majority of the population uses a relatively small amount of the funding allocated every year. However, there is a small group of people (referred to as super-utilizers, high-utilizers, chronics, problem patients) whose medical, psychological, and addiction problems end up using a large share of healthcare costs in the United States. For example, in 2013, Medicaid covered about $440 billion of expenditures in healthcare; about half of this spending could be attributed to the 5% of individuals with the highest costs [2]. Similarly, the National Institute for Health Care Management (2012) reports that the top 1% of utilizers of healthcare accounted for over 20% of spending in 2014 and the top 5% accounted for half of spending in healthcare (see Fig. 1.1) [3]. Other

Figure 1-1.  Healthcare spending is highly concentrated among a small portion of the US non-institutionalized population [3]. (Reprinted from National Institute for Health Care Management. The Concentration of US Health Care Spending. July 2017. https://www. nihcm.org/topics/cost-quality/concentration-of-us-health-care-spending) 1  Fundamental Concepts of Integrative Medicine

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Figure 1-2.  Mean spending per person varies dramatically across spending groups [3]. (Reprinted from National Institute for Health Care Management. The Concentration of US Health Care Spending. July 2017. https://www.nihcm.org/topics/cost-quality/ concentration-of-us-health-care-spending)

data from the National Institute for Health Care Management break down expenses by the average cost per person in 2014 (see Fig. 1.2); as can be seen, the top 1% of healthcare utilizers cost a mean of about $107,000 per person annually. The top 50% of healthcare users averaged about $9000 per person, while the bottom 50% averaged $264 per person [3]. Because healthcare interventions are often limited in their effectiveness, these same patients return time and time again to emergency rooms, new doctors, and endless specialists to try to resolve their problems. The more chronic conditions a person is diagnosed with, the more often they end up in the hospital [4]. Many of these people are not getting better. In fact, Jiang et al. (2015) found that readmission rates to hospitals are four to eight times higher for super-utilizers than other patients within a 30-day period, totaling over half of all readmissions in that period [4]. It is important to note that while chronic conditions are a trademark of super-utilizers, acute conditions like pneumonia and urinary tract infections are often in the top conditions being treated in this subset of patients [4]. Overall, super-utilizers are significantly more likely to report poor health (see Fig. 1.3). Mood disorders and addiction are among the top diagnoses facing super-­utilizers [4]. Addiction alone causes a significant increase in the number of emergency room visits—both by patients seeking drugs and to deal with the increased medical problems that arise from chronic use. Add in chronic medical conditions like hepatitis C or HIV, or suicidality

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Figure 1-3.  Highest spenders are much more likely to report being in worse health [3]. (Reprinted from National Institute for Health Care Management. The Concentration of US Health Care Spending. July 2017. https://www.nihcm.org/topics/cost-quality/ concentration-of-us-health-care-spending)

linked to depression, and the number of hospitalizations, medications, and doctors’ visits multiplies. Especially when patients must visit numerous specialists or doctors for each aspect of their complex conditions, the costs pile up. However, the patient who is able to visit one integrative medicine practice to simultaneously deal with their depression, suicidality, HIV, and addiction has fewer medical visits each year and gets better more consistently, resulting in fewer hospitalizations and fewer resources needed. For these patients, integrative medicine is more cost-effective for the healthcare system in the long run and, in addition, brings about better outcomes (see Figs. 1.4 and 1.5).

 hilosophical Barriers: The Problem P with Mind-­Body Dualities There are legions of philosophical barriers to successfully practicing integrative medicine. One of them is mind-body duality. The belief that the mind and body are different or separate is a widely criticized fallacy. Almost no one would dispute the idea that the mind influences the body and the body influences the mind. Yet, even the most holistic practitioner has to resist the 1  Fundamental Concepts of Integrative Medicine

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Figure 1-4.  Inpatient care drives high spending, but highest spenders spend more on all types of care [3]. (Reprinted from National Institute for Health Care Management. The Concentration of US Health Care Spending. July 2017. https://www.nihcm.org/topics/ cost-quality/concentration-of-us-health-care-spending)

Figure 1-5.  Care for highest spenders dominated by inpatient services, prescription drugs, and outpatient and ED care [3]. (Reprinted from National Institute for Health Care Management. The Concentration of US Health Care Spending. July 2017. https:// www.nihcm.org/topics/cost-quality/concentration-of-us-health-care-spending)

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constant urge to attribute physical symptoms to a physical cause and mental symptoms to a mental cause. A stark example of the interaction between mind and body is in Charles Bonnet syndrome. Charles Bonnet syndrome is a medical condition related to changes found in visually impaired people, especially in older patients, which causes complex visual hallucinations, usually silent and often amusing [5]. An example of this condition is a patient reporting seeing tiny cartoon people walking up and down the walls which they may or may not know are hallucinations. Despite knowing that these little people are not real, the experiences of the hallucinations are very real to the person; the brain thinks that they are seeing these images in front of them. Hallucinations from Charles Bonnet syndrome are usually related to macular degeneration in the eye and a misinterpretation by the brain of sensory noise from the decaying retina. However, they are not the same as hallucinations caused by psychotic disorders which have a different etiology. This distinction is difficult for patients and physicians to recognize. Patients will often not report these hallucinations because of the fear they have regarding having a mental illness or the stigma that might be associated with admitting they have visual hallucinations [5]. Furthermore, medical physicians may not be aware of Charles Bonnet syndrome, or they may fall in the trap of the common assumption that all seemingly mental symptoms have a mental cause. Yet, this well-documented syndrome proves that the mind and body are not so simple. A much less dramatic example, yet significantly more common, is the impact of stress on both physical and mental symptomatology in patients. Stress is described as the response to threat or demand and is a part of all normal life. In patients with different histories, intense stress may occur in response to mild threats or demands, and mild stress may occur in the face of intense threats or demands. Stress is a common cause of worry, fear, and fatigue in the patients that we see. When life is overwhelming or negative events or thoughts are looming, it is unsurprising that people are distracted and less able to focus on other aspects of their lives. However, stress impacts more than just the psychological. When we are stressed, our sympathetic nervous system within the autonomic nervous system is activated; this is the part of the body that evolved to protect us in times of grave danger. Commonly called the “fight or flight instinct,” our body reacts to alarming situations by giving us a burst of energy to fight external threats; back in the days when our early ancestors were living in the wilderness, these bursts were vital for surviving when a bear or a lion was chasing them. Heart rate, breathing, muscle tension, metabolism, and blood pressure increase, vision and hearing become sharper, and hormones like adrenaline are released to facilitate this survival reflex [6]. In the process, other internal systems, like our immune system, may be inhibited or disordered. In short bursts, and in the face of a threat like a bear, these fight or flight body reactions are incredibly important. However, modern humans continue to have these reactions not just when our lives are in danger, but when we are nervous about a test or are driving during a snowstorm. Again, short bursts of sympathetic arousal can be useful in helping us to manage taxing situations; after the situation goes away, our body functioning returns to normal. However, prolonged or chronic stress throws the body off from its normal functioning and has been shown to 1  Fundamental Concepts of Integrative Medicine

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contribute to a number of medical disorders, including muscle tension, migraines, respiratory conditions (e.g., exacerbated symptoms of asthma or bronchitis), suppression of the reproductive system (e.g., amenorrhea, fertility problems, or decreased libido), osteoporosis, or exacerbating conditions that are harmed by suppression of the immune system like HIV [6]. In the reverse of Charles Bonnet syndrome, chronic stress exemplifies how a psychological or mental cause leads to medical problems. There are many other concrete examples of the mind-body connection. Evidence shows that chronic inflammation from stress increases the likelihood of coronary artery disease. In a more dramatic example, Takotsubo cardiomyopathy, or broken heart syndrome, first described in 1990 Japan, is characterized by weakening of the heart’s left ventricle, as a result of the surge of stress hormones during a severe episode such as the death of a loved one or a sustained natural disaster. The surging stress hormones trigger changes in the heart muscle or coronary blood vessels so that the left ventricle cannot pump effectively. This condition is more common in women, and its symptoms are often difficult to distinguish from a heart attack as both are characterized by chest pain and shortness of breath. Imaging studies demonstrating typical abnormal movements of the left ventricle without coronary artery obstruction are diagnostic. Specifically, when the heart contracts, the apex balloons to form the shape of a Takotsubo, a pot Japanese fishermen use to catch an octopus [7]. Despite clear examples of the intersectionality of mind and body across fields of study, the tendency to fall back to mind-body dualities is common. There is not yet a paradigm that can fully replace mind-body duality in the minds of clinicians and patients. This philosophical barrier makes conceptualization of a complex case difficult for clinicians and confusing, surprising, or even disturbing for patients. A great deal of patient education and dialogue about health literacy may need to occur for integrative medicine patients to understand their own case conceptualizations. In order to successfully practice, the integrative medicine team has to abandon the philosophy of a mind-body duality and actively work to counteract the habit of neglecting to consider the whole person in searching for a conceptualization for a patient’s presentation.

References 1. Archer J, Bower P, Gilbody S, Lovell K, Richards D, Gask L, et al. Cochrane Database Syst Rev. 2012;10:CD006525. 2. Paradise J. Medicaid moving forward. The Henry J. Kaiser Family Foundation. Mar 9 2105. Retrieved October 2018 from http://kff.org/health-reform/issue-brief/ medicaid-moving-forward/. 3. National Institute for Health Care Management. The Concentration of US Health Care Spending. July 2017. Retrieved January 2019 from https://www.nihcm.org/topics/ cost-quality/concentration-of-us-health-care-spending.

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4. Jiang HJ, Weiss AJ, Barrett ML, Sheng M Characteristics of hospital stays for super utilizers by payer, 2012: HCUP Statistical Brief #190, 2015. Rockville: Agency for Healthcare Research and Quality. Retrieved October 2018 from http://www.hcup-us.ahrq.gov/ reports/statbriefs/sb190-Hospital-Stays-Super-Utilizers-Payer-2012.pdf. 5. Menon GJ, Rahman I, Menon SJ, Dutton GN. Complex visual hallucinations in the visually impaired: the Charles Bonnet syndrome. Surv Ophthalmol. 2003;48(1):58–72. 6. Davis M, Eshelman ER, McKay M. The relaxation & stress reduction workbook. Oakland: New Harbinger Publications; 2008. 7. Prasad A, Lerman A, Rihal CS. Apical ballooning syndrome (Takotsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J. 2008;155(3):408–17.

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2

Models of Integrative Practice Julia Hodgson, Kevin Moore, Trisha Acri, and Glenn Jordan Treisman

Historically, medicine has been practiced with a hierarchical structure where the doctor is at the top of the pyramid providing expert opinions and giving orders to nursing staff in a top-down approach. In this model, primary care providers are gateways to medical specialists, while mental health, substance abuse, and dental care stand as silos outside the medical referral web. In modern practice there may also be team members called case managers, care coordinators, or patient navigators, particularly in medical practices that care for complex patients, like cancer care or infectious disease specialists. These additional team members traditionally also take orders from the physician, and they help the patient to navigate the system. Otherwise, the only person to talk to all of these professionals about the patient is the patient him-/herself, despite the patient having the least practice in processing health information, potentially not having all of the information themselves, and likely having emotions that interfere with grasping parts of the information. Yet this system has persisted despite the logical fallacies in such fractured healthcare that is based on an antiquated historical structure. When we talk about integrated care, we mean care that is provided by teams of experts from different fields of study including medicine, psychology, and nursing. Team members meet frequently and will discuss patients’ cases from different philosophical perspectives. We have found that this approach helps the team members to better understand the patient’s conditions in a more comprehensive and detailed way. The physician can understand the patient from the psychologist’s perspective and vice versa, and the team can improve upon the formulation of the patient’s diagnosis together. In this model, the case formulation or diagnosis specifically embraces the mind-body connection to see that the patient has more back pain when his family life is chaotic and therefore has increased likelihood of drug relapse requiring more intense follow-up with the therapist. In a patient

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with chronic low back pain, therapy that helps a patient to better understand their psychological underpinnings and deals with their major depression, alongside a comprehensive physical approach including medication, physical therapy, and massage, can provide direct benefit for their back pain. There is a movement toward integrated care at a federal level that is looking at improved outcomes from integrative medicine and developing guidelines for integrated healthcare. Heath, Wise-Romero, and Reynolds (2013) proposed a framework for the levels of integrated care nationwide that is used for the subset of the US Department of Health and Human Services that focuses on these topics, the SAMHSA-HRSA Center for Integrated Health Solutions [1]. There is a need for unified language around integration in order to produce meaningful outcome studies, comparisons, and dialogue around efforts to move toward this model of healthcare. While this text describes our idealized model of integrative care, there are varying levels and models of integration that need to be addressed in order to understand how integration can occur.

Levels of Integration The most recent models break integrative medicine into three main groupings, each broken into two subcategories. These six levels are seen along a continuum from minimal collaboration to fully integrated models (Table 2.1).

Models of Integrated Practice In addition to the varying levels of collaboration within integrated models is a consideration of how integrated practices are created and maintained, especially as integration is often an evolving process.

Co-location When talking about integrative medicine models, co-location is defined as adding behavioral health services into pre-existing medical practices. Patients often come to a primary care or other medical provider and are then referred to the embedded behavioral health services, often a therapist or psychologist, if issues arise that warrant such services. Because of the nature of the referral process, these practices often serve people who do not have severe levels of need, like patients with schizophrenia who need residential services. Patients who come in for primary care but may have depression or addiction issues are often the target of these clinics. Because providers are practicing in the same location, it increases the chances of communication between providers and an ability to get patients connected to

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Providers work in separate locations, systems, practices, etc. Communication is rare and, if it occurs, is only because one provider needs some specific information about a patient

Level 1: Minimal collaboration

Coordinated care

Integrated care

Level 3: Basic collaboration onsite

(continued)

Level 6: Full Level 5: Close Level 4: Close collaboration collaboration collaboration in a approaching an with some system transformed/ integrated practice integration merged practice Co-location that Providers work in Completely Team of clinicians Providers are involves one separate merged and with high level of co-located in the practice locations, systems, integrated communication same place but may embedded in practices, etc. practice, working with have own practice another, for Communication is clinicians work patients. Practice space and have example, a occasional as a team and has started to different systems. primary care around specific a single change/adapt Communication is office that hires a issues with healthcare unit structure to format more common due psychologist to patients, but that treats the of serving patients, to closeness (phone, work within their providers see whole person but some barriers email, meetings). practice shares a each other as a of the patient may exist like Decisions about medical record resource integrated medical patient care usually system and office records individual by staff. Clinicians providers. Patients share more are referred from patients, allowing practice to practice, for consultation but success is higher and because of common communication, location especially with complex cases

Level 2: Basic collaboration at a distance

Co-located care

Table 2.1  SAMHSA-HRSA levels of integration [1]

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Co-located care

The difference between these two levels Physical proximity is key. It does not guarantee coordination, but increases is the frequency and type of the chance. Collaboration face-to-face communication, the second level increases, plus it strengthens the increasing strength of relationships and relationship between providers strength of understanding about patient

Coordinated care

Table 2.1 (continued) Practice change is key in this level. The behavioral health and medical practice need to change how they practice in order to fully integrate, challenging pre-existing practices and cultures within each discipline. No one can be greater than the other, and all have to believe in the value of coordination

Integrated care

behavioral health services than if referrals are made to offsite behavioral health clinics. Furthermore, getting patients involved in behavioral health services is likely to decrease the amount of medical services needed and leads to better patient outcomes [2]. Logistically, behavioral health providers may benefit from joining medical practices because there are already established systems for payment, office space, and support staff that aid a practice. On the other hand, the specific barriers erected by payers to behavioral health are often overwhelming for the staff of medical offices, and medical practices may underestimate the value of behavioral health services. At the outset of establishing integrated care, there are issues of shared resources, room space, scheduling, and support staff time. Once established, our experience is that behavioral health is seen as a huge asset by those who were there before it began, but after it has been present for a number of years, it is often taken for granted, and people may grumble about the expense, inconvenience, or costs of having integrated health. The value of integration is often not on the radar of medical practices, so efforts may need to be made in providing education about the importance and benefits of behavioral health and integrative practices.

Reverse Co-location Reverse co-location takes the idea embedding one practice in another and uses it to bring medical care into pre-existing behavioral health programs or practices. Motivations for these models often lay in improving physical health for those with more severe and persistent mental illness as these populations are at high risk of comorbidity of medical conditions [2]. This model of program is often seen in inpatient settings or day treatment programs, but may also include outpatient mental health programs and addictions treatment centers. In addition to the benefits of co-location listed above, this model has the added advantage of allowing medical practitioners to work closely with behavioral health clinicians to understand the patients, take the time to understand the relationship between medical and psychological symptoms, and to increase compliance with medical appointments by coordinating with behavioral health appointments that are already scheduled [2].

Integrative Behavioral Medicine To avoid some of the challenges of embedding programs, it may be most advantageous to start a practice with the initial intention of fully integrating behavioral health and medical care from the outset. Creating a practice that is integrated allows the members to choose the team, fully design internal processes, create a joint space, and develop a practice mission statement that is true to the values of integration. A challenge to embedding behavioral or medical services in the colocation and reverse models above are the challenges of breaking into an already established practice. At the most superficial level are the challenges of incorporating the record keeping, equipment, finding space, and 2  Models of Integrative Practice

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retooling support services to provide for the needs of the often shifting and barrier-ridden insurance requirements for behavioral care. However, there is also the challenge of attempting to gain entry into an existing culture, one that may not understand the value of the others’ presence or of integration at all. Sometimes major efforts must be made to even convince clinicians to talk to one another, let alone train them on how to collaborate effectively. Without the mind-set of integration, creating change in a culture is increasingly difficult. However, when a practice begins at its outset with the mind-set of integration, systems and practices are able to be implemented that promote a culture of collaboration. Nothing needs to be adapted; everything can be created in a joint manner. Individuals may need training in integration as graduate programs and other practices have likely shaped clinicians to think independently of other disciplines, but this is less difficult than changing a culture of an entire practice (see more on this topic in Chap. 11 “An Integrative Training Model”). Hiring can occur in a way that seeks out individuals who are at least open to the mind-set of collaboration and integration. Any new practice has start-up challenges. Considering financial realities, how does one build up a practice and pay its employees before there are any patients to generate income? This is not unique to integrative medicine, but it is certainly a barrier to starting a new practice. Furthermore, how does the team get reimbursed for its integrative efforts, like team meetings, which are rarely covered by insurance companies? As has been addressed, there are philosophical concerns to address as well, like questions of leadership and liability.

Billing and Finances As described in this book, many integrative medicine activities are not billable services in a standard fee-for-service insurance contract nor are typical capitation payments able to cover the salaries of a highly skilled and highly motivated staff. Yet, integrative medicine is only successful if it is financially viable for many years. It is continuity of care over time that maximizes optimal clinical outcomes. Outside of academic institutions that can supplement operational costs with funding for training or research, there are currently relatively few financially self-sustaining integrative medicine practices in the United States. HIV clinics and cancer centers are two successful examples of specific disease state delivery systems where an emphasis on watching longterm clinical outcomes has shown the financial wisdom inherent to integrative medicine. Federally qualified health centers often try to practice integrative medicine because they frequently co-locate primary care and behavioral health; however these centers rarely have more than a referral system in lieu of care coordination. Patient-centered medical homes do emphasize integrative medicine in order to achieve better outcomes, but this model is still emerging

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and gaining the fiscal and clinical maturity to be consistently viable, as well as burdened by an inflexible system of requirements for every patient that may be redundant or unnecessary. The variability in patient-centered medical homes’ clinical outcomes is probably because they have been applied to all types of patients. Integrative medicine interventions are best applied to complex patients with comorbid and severe physical health and mental health diagnoses. During this era of healthcare reform, everyone (except perhaps for insurance companies) is hoping that new payment models take root, especially “pay-for-performance” models where integrative medicine practices caring for the most complex patients would thrive as long as the targets for performance do not disenfranchise difficult patients. There are some liabilities in this system as performance can be measured many different ways. Pay-for-­ performance and other clinical outcome measures often make it financially desirable to care for patients who will have good outcomes, and the “system” may try to shed high-cost patients by frustrating them or erecting barriers to their care. If patient satisfaction is a performance measure, doctors may overprescribe medications that patients demand, often to their detriment (see below). If markers of morbidity or mortality are the targets, practices will be rewarded financially for caring for patients with less disease, and the sickest patients will be pushed out of care. A physician who has 7 min per patient and is monitored in numerics related to glucose control may try to avoid patients with substance abuse, schizophrenia, intellectual disability, or personality disorders. These types of patients will be labeled “difficult,” particularly because they MAY not maintain appropriate boundaries, and they will be administratively or otherwise discharged from care. Insurance companies are organized in a way that rewards quarterly income and minimizes quarterly cost. This means expensive care that will come later has no salience now and rewards systems like those currently in place. They “carve out” mental health services and addictions despite evidence of better outcomes when care is integrated and coherent. They erect barriers to care such as requiring prior authorization, poor reimbursement, delayed and contested payments, and narrow benefits despite the fact that in the long run these services will save money. Every company is different, requiring a support staff with a nuanced knowledge of co-payments, prior-­ authorization requirements, and billing allowances, many of which change all the time. Furthermore, some companies may prohibit certain codes from being billed on the same day, for example, a therapy code and an “evaluation and management code” [2]. Others may require that the behavioral health staff are employees of the medical providers, refusing to acknowledge the team or integrated approach at all. To even bill insurance, providers may be required to apply and be accepted on insurance panels, sometimes limiting where practices can open. When the patient’s insurance does not cover beneficial services that are provided, clinicians must make decisions between losing money by covering the cost of a service or forgoing optimal care for patients. When patients are covered by more than one insurance company, by both Medicaid and Medicare, for example, billing practices become even more complex. Because integrative medicine often

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targets the most chronic and complex patients who tend to also be vulnerable and underserved and have lower socioeconomic status, demanding full payment by patients in lieu of taking insurance is not an option. This reality demands that payers and health systems take notice of these complexities and begin to make changes at the core of healthcare.

References 1. Heath B, Wise-Romero P, Reynolds K. A review and proposed standards framework for levels of integrated healthcare. Washington, D. C.: SAMHSA-HRSA Center for Integrated Health Solutions; 2013. Retrieved October 2018 from http://www.integration.samhsa.gov/ integrated-care-models/A_Standard_Framework_for_Levels_of_Integrated_Healthcare. pdf 2. Collins C, Hewson DL, Munger R, Wade T. Evolving models of behavioral health integration in primary care. New York: Milbank Memorial Fund; 2010. https://doi.org/10.1599/ evolvingcare2010.

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3

Requisite Practices of Integrative Medicine Julia Hodgson, Kevin Moore, Trisha Acri, and Glenn Jordan Treisman

Most patients know the core contract of the doctor-patient relationship. (we use doctor-patient relationship due to the extensive literature in this area, but this applies to all the members of the patient care team.) The doctor/clinician is obligated to act in the best interest of the patient (not what is in the doctor’s best interest, the hospital’s best interest, the insurance company’s best interest, or the society’s best interest), and the patient follows the prescribed treatment after deciding that the diagnosis and treatment plan are sensible. The patient questions how the doctor knows what their diagnosis is, why this treatment is best, what are the alternative treatment options, and what the prognosis is and is educated about the issues of the problem they face. The doctor also encourages a second opinion in difficult cases or if there are unresolved questions. Once the patient decides to commit to a course of treatment, they are obligated to follow the treatment plan as best as they are able (take the medication, do the therapies, follow the restrictions, and keep the doctor informed of progress). Some patients, however, do not understand the treatment contract. They may have had negative experiences with other clinicians or have cultural reservations about medical treatment and models, or have cognitive limitations, or have a temperament that pushes them to follow their feelings, or many other barriers. Following Treisman and Angelino’s (2004) articulation of role induction, integrative medicine teams sometimes need to teach some people how to become patients [1]. To be a patient is to accept that the treatment team is working on the patient’s best interest and that the education and expertise of the team means knowing more than the patient about the psychological, biological, and developmental processes of the patient. We do not endorse any “blind trust” but rather a commitment to following through on the prescribed treatment. In order to do this effectively, the team needs to communicate with one another, with the patient, and in a way that © Springer Nature Switzerland AG 2020 J. Hodgson et al., Integrative Medicine for Vulnerable Populations, https://doi.org/10.1007/978-3-030-21611-5_3

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considers that patient’s history and future. At the core of integrative medicine are a few foundational activities upon which the system and process of integrative medicine rest: communication and collaboration, gathering records and complete case history, and advocating for the patient.

Communication and Collaboration The most important element of integrative medicine is professionals communicating and collaborating about mutual patients. The patients who we feel need this kind of care have complex comorbidities that include issues outside of the scope of practice for one clinician, and treatment in one domain affects treatment in other domains. Communication is the foundation that allows integrative medicine to function, bringing a patient’s team together to effectively coordinate care and work in tandem toward the mutual goal of patient health. Too often, when care is not integrative in its approach, a patient sees multiple providers such as a primary care physician, a psychiatrist, and a therapist, none of whom are communicating with one another. This lack of communication places the burden of sharing information on the patient, who may be unable to retain or disseminate the appropriate information about the nuances of their medical care. Even a person who is not dealing with schizophrenia or the aftermath of a brain injury will not have the training in each of the fields that they interact with to know what small pieces of information can make a big difference in making important decisions about treatment. Beyond removing the burden of coordination from the patient, communication among a treatment team compensates for specialized training each clinician has in their respective fields. It is undeniable that a psychologist may be able to differentiate between depression and bipolar disorder but likely is not able to speak fluently on which blood tests would best screen for hepatitis C; this task would obviously fall to a medical provider. More importantly, when psychological and medical services overlap, an integrative team is in the unique position to intervene in a meaningful and competent manner. For example, some psychiatric conditions interact with medical conditions such as heart disease. Patients who develop depression postmyocardial infarction are more likely to die than those without depression, and depression is a risk factor for behaviors (smoking, overeating, lack of exercise, poor adherence to medication) that increase the risks of myocardial infarction. These independent but interlocking conditions require diagnostic acumen that may be beyond the solo practitioner. Treatment of these interlocking conditions requires a team that can simultaneously approach the whole patient rather than individual clinicians trying to treat conditions that are unresponsive without collateral treatment. In addition to the benefits of communication, a lack of communication may inadvertently lead to clinicians acting in ways that contradict one another, leaving a patient confused at best and being harmed at worst. For example, a patient who is in recovery from heroin addiction with his therapist

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might be suffering from chronic back pain. When he asks his primary care doctor what to do about the pain, he may not admit his addiction to the doctor because he did not believe psychological treatment was relevant to physical pain. However, the seemingly appropriate prescription of a narcotic painkiller by the primary care doctor will trigger addiction issues due to being in the same class of drugs as heroin. As will be illustrated in later chapters of this book regarding opioid addiction, intentionally seeking out medications from multiple doctors who are not coordinating is a common way for an addict to feed their addiction, thus increasing the demand for communication with such difficult populations. Providers who are in close contact and work together in the treatment of their mutual patient can avoid scenarios such as the above to best care for their patients’ health overall. Effective communication is vital to integrated and coordinated care.

Gather and Share Available Records The second most important activity is gathering and sharing all available care records. To the surprise of no one who works in healthcare, and to nearly everyone who does not, the thicker the chart, the fewer professionals who have read it. Decisions are made about a person’s care daily without full knowledge of whether those approaches have been attempted in the past, if there is something in the history that could be contributing to the current situation, and that might give clues as to the origin or progression of difficult cases. The integrative medicine team not only seeks out as thorough a medical record as possible, requesting records from every provider that a patient has seen, but takes the time to actually read and review past records in order to best inform current care. Understanding what a patient has done in the past, and whether the results were successful or not, provides important information that may guide the treatment team to make well-informed decisions. It may also allow the team to avoid repetitive or redundant procedures from being done. For example, a patient seeking treatment for hepatitis C may require certain blood work or a liver evaluation for fibrosis in order to obtain approval for antiviral medication. Discovering that a patient had a liver biopsy done previously may allow the clinician to move forward in acquiring the appropriate treatment more quickly. Another example is a patient who has a long history of depression and is seeking psychological and psychiatric care. Knowing which medications have been used in the past, both which ones may have decreased symptoms and which ones were harmful or ineffective, allows the prescribing physician to make better decisions. In the case of antidepressants, which can take up to 6 weeks to start having an effect, this is particularly important in helping to expedite results as much as possible. Furthermore, by sharing this information with the therapist, the therapist may help the patient to understand why the medications aren’t working immediately and help to start therapeutic work in the meantime that may alleviate symptoms of depression as well.

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Another common integrative care situation is the patient who has substance use disorder and suffers from low back pain. Having access to previous records of imaging scans and what has been tried previously, including steroid injections and physical therapy modalities, helps the clinician to come to a decision regarding treatment planning more rapidly and efficiently. Patients often have received fractured care in the past, and many of the initial evaluative and diagnostic tools have already been completed despite the fact that no one has reviewed the comprehensive records of all that has been done. Alternatively, it is also possible that the patient saw a clinician looking for a quick and easy fix who prescribed only medication. In the latter case, a full evaluation including careful history and examination and imaging modalities will be necessary. We have found that a comprehensive approach to treating pain, including multiple modalities and a team-based approach to care, is more effective than any treatments the patient has received previously. Taking the time to collect and actually review records may be typically avoided because of its time-consuming nature. However, when at least one person on the team is able to gather these records and someone takes the time to read them, care of the patient becomes more streamlined and effective, helping the clinicians to provide better care, and the patients are less frustrated at unnecessary redundancies in their treatments.

Advocacy for Patients Finally, the third key integrative medicine activity is advocacy for the resources to help the patient succeed in treatment. In addition to interventions, it is vital to set up our patients to succeed, helping them in gaining necessary tools such as insurance and public benefits. With this level of directiveness comes additional demands on the integrative medicine team to ensure that proper care is provided. For example, clinicians often struggle with the medical system to get patients access to specialists, medication, and resources that assist in accomplishing patients’ treatment goals. Insurance companies may be reluctant to pay for treatments, and it is often up to the integrative medicine team to convince the insurance companies that their medications or treatments are necessary. This role may fall outside of what medical physicians or psychologists are used to considering in treating patients, but it is important for the team as a whole to consider and meet this need. This is covered in more depth in a chapter on compiling the ideal integrative medicine team. We assist our patients in navigating available public benefits not only because addiction has created poverty in our patients but because benefits are important resources for nearly everyone needing chronic care services. Chronic medical and behavioral health disorders put those affected at highest risk for treatment nonadherence, hospitalization, homelessness, and incarceration and relapse. Even for patients from an affluent background chronic conditions are the largest social determinants of poverty and additional

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physical and mental health problems. Although our public safety net is badly frayed, public benefits remain available to alleviate the worst of poverty. Too many do not take advantage of available benefits. In our area (Philadelphia), one out of five who are eligible for food stamps is not enrolled [2].

 atient Demands—and Satisfaction—Should P Not Dictate Treatment Patient-centered care is often confused with patient-directed care. Disagreeing with a patient about what to do is not the same as not hearing the person or not advocating for them. Patients must be reassured that the clinicians will keep working to get them better if they keep coming and engaging in treatment. Ironically, the desired medications often act in ways that may cause problems to get worse instead of better. When patients complain that they are not being heard because they aren’t getting the medication that they want, it is important to remember that advocacy for the patient is not giving them what they want; it is getting them better. Often one must say “I am listening to you and have heard what you said but I disagree with you.” At this point in healthcare, outcomes and physician effectiveness are often measured by overseeing bodies via patient satisfaction ratings [3]. Patient satisfaction may work against effective healthcare as it emphasizes patients’ subjective perceptions of their treatment and health and ignores efficacious medical interventions and actual best practice. A subset of patients goes to the doctor with a unitary problem and the clear goal of getting better, and for them patient satisfaction relates to their improvement and, can be a fair assessment of quality. For these patients, the goals of the doctor and of the patient are the same. In vulnerable patients with complex comorbidity, the goal of going to the doctor is often to feel better or to be more comfortable; for these patients, patient satisfaction is a destructive measure. When the patient’s goal is feeling good and the clinician’s goal is improving health and function, the goals are not aligned, and patient satisfaction will reflect this disconnect between provider and patient. However, this does not mean that the clinician should just give the patient what they want. Furthermore, recent research has indicated that this system of outcome measurement is not reflective of patient care nor predictive of patient health (e.g., [3–5]). When patients rate satisfaction, they are influenced by a number of factors unrelated to outcomes. For example, factors such as wait time lead patients to report lower satisfaction rates, even if those wait times are caused by physicians providing comprehensive exams [3]. Given research around the poor correlation patient ratings have with actual outcomes or quality of care, it is bewildering that patient satisfaction ratings continue to make up such a significant portion of quality measurement in healthcare. This is in part because it is easy to measure. In the words of William Bruce Cameron (though often misattributed to Einstein), “Not everything that

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counts can be counted, and not everything that can be counted counts” [6]. An unfortunate side effect of these patient satisfaction ratings is that poor ratings can actually lead to worse care. Community clinics may depend on payments from insurance companies that provide the lowest premiums and are therefore the most restrictive. These companies may use patient satisfaction ratings to determine the amount of reimbursement. Thus, when patients rate their care poorly—despite the true efficacy of treatment—reimbursement decreases. When funding goes down, clinics can no longer afford to have as many clinicians or services available because of a decreased budget. As a result, the quality of care decreases. When sources of funding use patient satisfaction as a determinant, they inadvertently cause the quality of care for patients to decrease, ironically possibly leading to even lower satisfaction ratings. Beyond the ineffectiveness of patient ratings in judging quality healthcare, there is evidence that higher satisfaction ratings are actually correlated with higher mortality rates. Fenton et al. conducted a national study analyzing the link between patient satisfaction and mortality rates and ultimately discovered that higher patient satisfaction ratings are actually correlated with higher mortality rates [4]. This data was criticized because sicker patients are more likely to die and may give better satisfaction scores because of their dependence on the doctor. The link between patient satisfaction and mortality is greater when the data were stratified for the healthier patients. In fact, when a 1.5

Mortality

1.125

All patients Patients in good health

0.75

0.375

0

1

2 3 Level of satisfaction (least to most)

4

Figure 3-1.  Increased patient satisfaction correlates with increased mortality. (Graph based on data from [4])

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follow-up was conducted years after the study’s conclusion, there was a 26% greater mortality rate in the most satisfied patients over the least satisfied (Fig. 3.1). Some patients tend to rate their satisfaction based on what they want rather than what is actually advisable or evidence-based. The desire for an antibiotic for cold or bronchitis symptoms is well documented as an issue for patient satisfaction. In one study of almost one million patient satisfaction surveys in primary care settings from 7800 primary care practices in England, antibiotic prescribing was the number one prescription-related factor in patient satisfaction. Based on that study, any effort to decrease overuse of antibiotics would negatively affect patient satisfaction [7]. Many patients bring Internet-based opinions or advice from friends or family to appointments with strong beliefs about what treatments they should or want to get. However, a patient’s ability to assess their own need or know what treatment is best is often very limited, even when the patient is well-­ intentioned [3]. For example, a patient may walk in believing that they need a certain medication or a surgical procedure; if the physician assesses and does not agree with these expectations, patient satisfaction decreases. It is further important to note that patient expectations often greatly impact physician prescribing and behaviors, both overtly and in subtle ways [5]. First of all, physicians feel pressure to increase patient satisfaction, both from patients and from overseeing bodies that emphasize this system of measurement. Second, patients express preference for interventions exclusively provided by medical providers, such as medication or surgeries [5]. In the case of chronic pain, for example, patients express great dissatisfaction when offered alternative treatments such as exercise, yoga, or deep breathing instead of opioid pain medications. In this situation, a patient is likely to rank their satisfaction much lower. If this influences physician prescribing, it only further increases in cases of addiction where the patient may be seeking certain medications for themselves or to sell to others and thus will be particularly demanding in appointments and potentially punitive in satisfaction ratings if demands are not met. Given the influence of patient expectations on physician behavior, it is important not only to be aware of pressures from patients but to enact systems of care that protect physicians from the harmful power of patient satisfaction ratings as sole measurements of service provided. Patient satisfaction rates can be maintained without caving to patient demands by addressing concerns in a patient-centered way that provides information and correlates with the preferences of the patients [4]. This not only improves patient satisfaction but is correlated with better health outcomes as well. However, this type of care introduces its own obstacles as it takes much longer because of the conversations required and can be difficult for physicians to implement, particularly given billing and the current level of demand on scheduling of physicians [4]. Regardless, a model of integrative medicine allows for the physician to meet with the patient in the time that they have and for other members of the team to supplement and assist in providing information and providing support for the patient in a way that not only helps the patient to feel supported but produces better outcomes in health.

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Example: Discussing Benzodiazepines with Resistant Patients  The idea of advocating for the patient can be misunderstood in ways that are bad for patients, such as providing them with whatever they want. Such patientdetermined prescribing ignores the expertise that clinicians have in knowing the risks and benefits of various alternative treatment options and therefore the healthiest treatment choice for patients. As is clearly described above, patient demands and/or satisfaction should not be the hallmark by which clinician effectiveness is ranked. A common example of allowing the patients to dictate treatment is the long-term prescription of benzodiazepines in the treatment of anxiety disorders. These medications have quick and/or “easy” results in temporarily reducing anxiety in patients. There is, however, rebound anxiety with long-term use as the brain adapts to the presence of the drug. Additionally, benzodiazepines impair learning, hindering patients from developing coping skills to deal with ordinary life stresses. The relief of the symptoms produces a psychological dependency on the drug, and ongoing use produces physical dependence. In fact, by shielding the patient from their anxiety, they are unlikely to develop coping skills for anxiety and instead depend more on medications for problem-solving. The medications can ultimately cause more problems by covering up the anxiety instead of creating meaningful change and simultaneously preventing the patient from truly engaging in therapeutic work that would be most beneficial in the long run. In the case of the example below, the patient may demand benzodiazepines, but the clinician, especially one working in an integrative medicine setting with a therapist, must help the patient to understand what is truly best for their well-being. Consider the example of Darla. Darla is a 45-year-old woman who has been prescribed benzodiazepines, namely, Xanax (alprazolam is the generic name, but patients often use the trade name, and in this case, we will use Xanax because that is the name she used) for the past 20 years by her family doctor; she came into treatment because her anxiety remains severe and her husband’s cancer is exacerbating her experience of fear in her life to the point where she is afraid to leave the house most days. She has been taken off her Xanax briefly in the past, but finds herself feeling so sick from withdrawal that the idea of stopping is terrifying. Furthermore, she feels that she cannot tolerate living without the drug and was able to get her doctor to prescribe it again right away. In one of the first sessions in our clinic, the following conversation occurred to help Darla understand that the prescription she had been given for so long was not helping her. [This conversation picks up after Darla has been describing her anxiety and her continued need for her Xanax repeatedly] Darla: You don’t understand. I need my Xanax so I don’t feel anxious. Therapist: Let me explain to you how these medications work, and you can tell me if this sounds familiar. Xanax is a benzodiazepine, which is a class of drugs that all work similarly. It is essentially alcohol in a pill in terms of how it impacts your brain. At first, it works very quickly, making you feel euphoric, more social, more uninhibited. Xanax initially increases your mood and decreases your anxiety. Most people like this experience. Does this sound right?

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Darla: Oh yes, I always feel better right after I take it. Therapist: Ok, so just like alcohol, Xanax is a depressant, a sedative. Their primary action is to decrease brain functioning. You might find yourself getting sleepy, maybe lightheaded, and many people want to go to sleep after that initial period. Some people even use benzos to help them go to sleep. However, they find that after they fall asleep, alcohol and benzos work the same way. In the body, what goes up must come down. There is a rebound effect because the brain is always working to find balance. When the brain is slowed down by a drug, it must speed up after. You don’t get a good night’s sleep because your mind is racing and you wake up groggy. It actually disrupts sleep! It might be good for a nap, but it’s bad for a night’s sleep and really bad over time. Did you have more problems with sleep before or after you started taking Xanax? Darla: Well, I have more problems now… Therapist: And this is why. Darla: But it still helps with my anxiety! Therapist: Like I said before, it does initially make you feel better. But, as that dose wears off, you are more anxious for the same reason. Your brain is pushing against the sedation, trying to balance out, so you feel even more anxious than before. We use benzos to try to push down the anxiety, but it always comes back. Over time, benzos make people more anxious across the board. Has your anxiety gotten better since you started taking them? Darla: No, it’s gotten worse. Therapist: Because a doctor prescribed it to you, people think of it as different than alcohol. However, they are doing the same thing in numbing you to your anxiety instead of helping you to deal with it. Those doctors aren’t doing their job to get you better; they are trying to be helpful, but they’re not. You’re sick and that’s unfortunate, but I am here to get you better. This is a unique and special program; we believe in working really hard to help people deal with their anxiety without just numbing you from it like your Xanax is doing. If you choose to be a part of this program, we can help you with this. Darla: I don’t know. I think I just need a higher dose of Xanax. Therapist: Benzodiazepines, like your Xanax, are a poison. They are interfering with how your brain is functioning. It impairs how you can think and, while it might be enjoyable or feel good, it is not how it is supposed to be used medically. Darla: But my doctor gave it to me. Therapist: True, but if you look at the insert that comes with your prescription, the FDA even recommends that benzos are only used for a short term. Eight to 10 weeks max. Alcohol makes you feel similarly; would you drink several shots of whiskey every night before bed? How would that work out? Darla: Well no, I wouldn’t do that! Therapist: This is what you have been living with, and why you have been getting more anxious over time so that you actually need more of the

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medication. I get that, but we have to get rid of the bad to start to fix the anxiety. Darla: I guess that makes sense, but I have gotten so sick when I have tried to stop it before. Therapist: You’re right that you can’t just stop like you have tried before. Unfortunately, now that you’ve been on it and your brain has been pushing against it, you’ve changed your seizure threshold. A seizure is when brain is so overwhelmed that it short circuits and shuts down for a few minutes. It is not just unpleasant, but it’s dangerous. The doctor here will slowly decrease your dose over months; this is the safe way to taper off the drug and keep you healthy while your brain adjusts back to a normal level. Darla: I guess… Therapist: This is scary. I know that benzos have been a safety blanket, something you have turned to for help, and giving that up is scary. I am not asking you to do this all today. Trust us and do this over time, allow us to help you. Your anxiety will peak when you take the last dose, but then will go down over time. Darla: That makes sense, but it helped me when my brother and I stopped speaking 10 years ago. Therapist: When you told me about that huge fight with your brother, you said that the Xanax helped you forget about it. But you recounted the whole thing now. Seems terrible, but also unresolved. We want to actively deal with these issues, rather than not deal with them in the moment. Darla: That’s true. I still feel bad when I think about that. I guess I’m just worried about how I will deal with things without the Xanax. It really has been a help, even in just getting through my day-to-day. Therapist: When you were talking to me about how you use Xanax, you said that there are real uses for it and also that you sometimes used more than you should have or snuck some sometimes. I gave you a physical explanation. But more of what is going on with you is battle with fear that is being played out over use of Xanax. You are afraid you can’t deal with life, sleep, or problems with your family, without Xanax. Remember that you have slept or done things before Xanax. And you can do it again after. You are capable. You have survived all these things in your life. You’re a survivor. You are strong enough to do all this without Xanax. You can prove this to yourself over time by doing what we ask you to do. Darla: Okay, I’ll give it a try. But I need you to help me so I can deal with my life! The above conversation covers a number of topics that come up when talking to someone about making a change like discontinuing the use of benzodiazepines. Our patients will fight our suggestions when they are not in line with what they want or seem scary to try. Acknowledging these fears, as well as providing information about misconceptions they may have, allows you to express empathy while still advocating for the patient’s best interests. Patients respond well when they understand the rationale behind intimidating interventions, which increases buy-in and willingness to consider these treatment options. Despite our patients’ resistance, this does not mean that we should sacrifice best care to maintain our patients’ short-term satisfaction with us as providers. In the end, as this example shows, advocating for best

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care may not be what the patient wants, but it is still the necessary route for clinicians to insist upon.

Conclusion The implications of the foundational assumptions of integrative care lead to an entirely different experience for the patient seeking medical care than anywhere else in healthcare. The patient is talking to someone whose default assumption is the patient will be served by the team for many years. All information about the patient’s life is potentially clinically relevant and part of the careful detective work needed to provide the highest level of care. Problems that arise for the patient are not the patient’s problems to solve alone, but issues that the team wants to see resolved so everyone can be as healthy and happy as possible. This method of conceptualizing care, based on coordination, seeking out a thorough medical history, and truly advocating for the patient to get the best care possible is what make integrative medicine so unique and transformational in providing the best patient care.

References 1. Treisman GT, Angelino AF. The psychiatry of AIDS: a guide to diagnosis and treatment. Baltimore: Johns Hopkins University Press; 2004. 2. Office of Community Empowerment and Opportunity. Access to benefits. n.d. Retrieved October 26, 2018, from http://sharedprosperityphila.org/access-to-benefits/. 3. Mazur MD, McEvoy S, Schmidt MH, Bisson EF. High self-assessment of disability and the surgeon’s recommendation against surgical intervention may negatively impact satisfaction scores in patients with spinal disorders. J Neurosurg Spine. 2015;22(6):666–71. 4. Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med. 2012;172(5):405–11. 5. Zgierska A, Miller M, Ragabo D. Patient satisfaction, prescription drug abuse, and potential unintended consequences. JAMA. 2012;307(13):1377–8. 6. Cameron WB. Informal sociology: a casual introduction to sociological thinking. New York: Random House; 1969. 7. Ashworth M, White P, Jongsma H, Schofield P, Armstrong D.  Antibiotic prescribing and patient satisfaction in primary care in England: cross-sectional analysis of national patient survey data and prescribing data. Br J Gen Pract. 2016;66(642):e40–6.

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PART II

Conceptualization and Diagnosis in Integrative Medicine

The target population for integrative medicine consists of the most complex and vulnerable patients with chronic and co-morbid conditions. As we reviewed in Section One, our defined goal for patient care is to improve quality of life, functioning, and longevity. At the core of this process are the key activities of communication, compiling and understanding a patient’s history through records, and advocating for the resources and treatment that will best serve the patient. However, the art of integrative medicine extends beyond just understanding the above elements. There are three processes that are integral to nuanced and effective care: correct diagnosis of the whole person including an understanding of the way in which these conditions exacerbate each other, treatment of each element of the diagnoses, and ongoing team-based coordination of care. Given the complexity and importance of these processes, this book will define and explore the concepts related to this process, such as personality structures or diagnostic strategies, in great depth. The final chapter of this section is entirely comprised of an in-depth case example to fully illustrate the diagnostic and treatment nuances of a real complicated case treated by one of our authors.

4

Understanding the Disease of Addiction Julia Hodgson, Kevin Moore, Trisha Acri, and Glenn Jordan Treisman

Addiction is an incredibly misunderstood aspect of behavioral health. Mischaracterized as an immoral personal choice or failing of character and will power instead of a disease of the brain, misinformation about the nature of addiction leads to ineffective and even harmful interventions. In this chapter, we will critically examine addiction in order to define it, and attempt to use an integrated clinical perspective to understand the current opioid epidemic in the United States. We will then discuss the challenges of diagnosis and treatment of addiction (Figs. 4.1 and 4.2). In recent years, the opioid epidemic in the United States has been in part due to opioid over-prescribing and poor understanding of the process by which addiction develops. The epidemic also has involved more use of other addictive substances including marijuana, alcohol, stimulants, benzodiazepines, and cocaine. Some of these compounding addictions have been perpetuated by misinformed doctors—and patients—and demands for finding a pill to “cure” mental health issues. For example, the widespread dialogue about ADHD has led to increased use of stimulants and a sharp increase of stimulant addiction. Stimulants have become increasingly used by people who do not have ADHD for the purposes of studying, staying attentive during meetings, and staying up to complete tasks. All of these drugs are amphetamine derivatives, which have been shown to have addictive qualities and have increased their hold on people in the United States dramatically in the last decade. Another example is the increasingly common prescription of benzodiazepines as a treatment for anxiety, as well as its increasingly common use as a recreational drug, which has led to epidemic proportions of benzodiazepine and related drugs in terms of use and death. The use of more than one class of agent plays a role in the severity of the epidemic (Figs. 4.3, 4.4, and 4.5).

© Springer Nature Switzerland AG 2020 J. Hodgson et al., Integrative Medicine for Vulnerable Populations, https://doi.org/10.1007/978-3-030-21611-5_4

37

100,000

Total Overdose Deaths

Male

Female

80,000

70,237

60,000 36,010

40,000 20,000 16,849 0

99 000 001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

19

Source: : Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 19992017 on CDC WONDER Online Database, released December, 2018

Figure 4-1.  National Drug Overdose Deaths—Number Among All Ages, by Gender, 1999–2017. More than 70,200 Americans died from drug overdoses in 2017, including illicit drugs and prescription opioids—a twofold increase in a decade. The figure above is a bar and line graph showing the total number of US overdose deaths involving all drugs from 1999 to 2017. Drug overdose deaths rose from 16,849 in 1999 to 70,237 in 2017. The bars are overlaid by lines showing the number of deaths by gender from 1999 to 2017. (Source: Reprinted from CDC WONDER [1]) 50,000 40,000 Other Synthetic Narcotics other than Methadone (mainly fentanyl), 28,466 Prescription Opioids, 17,029

30,000 20,000

Heroin, 15,482 Cocaine, 13,942 Benzodiazepines, 11,537

10,000

Psychostimulants with Abuse Potential (Including Methamphetamine), 10,333 Antidepressants, 5,269

0

99

19

01

20

03

20

05

20

07

20

09

20

11

20

13

20

15

20

17

20

Source: : Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 19992017 on CDC WONDER Online Database, released December, 2018

Figure 4-2.  National Drug Overdose Deaths—Number Among All Ages, 1999–2017. Among the more than 70,200 drug overdose deaths estimated in 2017, the sharpest increase occurred among deaths related to fentanyl and fentanyl analogs (other synthetic narcotics) with more than 28,400 overdose deaths. (Source: Reprinted from CDC WONDER [1])

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25,000

Psychostimulants Psychostimulants and Any Opioid Psychostimulants Without Any Opioid Psychostimulants and Other Synthetic Narcotics

20,000

15,000 10,333

10,000

5,000 547 0

1,378

99 000 001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

19

Source: : Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 19992017 on CDC WONDER Online Database, released December, 2018

Figure 4-3.  National Drug Overdose Deaths Involving Psychostimulants with Abuse Potential (Including Methamphetamine), by Opioid Involvement, Number Among All Ages, 1999–2017. The figure above is a bar and line graph showing the total number of US overdose deaths involving psychostimulants from 1999 to 2017. Drug overdose deaths rose from 547 in 1999 to 10,333 in 2017. The bars are overlaid by lines showing the number of deaths involving psychostimulants and any opioid, psychostimulants without any opioid, and psychostimulants and other synthetic narcotics. The number of deaths involving the combination of psychostimulants with any opioid has been increasing steadily since 2014 and is mainly driven by the involvement of other synthetic narcotics; however, deaths involving psychostimulants without the involvement of any opioid are also on the rise. (Source: Reprinted from CDC WONDER [1])

The Disease of Addiction The concept of addiction has been heavily debated historically. Ideas about morality, personality, choices, and criminality as well as ideas about tolerance, physical dependence, and reinforcement have been argued back and forth for decades. The term addiction was not adopted by the APA in the DSM-5 categorization of mental disorder, which instead used substance use disorder as a more neutral term that was thought to be less stigmatizing [2]. We use the term addiction because it persists in clinical practice, captures the overarching nature of addiction as a condition, and it is the term used most widely by people in recovery. Drugs that produce addiction have certain features in common and clearly produce a continuum of disorder. Other commonly used phrases like substance abuse, misuse, dependence, and use are difficult to separate out in the clinic and in research.

4  Understanding the Disease of Addiction

39

25,000

Cocaine Cocaine and Any Opioid Cocaine Without Any Opioid Cocaine and Other Synthetic Narcotics

20,000

13,942

15,000

10,000 6,512 5,000 3,822

0 99 000 001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

19

Source: : Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 19992017 on CDC WONDER Online Database, released December, 2018

Figure 4-4.  National Drug Overdose Deaths Involving Cocaine, by Opioid Involvement— Number Among All Ages, 1999–2017. The figure above is a bar and line graph showing the total number of US overdose deaths involving cocaine from 1999 to 2017. Drug overdose deaths involving cocaine rose from 3822 in 1999 to 13,942 in 2017. The bars are overlaid by lines showing the number of deaths involving cocaine and any opioid, cocaine without any opioid, and cocaine and other synthetic narcotics. The number of deaths in combination with any opioid has been increasing steadily since 2014 and is mainly driven by deaths involving cocaine in combination with other synthetic narcotics. (Source: Reprinted from CDC WONDER [1])

We define addiction as increasing use, more stereotyped use, and more time and energy spent on the use of a substance despite mounting consequences and disruption of function in multiple areas of life. As an addiction evolves, the use of the substance becomes more ritualized and repetitive, with the drug of choice being used in the same ways and the same location. The use of the substance also becomes more and more of the focus of organizing each day and produces increasing isolation. Increasingly, addiction produces a characteristic state of lying to oneself about the use of a substance. This constellation develops on a continuum and does not divide up into simple categories such as use, misuse, abuse, and dependence, hence in DSM-5 the adoption of the term substance use disorder, a synonym for addiction. Unfortunately, addiction is commonly misperceived as poor impulse control, not trying hard enough, naivety about the harm of using, a moral failing, or simply a bad choice; addiction is none of the above. Those who are addicted often understand the negative consequences of their use, but they make psychological adaptations to justify, downplay, and rationalize their use. Seemingly beyond the control of the person, addiction takes on a powerful life of its own, leaving destruction in its wake.

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25,000

Benzodiazepines Benzodiazepines and Any Opioid Benzodiazepines Without Any Opioid Benzodiazepines and Other Synthetic Narcotics

20,000

15,000 11,537 10,000 4,500

5,000 1,135 0

99 000 001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

19

Source: : Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 19992017 on CDC WONDER Online Database, released December, 2018

Figure 4-5. National Drug Overdose Deaths Involving Benzodiazepines, by Opioid Involvement—Number Among All Ages, 1999–2017. The figure above is a bar and line graph showing the total number of US overdose deaths involving benzodiazepines from 1999 to 2017. Drug overdose deaths involving benzodiazepines rose from 1135 in 1999 to 11,537 in 2017. The bars are overlaid by lines showing the number of deaths involving benzodiazepines and any opioid, benzodiazepines without any opioid, and benzodiazepines and other synthetic narcotics. The number of deaths involving benzodiazepines in combination with other synthetic narcotics has been increasing steadily since 2014, while deaths involving benzodiazepines without any opioids have remained steady. (Source: Reprinted from CDC WONDER [1])

Understanding addiction requires an understanding of the interaction between behavior and brain physiology. All known addictive drugs work on the primary reward pathways of the brain which control drive, activation, behavioral goals, and rewards. This pathway, relying on the release of the pleasurable neurotransmitter dopamine, controls the rewarding nature of certain behaviors. When the brain gets extra dopamine, the body feels good and seeks out those feelings again. It is reinforcing. This cycle, as shown in Chap. 5, of positive feedback amplifies behaviors needed for survival, such as eating, sleeping, and sex. The amplification loop causes these behaviors to continue despite a severe aversive experience (e.g., we still seek out food even after experiencing a bout of food poisoning). These loops are tightly controlled by regulatory “turnoffs” that determine satiety from the behavior. At some point, people have eaten enough, and the idea of eating becomes uninteresting or even aversive. Addictive drugs short-circuit this cycle and have no turnoff mechanism. The elements of addictive behavior can be modeled easily using animals and behavioral manipulations. Models of addiction in animals can demonstrate the primary features of addiction seen in humans: an increased use

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Figure 4-6.  Illustration of a Skinner box

LIGHTS

FOOD

LEVER

FLOOR (ELECTRIFIED)

over time, and increasing amount of time and energy spent using, and increased use despite mounting consequences. Animal behavioral studies can even model the relapse patterns seen in humans. All addictive drugs share certain properties in these models. The figure below shows a “Skinner box” with a mouse in it. The mouse is taught to press the lever for food when a light comes on and then is taught to press the lever for drugs when the light comes on and will “work,” that is, press the lever, in order to get the drug (Fig. 4.6). This type of apparatus allows one to see the elements of addiction in animal behavioral models. The mouse in the figure will “learn” to press the lever to get an addictive drug. He will then gradually increase the number of times he will press the lever to get the drugs; behaviorists use the term “self-­ administration.” Opioids, benzodiazepines, stimulants (including cocaine), and other addictive drugs will gradually cause the animal to increase the amount of “work” it will do to get the drug. Given a more complex apparatus, we can give the animal a choice between getting the drug, or pressing another lever to get food, access to other animals, and to avoid aversive stimuli. Initially, an animal will not choose the drug over aversive stimuli, but over time and with increased dose and exposure, the animal will come to tolerate an aversive stimulus to get the drug [3]. This model demonstrates rats increasing their use of the drug, increasing their efforts and energies to get the drugs, and increasing their will to tolerate increasing aversive stimuli (foot shocks) to get the drugs. In an interesting set of experiments, Grimm, Hope, Wise, and Shaham (2001) [4] demonstrated that rats who were removed from an environment where they self-administered drug would “relapse” and “crave” the drug when placed back in the environment where they “learned” to use the drugs. They also showed that the longer the animal was out of the environment, the more severe the “craving” appeared to be. Lastly, they showed that animals given “cues,” that is, sounds during exposure to the drug or other stimuli associated with the drug, would dramatically increase their efforts to get the drug [4] (Fig. 4.7).

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A

300

*

Responses (6 h)

240 180

*

*

15

29 *

60

29

60

*

120 60 0 1

B

2

4

7

100 Baseline Cues available

80 Responses (1 h)

Figure 4-7.  Persistence of a cocaine-seeking habit as a function of time since the last day of self-­ administration of cocaine. (a) Mean (±standard error) number of nonreinforced responses on the lever previously associated with cocaine, from six extinction sessions in the presence of the house light and lever cues that were previously associated with cocaine availability. (b) Mean (±standard error) number of non-reinforced responses on the lever previously associated with cocaine in the subsequent presence of the light-tone signal (conditioned reinforcer) that was previously associated with earned cocaine injections.” (Reprinted with permission from Springer Nature Grimm et al. [4])

*

*

60 *

40 20 0 1

2

4 7 15 Withdrawal period (d)

Human Addiction Is More Complicated The above experiments show that the primary elements of addiction (increasing use, use despite increasing consequences, increasing investment in use, and relapse after cessation) can be clearly demonstrated in animals. What they do not show is the range of human elements that shape addiction in terms of psychology, vulnerability, resilience, and most importantly, recovery. Humans have the ability to overcome addiction, to recover from the disorder by using therapeutic techniques and human contact. Millions affected by the disease of addiction are sober and in recovery despite the biology of addiction being present in their brains. Relapses in animals are predictable under controlled conditions, but in humans they are affected by a vast array of factors that sustain recovery or sabotage it. Because addiction is a disease which requires lying to oneself, it is the job of the integrative medicine team to help build up the practice of truth. It is unsurprising that people struggling with addiction will often downplay or lie about relapses as they occur. This is exacerbated for those who have experience with probation, parole, or other recovery programs that have

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43

relaxed or insufficient standards for checking compliance with medications and monitoring relapses. Many patients come in and tell how they successfully managed to “get away with using” in past programs. As we will elaborate upon in Chap. 8, strict and thorough systems for monitoring for relapse hold patients accountable to being forthcoming when relapses and use occur; being able to verify retrains the person to be oriented toward truth and honesty. Without observed urine drug screens, partial relapses can go uninterrupted by family members and integrative medicine staff until the relapse intensifies and significant functional impairment is obvious. Addiction is a chronic condition, more complicated and difficult than many others to treat. Those who have heard people with decades of sobriety refer to themselves as “recovering addicts” have witnessed the need to monitor for relapse potential in the long term. Stories we have encountered of relapse in our practices illustrate the same: Charles had been clean for 12 years from any use. He owned a recovery home and led 12-step meetings multiple nights per week. Then, doctors discovered a tumor, and Charles was diagnosed with cancer. He was able to manage the stress and emotional toil of his diagnosis. However, to deal with the pain of the disease and the chemotherapy, Charles was given narcotics. Within months, his addiction was back, and he lost all of his property and had abandoned the meetings he used to lead. He was soon arrested and charged with another possession charge, landing him in and out of jail for years.

Georgia was an active member in the recovery community, outspoken in her activism for policy changes that would better help addicts like herself in overcoming their disease. She had 27 years of clean time when she got in a car accident. At the hospital, she told the doctors that she was a recovering addict and was adamant that she could not be given opioids, even insisting that she watch them write this demand in her chart. However, they gave her morphine against her will. Her relapse was imminent and she began using heroin again as soon as she was discharged from the hospital. Sadly, she overdosed within 2 years.

Even more common are the stories of people with 1 month or a few weeks of sobriety relapsing. It often takes many attempts for people to successfully overcome addiction. As will be elaborated upon in Chap. 7, treatment for addiction is long term and necessitates patience and perseverance on the part of the integrative medicine team and the patient (Figs. 4.8, 4.9, and 4.10).

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Integrative Medicine for Vulnerable Populations

50,000

Opioids

Male

Female

47,600

40,000 30,000 18,515

20,000 10,000 8,048 0

99 000 001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

19

Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 19992017 on CDC WONDER Online Database, released December, 2018

Figure 4-8.  National Overdose Deaths Involving Any Opioid—Number Among All Ages, by Gender, 1999–2017. The figure above is a bar and line graph showing the total number of US overdose deaths involving opioids from 1999 to 2017. Any opioids includes prescription opioids (and methadone), heroin, and other synthetic narcotics (mainly fentanyl). Drug overdose deaths rose from 8048 in 1999 to 47,600 in 2017. The bars are overlaid by lines showing the number of deaths by gender from 1999 to 2017. Overall, there have been a higher number of drug overdose deaths among males. (Source: Reprinted from CDC WONDER [1]) 25,000

Prescription Opioids Prescription Opioids Without Other Synthetic Narcotics Prescription Opioids and Other Synthetic Narcotics

20,000

17,029 15,000

12,796

10,000

5,000 3,442 0 99 000 001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

19

Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 19992017 on CDC WONDER Online Database, released December, 2018

Figure 4-9.  National Overdose Deaths Involving Prescription Opioids—Number Among All Ages, 1999–2017. The figure above is a bar and line graph showing the total number of US overdose deaths involving prescriptions opioids (including methadone) from 1999 to 2017. Drug overdose deaths involving prescription opioids rose from 3442 in 1999 to 17,029 in 2017. Since 2016, however, the number of deaths has remained stable. The bars are overlaid by lines showing the number of deaths involving prescription opioids in combination with other synthetic narcotics (mainly fentanyl) and without other synthetic narcotics from 1999 to 2017. The number of deaths involving prescription opioids in combination with synthetic narcotics has been increasing steadily since 2014 and shows that the increase in deaths involving prescription opioids is driven by the use of fentanyl. (Source: Reprinted from CDC WONDER [1])

4  Understanding the Disease of Addiction

45

25,000

Heroin Heroin Without Other Synthetic Narcotics Heroin and Other Synthetic Narcotics

20,000 15,482 15,000

10,000

5,000 1,960

2,399

0

99 000 001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

19

Source: : Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 19992017 on CDC WONDER Online Database, released December, 2018

Figure 4-10.  National Overdose Deaths Involving Heroin—Number Among All Ages, 1999–2017. The figure above is a bar and line graph showing the total number of US overdose deaths involving heroin from 1999 to 2017. Drug overdose deaths involving heroin rose from 1960 in 1999 to 15,482 in 2017. The bars are overlaid by lines showing the number of deaths involving heroin in combination with other synthetic narcotics (mainly fentanyl) and without other synthetic narcotics from 1999 to 2017. The number of deaths involving heroin in combination with synthetic narcotics has been increasing steadily since 2014 and shows that the increase in deaths involving heroin is driven by the use of fentanyl. (Source: Reprinted from CDC WONDER [1])

The Opioid Epidemic Heavily reported upon in the news, the opioid epidemic refers to the use and abuse of substances like heroin as well as narcotic painkillers like Percocet (Tylenol with oxycodone), morphine, Dilaudid (hydrocodone), and fentanyl. In the past two decades, opioid abuse in the United States has more than tripled [5]. “From 2000 to 2014, nearly half a million persons in the United States have died from drug overdoses” [6] (Fig. 4.11). Hundreds of federal, state, and local interventions have been implemented to address this public health crisis. All addiction treatment advances are critically needed, but opioid addiction treatment is especially critical due to its potential for overdose death (Fig. 4.12). Opioids work by attaching to opioid receptors in the brain, thus impacting different systems in the brain and body. Desirable effects of opioids include decreased physical pain as well as increased sensations of pleasure and

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Integrative Medicine for Vulnerable Populations

10

Drug overdose deaths involving opioids

Deaths per 100,000 population

9

Natural and semisynthetic opioids Synthetic opioids excluding methadone

8

Methadone

7

Heroin

6 5 4 3 2 1 0 2000

2002

2004

2006

2008

2010

2012

2014

Year Figure 4-11.  Line chart showing drug overdose deaths involving opioids, by type of opioid, in the United States during 2000–2014 [6]. (Reprinted from Rudd et al. [6]. https:// www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm)

Heroin Use Has INCREASED Among Most Demographic Groups 2002-2004*

2011-2013*

% CHANGE

2.4 0.8

3.6 1.6

50% 100%

1.8 3.5 1.2

1.6 7.3 1.9

-109% 58%

1.4 2

3 1.7

114% --

3.4 1.3 1

5.5 2.3 1.6

62% 77% 60%

6.7 4.7 1.3

60% -63%

Heroin Addiction and Overdose Deaths are Climbing

SEX Male Female

3

Heroin-Related Overdose Deaths

AGE, YEARS

RACE/ETHNICITY Non-Hispanic white Other

2

RATE

12-17 18-25 26 or older

286% increase

(per 100,000 people)

1

ANNUAL HOUSEHOLD INCOME Less than $20,000 $20,000−$49,999 $50,000 or more

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

HEALTH INSURANCE COVERAGE None Medicaid Private or other

4.2 4.3 0.8

Heroin Addiction (per 1,000 people) 0

YEAR

SOURCES: National Survey on Drug Use and Health (NSDUH), 2002-2013. National Vital Statistics System, 2002-2013.

Figure 4-12.  Heroin Use, Addiction, and Overdose Deaths Climbing. (Reprinted from Centers for Disease Control [7])

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relaxation. Opioids also interact with the respiratory system, depressing breathing and lung functioning, which can make them particularly dangerous in combination with other depressants, such as alcohol or benzodiazepines because of compounding effects on breathing. Opioids also cause physical and psychological dependence, leading to painful and unpleasant withdrawal symptoms when the body is without an opioid for too long. In addition to cravings and urges to use, a person in withdrawal may experience symptoms such as gastrointestinal distress such as vomiting or diarrhea, elevated heart rate, sweating or chills, irritability or anxiety, and bone or joint aches. These feelings, in a person who is addicted, unsurprisingly lead to continuous use even when pleasurable effects aren’t as strong, just to stave off withdrawal. According to the Center for Substance Abuse Treatment, opioid addiction is defined as “a neurobehavioral syndrome characterized by the repeated compulsive seeking or use of an opioid despite adverse social, psychological, and/or physical consequences” [8]. Diagnosis of a substance use disorder according to the APA builds upon the above definition and looks at problems in the following areas: impaired control (e.g., using more than intending, failing to cut down), social impairment (e.g., failing to fulfill obligations at home or work, withdrawing from social systems), risky use (e.g., using despite danger), and pharmacological criteria (e.g., increased tolerance or withdrawal upon stopping use) [2]. Withdrawal from opioids occurs after stopping use after a prolonged period of time and may include the following symptoms: dysphoric mood, nausea/vomiting or diarrhea, muscle or joint aches, dilated pupils, sweating, piloerection (goosebumps), yawning, fever, and insomnia [2]. The opioid epidemic is causing increased visits to the emergency room, record-high deaths from overdose, and numerous social, economic, and medical problems [8, 9]. Commonly becoming problematic for people in their late teens and early 20s, the prevalence of opioid use disorder in the United States is about 0.37% among adults in the community. Opioid use disorder can occur for decades at a time, though high mortality rates and a pattern of stopping in one’s 40s decrease prevalence in populations over 40 [2]. Less than 25% of people addicted to opioids even get treatment [8]. Once in treatment, relapse is very common among populations in treatment. However, 20–30% of individuals are able to achieve abstinence long term [2]. There are a number of factors that contribute to the development and sustainment of opioid addiction. Some contributing factors include pre-­ existing psychiatric disorders; the influences of social, familial, and cultural environment; personality traits; the availability of drugs; and how reinforcing drug use is for the individual [8]. An environmental factor includes a change in the drug itself. In the last 15–20 years, there has been an increase in the purity of heroin available as well as a decreasing cost, raising from 10% to 50–80% in the late 1990s, which has enabled heroin to be more effective through snorting or smoking instead of just through injection [8] as well as producing more dependence and addiction. The increased vulnerability to addiction in those with psychiatric disorders has led to the idea that substance use serves as a mechanism to cope with or “self-medicate” negative emotional or psychological states [10]. Conditions, such as depression, bipolar disorder, and schizophrenia, and even poor affect regulation skills,

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especially related to difficulty managing rage and aggression, are associated with opioid addiction. Let us be clear. Opioid addiction is an epidemic. In 2016, over 62,000 Americans died from opioid overdoses. That is more than the number who died from AIDS at the height of the HIV epidemic in 1995 [11] and more than the number who died in the entire 13 years of the Vietnam War [12]. In 2014, almost two million Americans abused or were dependent on prescription opioids [13]. As many as one in four people who receive prescription opioids long term for noncancer pain in primary care settings struggles with addiction [14]. Every day, over 1000 people are treated in emergency departments for misusing prescription opioids [15].

Integrative Diagnosis of Addiction Patients Nearly every patient who has been seen at other substance abuse treatment facilities or community mental health centers has multiple severe mental health diagnoses. A typical list includes schizophrenia, bipolar disorder, and major depression, each of which is a mutually exclusive diagnosis as defined by the DSM-5 [2]. More so, mental health diagnoses are often assigned in lieu of acknowledging the effects of addiction on a person. In some, the intoxication effects of the substance masquerade as psychiatric conditions. For example, someone taking methamphetamine may stay awake for days, mirroring a manic episode. Amphetamine and cocaine can induce a schizophrenia-like psychosis, and hallucinogens may also simulate psychosis. In others, the withdrawal effects, like in a person who has been using stimulants (cocaine or prescription Adderall), are increased irritability or depression. If a person experiencing any of these occasions were to go to the hospital, it is unsurprising that brief encounters might lead to psychiatric diagnoses. Thus, patients arrive to outpatient clinics with laundry lists of diagnoses and convoluted understandings of their own well-being and/or pathologies. A busy clinician might take historical diagnoses at face value, assuming the legitimacy of poorly conceptualized diagnoses. Acknowledging the likely falsities that exist in the diagnostic lists that accompany complex substance using and disenfranchised patients, clinicians need to use the historical record, but they must also conduct their own assessments to establish a correct diagnosis. There is debate about whether a diagnosis of a psychiatric condition can be made in the period immediately after substance use and about how long a clinician should wait before making the diagnosis. Diagnosis should be an ongoing process. During the 1st month of treatment, the psychotherapist begins to establish correct diagnoses based on gathering additional historical material and assessing current symptoms. The primary care physician collaborates to conceptualize diagnosis and prescribes appropriate psychotropic medications based largely on the psychotherapist’s report of the patient’s symptoms. Prescriptions can be made using empiric guidelines and with the consultation of a psychiatrist when necessary, but should be tailored to the specific issues of the patient and their complex presentation. A clinician who is the primary contact for the patient monitors symptom response 4  Understanding the Disease of Addiction

49

and medication adherence, consulting with the entire care team ongoingly. In our clinic, the primary contact is usually the primary therapist, and this person oversees the patient’s well-being with input from primary medical care, psychiatry, and other members of the care team. Some patients may also meet with an integrative medicine pharmacist, nurse, or medical assistant for medication reconciliation, e.g., a pill box count with health education about the purpose and proper use of each medication. As the patient begins to recover from intoxication and withdrawal, medically, and psychologically, psychiatric diagnoses become clearer and are able to be effectively managed.

Barriers to Treatment There are any number of reasons that individuals struggle to receive help in treating addiction, even when they are ready or looking for help in overcoming their addiction. Even when the patient is “ready,” a condition which may take several contacts to achieve, insurance, cost issues, inadequate availability of treatment, and the belief that treatment will be ineffective all act as barriers to getting the patient started on recovery [8]. Integrative medicine clinics that include patient navigators who might lead the patient through the obstacles of insurance and benefits can overcome some of these barriers. Access to treatment is increased within a team as there are multiple avenues into treatment, whether it be through the primary care physician, the therapist, or other services the team may provide. Fears about legal consequences due to addiction and related behaviors may also keep away a patient who does not understand the protective confines of laws and ethics codes around confidentiality and HIPAA laws. With few exceptions (notably related to the abuse of children or vulnerable adults or suicidal or homicidal threats), clinicians are forbidden to reveal the content of sessions even if illegal activity is disclosed. However, without coming into treatment in the first place, the patient will never know the protections that they are afforded by their treatment team. Even if the law would allow for disclosure, those who work with these populations understand that patient confidentiality is critical to the therapeutic relationship between clinician and patient and would not choose to disclose confidential information about a patient who is working on their recovery and bettering their lives. However, in the United States, the point is moot as patients are protected when they come into treatment.

Stigma and Stereotypes Perhaps one of the greatest barriers to treatment, and recovery, is the stigma and shame cast upon those with addiction. Those who have addiction are blamed for their disease, characterized (vilified, even) by the

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public as being responsible or morally at fault for their addiction. Associated cultural beliefs about those with addiction are highly negative and stereotyped [16–18]. Stigma is more than a negative experience, however. The stigma revolving around addiction may result in discrimination toward, limited opportunity, threats to the self, identity, and well-being for sufferers of the disease, both during use and in recovery. Research has shown that exposure to this kind of stigma “has been linked to poor mental health, physical illness, academic underachievement, infant mortality, low social status, poverty, and reduced access to housing, education, and jobs” [19]. Stigma is also often internalized by the patients, including stereotypes that convince them to see themselves as damaged, harmful, or not worthy of better life circumstances [16]. Once a person is a member of a stereotyped group, others will only look for evidence to support their judgments and misperceptions, neglecting information to the contrary, often at an unconscious level [20]. This phenomenon is important to understand as clinicians because the assumptions and judgments of the treatment team can counter or perpetuate such stigma. Further, treatment must often address the compounding effects of stigma on the already present struggles of addiction, mental health, or certain medical diagnoses. A person may resist treatment or face stereotyping that is most distressing even well beyond achieving a stable recovery.

Conclusion The core behavioral features of addiction help to explain that it is a biological condition easily demonstrated in animal models and not a moral or character-­based “choice” made by our patients. Beyond these elements, the disease of addiction is complex, chronic, and difficult to treat. Factors that increase risk come out of temperament, life circumstances, meaningful understandings, psychiatric disorders, and social and cultural elements of the patient’s’ life. Understanding the nature of addiction improves the effectiveness of the treating clinician. Later in this text, we will describe medical and psychological interventions that have been shown to be effective in treating patients with addictions. See Chap. 7 on “Behavioral and Psychological Interventions for Addiction” and Chap. 8. on “Adjunctive Pharmacotherapy for Opioid Addictions.” While addiction is an area of behavioral medicine that many in the healthcare field are loathe to attempt, integrative medicine is particularly effective for the treatment of these patients who have a myriad of compounding psychological and medical concerns that move them into the category of super-utilizers. To treat the psychological and medical, one must be able to address the addiction as well; the three components are too intertwined to act otherwise.

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References 1. National Institute on Drug Abuse. Overdose death rates. Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple cause of death 1999–2017 on CDC WONDER Online Database, released December, 2018. 2018. Retrieved from https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. 25 Feb 2019. 2. American Psychiatric Association (APA). Diagnostic and statistical manual of mental disorders. 5th ed. Washington, D.C.: American Psychiatric Association; 2013. 3. Robinson TE. Neuroscience. Addicted rats. Science. 2004;305(5686):951–3. 4. Grimm JW, Hope BT, Wise RA, Shaham Y. Neuroadaptation. Incubation of cocaine craving after withdrawal. Nature. 2001;412(6843):141–2. 5. Dart RC, Surratt HL, Cicero TJ, Parrino MW, Severtson SG, Bucher-Bartelson B, Green JL. Trends in opioid analgesic abuse and mortality in the United States. N Engl J Med. 2015;372(3):241–8. https://doi.org/10.1056/nejmsa1406143. 6. Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in drug and opioid overdose deaths – United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2016;64(50–51):1378– 82. https://doi.org/10.15585/mmwr.mm6450a3. Retrieved from https://www.cdc.gov/ mmwr/preview/mmwrhtml/mm6450a3.htm. 25 Feb 2019. 7. Centers for Disease Control. Vital signs. Today’s heroin epidemic infographics. Retrieved from https://www.cdc.gov/vitalsigns/heroin/infographic.html. 25 Feb 2019. 8. Center for Substance Abuse Treatment. Clinical guidelines for the use of buprenorphine in the treatment of opioid addiction, DHHS Publication No. SMS 07-3939. Rockville: Substance Abuse and Mental Health Services Administration; 2010. 9. Mendelson J, Flower K, Pletcher MJ, Galloway GP. Addiction to prescription opioids: characteristics of the emerging epidemic and treatment with buprenorphine. Exp Clin Psychopharmacol. 2008;16(5):435–41. https://doi.org/10.1037/a0013637. 10. Suh JJ, Ruffins S, Robins CE, Albanese MJ, Khantzian EJ. Self-medication hypothesis: connecting affective experience and drug choice. Psychoanal Psychol. 2008;25(3):518–32. https://doi.org/10.1037/0736-9735.25.3.518. 11. Holmes SA. AIDS deaths in U.S. drop by nearly half as infections go on. 1998. Retrieved from http://www.nytimes.com/1998/10/08/us/aids-deaths-in-us-drop-by-nearly-half-asinfections-go-on.html. 25 Feb 2019. 12. Vietnam War Casualties (1955–1975). n.d.. Retrieved from https://www.militaryfactory. com/vietnam/casualties.asp. 25 Feb 2019. 13. Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2014, Center for Behavioral Health Statistics and Quality. 2014 national survey on drug use and health: detailed tables. Rockville: Substance Abuse and Mental Health Services Administration; 2015. Retrieved from https://www.samhsa.gov/data/ sites/default/files/NSDUH-DetTabs2014/NSDUH-DetTabs2014.pdf. 25 Feb 2019. 14. Boscarino JA, Rukstalis M, Hoffman SN, et al. Risk factors for drug dependence among out-patients on opioid therapy in a large US health-care system. Addiction. 2010;105:1776–82. https://doi.org/10.1111/j.1360-0443.2010.03052.x. 15. Substance Abuse and Mental Health Services Administration. Highlights of the 2011 Drug Abuse Warning Network (DAWN) findings on drug-related emergency department visits, The DAWN Report. Rockville: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; 2013. Available from URL: http://www. samhsa.gov/data/2k13/DAWN127/sr127-DAWN-highlights.htm. 16. Luoma JB, Kohlenberg BS, Hayes SC. Acceptance and commitment therapy group therapy manual for self-stigma and shame in substance use disor-

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der. 2005. Unpublished Manuscript, retrieved from http://contextualscience.org/ selfstigma_and_shame_in_substance_addiction. 17. Luoma JB, Kohlenberg BS, Hayes SC, Bunting K, Rye AK. Reducing the self-stigma of substance abuse through acceptance and commitment therapy: model, manual development, and pilot outcomes. Addict Res Theory. 2008;16(2):149–65. 18. Luoma JB, Kohlenberg BS, Hayes SC, Fletcher L. Slow and steady wins the race: a randomized clinical trial of acceptance and commitment therapy targeting shame in substance use disorders. J Consult Clin Psychol. 2012;80(1):43–53. https://doi.org/10.1037/ a0026070. Epub 2011 Oct 31 19. Major B, O’Brien LT. The social psychology of stigma. Annu Rev Psychol. 2005;56:393–421. https://doi.org/10.1146/annurev.psych.56.091103.070137. 20. Aronson E. The social animal. 10th ed. New York: Worth Publishers; 2007.

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5

The Four Facets of Patient Conceptualization Julia Hodgson, Kevin Moore, Trisha Acri, and Glenn Jordan Treisman

William of Ockham, a Franciscan in the fourteenth century, described a lex parsimoniae, or “law of parsimony,” that essentially says that the most parsimonious explanation, the one that uses the fewest parts or is the most straightforward or requires the least complexity, is the most likely. In medical care, this is often quoted to emphasize that a series of symptoms are most likely to stem from a single underlying pathological entity. While this is true of many patients, it does a disservice to the issue of comorbidity found in the complex patients we are discussing here. These patients have repeatedly “failed” earlier medical interventions because their interacting conditions have to be treated in concert. Integrated care begins with a careful and thoughtful conceptualization of the patient’s current and past conditions and underlying elements. The diagnostic formulation attempts to explain all the elements of dysfunction that the patient suffers from in a coherent way. The biopsychosocial model is a common way to refer to the consideration of biology, psychology, and social factors in a person’s life. We discuss a more specific approach that emphasizes the nature of different conditions and owes most of its conceptual basis to Karl Jaspers and is best articulated in the book The Perspectives of Psychiatry by Paul McHugh and Phillip Slavney [1]. Clinicians must gather the information needed to create a complete conceptualization of a person, a task vital to creating accurate and nuanced diagnostic pictures of a patient’s whole situation. They then synthesize the gathered information into a formulation that considers psychiatric disorders in four core categories: deviations of life story/environment, vulnerabilities of temperament, misdirection of behavior, and damage from disease. Looking at these four aspects of a person’s dysfunction creates a complex picture of a person, allowing us to consider how these different features interplay and influence the current circumstances and choices that are influencing patients’ lives.

© Springer Nature Switzerland AG 2020 J. Hodgson et al., Integrative Medicine for Vulnerable Populations, https://doi.org/10.1007/978-3-030-21611-5_5

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Disrupted Life Story Psychology underwent a great divide around the beginning of the twentieth century, partially sparked by attempts to explain all human dysfunction from a single etiological point of view. The history of introspection and self-analysis and description is as old as written literature, but began to flower with the idea of a dynamic unconscious and Freud and his followers’ analysis of dysfunction as a product of psychological experience. A forgotten voice in this element of understanding of human behavior is that of Adolf Meyer, who originated an item he titled the “Life Chart” [2] in which all events in the life of the patient were organized in a graphic way to try to explain their illness. This is the basis of the psychological history that we still obtain from patients. Traditionally considered the bread and butter of psychology, the life story aspect of conceptualizing a person allows us to consider a person’s story and how it has influenced a person’s current life. Experiences in life create the “software” or “programming” of a person, the set of assumptions about the world which direct their behavior, feelings, and thoughts. In patients with disorders caused by disruptive events in their life, the experiences lead to a way of thinking about events in a way that negatively affects function. Trauma, loss, deprivation, adversity, and dislocation are examples of events that can alter the development of a functional view of life and create a “programming” or “software” problem. In therapy, we work to “rewrite” the software that directs how a person is living their life. Therapy allows people to discover a new way to look at the problem, thus giving them a new way to assess situations in their lives. Old hurts and traumas may be worked through, and the ongoing influence on life is diminished or reframed to help a person with their goals. An oversimplified model of this loop is shown in Fig.  5.1. Patients have an experience that provokes an emotional change. They psychologically “digest”

Experience

Behavior

Meaning

Assumption Figure 5-1.  The cycle of experience [3] (Reprinted from Treisman, Glenn J., M.D., Ph.D., and Andrew F. Angelino, M.D. Foreword by John G. Bartlett, M.D. The Psychiatry of AIDS: A Guide to Diagnosis and Treatment. pp. 82, Fig. 4.2 and Fig. 4.3; pp. 83, Fig. 4.4; pp. 103, Fig. 5.1; pp. 104, Fig. 5.2; and pp. 106, Fig. 5.3. © 2004 The Johns Hopkins University Press. Reprinted with permission of Johns Hopkins University Press)

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that experience and abstract a meaning from it. The meaning produces a series of assumptions about the world and how to function in it, and those assumptions are used to generate the behavior that is directed at achieving goals. An example of this is the patient who has experienced drug addiction in the family. All needs and desires are subordinate to the need for drugs and the immediate needs of the constant crises that emerge. As an adult, patients raised in this kind of environment are more likely to see goal of the interaction with the clinician as obtaining the goal of the interaction what they desire or “need.” They “assume” that they will be disappointed and display angry and hostile “behavior,” leading to a negative “experience,” which “means” that healthcare providers are obstructing their attainment of their goals, which leads to further “assumptions” that they will be disappointed in healthcare settings. The cycle of experience we are discussing illustrates how a disruptive event may perpetuate a maladaptive set of assumptions leading to more and more disrupted life course. Disrupted life course sets up a series of less desirable opportunities, each of which increases risk for languishing rather than flourishing. An example of how these issues can play out is illustrated below. The diagram shows the influence of child-adult sexual contact in terms of disrupted life experiences from a study published in American Sociological Review [4]. The arrows show the increased odds ratios of further kinds of disruptive life events as compared to peer sexual contact associated with the initial event and then the ongoing risks downstream from those events. The graphic (Fig. 5.2) shows odds ratios that indicate comparative likelihood of an outcome in the group with adult-child sexual contact rather than definite outcomes, and other aspects influence whether these experiences will ultimately occur. The world the patient lives in, their environment, determines the response they will experience from their behaviors. No matter how much work is done in the clinic, the patient will return to the same toxic environment and struggle to thrive. A patient who has been sexually abused in early life may become sensitized to danger and struggle with trust and intimacy issues. This may lead to avoidance of intimate friendships, which during development

1.6* 1.6* Adult-child sexual contact

2.1**

First intercourse before age 16

4.8**

Had at least one sexually transmitted infection

Teen Childbirth 2.9**

Peer sexual contact

5.7**

11 or more sexual partners since age 18

3.4** Note: Numbers are Change in odds. Model also includes background variables. *p < .05 **p < .01 **p < .001

Figure 5-2.  Associations between adult-child sexual contact and sexual career variables [4] (Reprinted with permission from Browning and Laumann [4]) 5  The Four Facets of Patient Conceptualization

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are important in learning to recognize who to trust and who to be wary of. This may lead to further difficulty in assessing dangerous situations and either increasing isolation or negative experiences because of an inability to process information. This cycle also illustrates the positive aspect of the life story approach; it is open to change at every point. Therapy addressed at understanding the meanings of events for patients, at changing assumptions, at changing behavior, and even at providing a different experience for patients will change the course of the patient’s life, as a change in any part of the cycle will begin to change the other elements of the cycle. Consider an example from our work. An addicted patient demanding narcotics who had been getting large quantities of opioids was referred for management to us. When he arrived, he was hostile and demanding, and we agreed together, after considerable discussion, that we would slowly taper his opioids but that when we got to a reasonable dose (which we agreed with him was 5  mg of oxycodone four times a day for his specific condition1), he could continue on that dose indefinitely as long as we were the only people giving him narcotics and that he was compliant with the other elements of his treatment. We initially had him come every day to get a day’s worth of medication and told him that as he complied with this, we would gradually increase the amount he received at each visit, so that after 2 weeks of compliance, we would go to once a week, and after a month of compliance, we would go to once every other week and the like. Initially, he ran out early repeatedly when we gave him a week’s supply, and we would go back to requiring him to come daily for his opioid medications for a week, and then we would try a 1-week supply again. He was also required to be polite to the staff, or he would not get his medication that day. The process took about 18 months, but he eventually settled down to six pills a day (while this was more than we had agreed on, it was far less than he had been taking for many years) and was compliant. At this point, he was also remarkably less demanding, rude, and disruptive. After a year and a half, he speculated to one of our staff members that there must have been a lot of staff turnover because the nurses in the clinic were a lot nicer to him. We were able to help him see that it was actually his behavior that had changed. After several years and a series of steps like this, he would tell the interns (in a tongue-in-­ cheek way) how terrible his treatment had been in the clinic when he had first arrived, but that he had “worked with the doctors” and that they had improved a lot. While he understood that it was he who had changed, he said it felt like the world had changed and that somehow he was living in a different world than the one he had grown up in. In a sense, his interpretation is correct. Altering behavior, experiences, meaning, and assumptions changes the world in which we live. People treat us differently, we are able to make progress and achieve goals, and our “software” is programmed for flourishing rather than languishing.

1

 This does not constitute medical advice but is offered as an illustration.

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Vulnerabilities of Endowment Endowments are normal human traits that vary in degree and are dimensionally distributed in the population. They are continuous rather than categorical, like height, IQ, or musical talent. Many of these traits are “normally” distributed in a population, meaning they fall on a normal curve as described below. Although categories can be imposed on the continuum, such as tall people, smart people, or gifted people, the dividing line between short, average, and tall is always arbitrary, such as the cutoffs for IQ in the definitions of mental subnormality, borderline intellectual capacity, and average. Arbitrary cutoffs such as standard deviations from average have been used to define clinical categories as in IQ; two standard deviations below the average score, an IQ of 70, is defined as mental retardation or subnormality. There is no meaningful difference in an IQ of 69 and an IQ of 71, and the person with 69 score might be doing more with their capacity than the person with the score of 71 and may be functionally “smarter.” Many human traits in mental functioning can be appreciated this way. Elements such as warmth, sociability, cheerfulness, optimism, maturity, mathematical ability, organization, and leadership are such traits. These represent a combination of natural inclination or disposition and learning and environmental influence. A person with an IQ of 70 raised in a rich environment will be “smarter” than a person with the same IQ raised in an impoverished environment. For the purposes of this discussion, we will use the term temperament to refer to the affective innate disposition that we believe to be inherent in people and the term personality for the characteristic behavioral and affective manner of functioning that is the combination of both innate temperament and learned patterns of behavior. The issue of nature and nurture in personality is still heavily debated, but most of us believe that at least some elements of temperament are encoded before birth and are part of the “nature” of a person. In our opinion there is no evidence that treatment can change temperament (the “nature” part), but we know with certainty that we can change personality because clinicians have accomplished it with patients. Personality can be defined as the affective style of relating to the world. It reveals not just how patients think, but what motivates them and how likely they are to follow through on tasks. Personality encompasses a person’s typical thoughts, emotions, and behaviors. In fact, understanding your personality as a clinician can also help you understand when you might not be seeing eye to eye with your patients. While personality does not dictate behavior, it plays a huge role in how people are likely to react emotionally to different situations and therefore how they are likely to behave. We will discuss some very basic elements of personality and temperament, including the concepts of introversion versus extraversion and stability versus instability. Our ideas of personality owe a great deal to Hans Eysenck, but owe a great debt to many other personality researchers as well. Most of the current ideas regarding personality involve trying to identify the fundamental “factors” of personality. The Greeks described four elements of personality thousands of years ago, but today’s more scientific approach still emphasizes identifying the fundamental building blocks of

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temperament or personality. Research on personality has looked at the enduring lifelong ways that people react to stimuli in life. It is important for readers to know that there have been several models of these factors that have profoundly influenced how we describe affective temperament, including the widely adopted five-factor model of Costa and McCrae, the OCEAN (openness, conscientiousness, extraversion, agreeableness, and neuroticism) model [5]. Philip Zimbardo described time orientation (futurefocused, past-focused, and present-focused) as a fundamental element of affective temperament [6]. Another compelling model is Robert Cloninger’s seven-factor model, including three of inherent temperament and four of developed personality [7]. One of the most widely recognized ways to describe temperament is that used by Hans Eysenck and Sybil Eysenck [8] that described two elements of personality, introversion vs extraversion and neuroticism vs stability. We have found this two-axis model to be the most clinically useful and directly addressable model in working with difficult patients, and it has been the most useful model in helping non-psychologically trained clinicians understand problems of personality in the clinic.

Extraversion and Introversion One aspect of personality style can be described on continuum of introversion to extraversion. While these terms are commonly used, we use them slightly differently than to describe fun-loving social people and quiet retiring people. Carl Jung’s conceptualizations from the 1900s [9] defined introversion as an “attitude type characterized by orientation in life through subjective psychic contents” (focus on one’s inner psychic activity) and extraversion as “an attitude type characterized by concentration of interest on the external object” (focus on the outside world). These descriptions are ways of categorizing how an individual responds to stimuli. Extraverts tend to respond with excitation, while introverts respond with inhibition [3]. However, these descriptions simply illustrate the two ends of a spectrum. The majority of the population falls somewhere between introversion and extraversion, exemplifying qualities of both introversion and extraversion to some degree (Table 5.1). Early writings describe extraverts as entirely interested in their external world, acting on emotions, and spending little time looking at their internal experiences [10]. While extraverts are described as cheerful, expressive, and able to connect well with others, introverts are characterized as withdrawn from the world, more attentive to their inner states, critical, anxious, emotionally hidden, and self-centered [10]. These categorical descriptions are extreme and lack a nuanced view of patient variability; more modern approaches to personality theory look at this dichotomy as a spectrum, describing traits in a more objective manner. There are no “good” personality styles; all traits have benefits in a particular environment and create vulnerability in others. Genetic selection for average in dimensional traits is illusory in the sense that in a changing environment, being average makes one able to survive in all environments, but also means one does not excel in any

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Table 5.1  The difference between introverts and extraverts Introverts

Extravert

Consequent-averse

Reward-driven

Future-focused

Present-focused

Functionality

Feelings

Intrinsically motivated

Extrinsically motivated

Pessimistic

Optimistic

Timid and cautious

Bold and impulsive

Comfort with routine

Comfort with novelty

Successful at organizing and planning

Successful at spontaneity and adaptability

Good at practiced behaviors

Good at new behaviors

Well suited for jobs like CFO, accountant, and physician

Well suited for jobs like CEO, rock star, and politician

Introvert Consequence Function Future

Extravert Reward Feeling Now

Figure 5-3.  The introversion/extraversion spectrum, 1 of 5 [3] (Adapted from Treisman, Glenn J., M.D., Ph.D., and Andrew F. Angelino, M.D. Foreword by John G. Bartlett, M.D. The Psychiatry of AIDS: A Guide to Diagnosis and Treatment. pp. 82, Fig. 4.2 and Fig. 4.3; pp. 83, Fig. 4.4; pp. 103, Fig. 5.1; pp. 104, Fig. 5.2; and pp. 106, Fig. 5.3. © 2004 The Johns Hopkins University Press. Reprinted with permission of Johns Hopkins University Press)

environment. An ideal adaptation to a particular environment means maladaptation to the opposite environment (Fig. 5.3). Extraversion can defined as a personality style that is reward-driven, present-­focused, and concerned with feelings. Extraverts are motivated by rewards, including tangible objects, pleasant feelings, or social reinforcement. They stay rooted in the present, paying less attention to the long-term or future effects of their decisions. They are driven by their feelings, relying on feelings to make decisions and judge situations. High endowment with extraversion is associated with success in circumstances demanding spontaneous responses, high adaptability, ease with novelty and change, persuasive emotional capacity, and optimism about the future. This leads to a natural capacity for leadership, performance, financial success, and decision-­ making but also has the vulnerabilities of impulsive behavior, desires for novelty in sexual practices, substance use, and high-risk/high-excitement recreation. 5  The Four Facets of Patient Conceptualization

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Introversion can defined as a personality style that is punishment-averse can be defined, future-directed, and function-focused. Introverts are less motivated by rewards, but act in order to avoid potential negative consequences. They consider the future and how their behaviors and choices will impact them more long term. Feelings are less important for introverts in how they make their choices; instead, this group considers the pragmatism and utility of decisions. High endowment with introversion is associated with success in circumstances demanding attention to detail, high reliability, ease with routine and practiced expertise, critical thinking capacity, and pessimism about the future. This leads to a natural capacity for detail-oriented work, reliability, financial stability, and seeing the consequences of various courses of action but also has the vulnerabilities of indecisiveness, discomfort with novelty, inflexibility, and rumination. It is important to acknowledge that there is no “good” type of personality. However, when people are extreme in either introversion or extraversion, this can become problematic and start interfering with how well a person is functioning in an environment unsuited to their temperament. Being entirely present-­focused or entirely future-focused, for example, might keep a person from evaluating the effects of their choices on both their current and future situations. For example, one of the authors shared the following interaction with a patient that highlights the difference between introversion and extraversion: My patients don’t understand why I work so hard and stay late at my job. I am salaried, so I get paid whether I stay late or not. They asked, “Why do you stay late then?” One time, I had to work late to finish my charts. I told my patients that I to stay late because I would be suspended if I didn’t keep up with my notes. The patient considered that and asked, “Would you still get paid if you were suspended?” I replied that I would. Again, I was met by utter confusion. “Why not just wait until tomorrow and do them when you are suspended?”

This is an important difference between extraverted patients and their introverted clinicians. Often the vulnerable patients with whom we are working are extraverts and are motivated by rewards. We are often just as confused by them as they are confused by us. Clinicians are usually more introverted, and they are motivated by avoiding negative consequences and internal motivators that keep them working. Clinicians work hard whether they are salaried or paid by the service they provide. Extraverts work harder when there are rewards for their productivity, like car salespeople being paid on commission for each car they sell or those in the military being rewarded with special honors, medals, and raising status for jobs well done. This has extraordinary implications for the treatments of patients. What might work well to motivate the clinician (“don’t use drugs because it will impact your health in negative ways in the long term”) will not work for the extraverted patient. Instead, we have to consider the use of rewards to motivate their treatment. More so, discussions have to be about doing something different instead of not doing something. Introverts are good at not doing things. Extraverts are good at doing something. Knowing more about the

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personality of a patient allows the clinician to tailor interventions to match characterological traits, thus increasing the potential for success.

Stability and Instability (or Neuroticism) In addition to the spectrum of introversion/extraversion, we find the stable/ unstable spectrum very useful as well. In the literature on personality, many people use the term neuroticism in place of instability. Because we think instability is adaptive in some circumstances, we avoid the term neuroticism because of the pejorative nature of the term. This dichotomy refers to emotional lability or reactivity or how large a reaction occurs in response to a stimulus. Those with stable personalities have smaller reactions and are less aroused by stimuli. Large emotional stimuli will induce a smaller emotional excursion. Furthermore, there is predictability to these individuals; given the same stimulus on different days, they will tend to have the same emotional response. They are slower to be aroused, and their behavior is less responsive to emotional excursions. Those with unstable personalities, on the other hand, have unpredictable and large emotional reactions even to small stimuli. They are easily aroused, have intense reactions, and are unpredictable in the intensity, type, and length of emotional response to events in their lives. Those with more intense reactions can be provoked into emotionally driven behaviors (Fig. 5.4). Figure 5-4.  The stable/ unstable spectrum, 2 of 5 [3] (Adapted from Treisman, Glenn J., M.D., Ph.D., and Andrew F. Angelino, M.D. Foreword by John G. Bartlett, M.D. The Psychiatry of AIDS: A Guide to Diagnosis and Treatment. pp. 82, Fig. 4.2 and Fig. 4.3; pp. 83, Fig. 4.4; pp. 103, Fig. 5.1; pp. 104, Fig. 5.2; and pp. 106, Fig. 5.3. © 2004 The Johns Hopkins University Press. Reprinted with permission of Johns Hopkins University Press)

Stable

Unstable

Large stimulus small change Small maximal excursion Predictable reaction

Small stimulus large change Large maximal excursion Unpredicatble reaction

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Just like extraversion/introversion, these traits are adaptive in some circumstances and maladaptive in others and tend to only be problematic for individuals with extreme endowments. Someone can struggle from being “pathologically stable” as much as being “pathologically unstable.” At its extreme, emotional instability is associated with higher occurrences of risky behaviors, including unsafe sex practices and addiction. Pathological stable individuals struggle to feel emotional reactions to any situation in their lives, sometimes leading to more extreme behaviors to seek out any sensation or alternatively failing to develop emotional attachments. For example, someone who is not distressed by their lack of emotion can live solitary lives and lack support in unforeseen circumstances. They also have less motivation to seek out help or treatment and may not come to clinical attention until their circumstances are catastrophic. As a term, “instability” may carry a pejorative connotation (particularly when linked to neuroticism) in comparison with its counterpart of “stability,” despite the undeniable strengths and weaknesses of each. Historically, Costa and McCrae used the phrase “neuroticism” to describe instability in their five-­factor conceptualization of personality traits. A bias against neuroticism becomes clear in the disparaging subcategories that describe this trait: anxiety, angry hostility, depression, self-consciousness, impulsiveness, and vulnerability [5]. The term neuroticism implies a criticism and underestimates the utility of instability in the portrayal of endowments and personality traits. The model of instability and stability we use tries to illuminate the potential strengths as well as the weaknesses for the varied elements of personality.

Four Quadrants of Personality Given the two spectrums thus far presented for personality conceptualization, we overlay the two in a group to come up with four main descriptors of personality style: unstable extraverts, stable extraverts, unstable introverts, and stable introverts (Figs. 5.5 and 5.6). These can be linked back to the four Greek humors described in antiquity. The Greeks believed that the four humors were given in different quantities and determined personality. Blood made a person sanguine, phlegm made a person phlegmatic, yellow bile made the person choleric, and black bile made the person melancholic. The further to the extremes of the curve, the more intense the endowment of temperament. In a medical setting, intense personality styles produce risk for certain kinds of dysfunction so it is necessary for clinicians to understand all types of personality vulnerabilities that may present. Again, these descriptions illustrate personality styles that are more extreme, but people fall in all places on these spectrums (Fig. 5.7).

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Stable

Large stimulus small change Small maximal excursion Predictable reaction

Introvert

Extravert

Consequence Function Future

Reward Feeling Now

Unstable

Small stimulus large change Large maximal excursion Unpredicatble reaction

Figure 5-5. Introversion/extraversion and stable/unstable representation, 3 of 5 [3] (Adapted from Treisman, Glenn J., M.D., Ph.D., and Andrew F. Angelino, M.D. Foreword by John G. Bartlett, M.D. The Psychiatry of AIDS: A Guide to Diagnosis and Treatment. pp. 82, Fig. 4.2 and Fig. 4.3; pp. 83, Fig. 4.4; pp. 103, Fig. 5.1; pp. 104, Fig. 5.2; and pp. 106, Fig. 5.3. © 2004 The Johns Hopkins University Press. Reprinted with permission of Johns Hopkins University Press)

Unstable Extraverts Unstable extraverts combine the pleasure-seeking, feelings-oriented, present-­focused traits with emotional lability and impulsivity. When these elements are disordering, the patients are identified as antisocial, borderline, histrionic, and narcissistic. These individuals are characterized by emotional impulsivity and minimal thinking through their decisions and described in the ancient Greek terminology as choleric. Thoughts, knowledge, and past experiences lack salience in determining behavior and making decisions. The feelings and potential rewards available are much more salient and motivate behavior. These individuals find it very difficult to tolerate painful

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Stable

Large stimulus small change Small maximal excursion Predictable reaction

Sanguine

Phelgmatic

Introvert

Extravert

Consequence Function Future

Reward Feeling Now

Melancholy

Choleric

Unstable

Small stimulus large change Large maximal excursion Unpredicatble reaction

Figure 5-6.  Introversion/extraversion and stable/unstable overlay representations with Greek labels, 4 of 5 [3] (Adapted from Treisman, Glenn J., M.D., Ph.D., and Andrew F. Angelino, M.D. Foreword by John G. Bartlett, M.D. The Psychiatry of AIDS: A Guide to Diagnosis and Treatment. pp. 82, Fig. 4.2 and Fig. 4.3; pp. 83, Fig. 4.4; pp. 103, Fig. 5.1; pp. 104, Fig. 5.2; and pp. 106, Fig. 5.3. © 2004 The Johns Hopkins University Press. Reprinted with permission of Johns Hopkins University Press)

feelings like boredom, sadness, and cravings. They seek to escape and avoid negativity. For this reason, we often find that our addicted patients fall in this category. A desire to numb pain or boredom, impulsivity, and an inability to foresee long-­term consequences are a perfect breeding ground for substance use. Furthermore, these patients are more susceptible to risky behaviors or unsafe practices that expose them to chronic conditions like hepatitis C, HIV, and other communicable diseases. Unplanned pregnancies, arrests, and fractured relationships are also unintended consequences of impulsive behaviors.

Stable Extraverts Stable extraverts are present-focused and pleasure-seeking, but their emotions are not as easily provoked as their unstable counterparts. In the Greek terminology, they were described as sanguine. They are easygoing,

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Stable

Phelgmatic

Large stimulus small change Small maximal excursion Predictable reaction

Sanguine

Introvert

Extravert

Consequence Function Future

Reward Feeling Now

Melancholy

Choleric

Unstable Small stimulus large change Large maximal excursion Unpredicatble reaction Figure 5-7.  Spectrum models of personality styles, 5 of 5 [3] (Adapted from Treisman, Glenn J., M.D., Ph.D., and Andrew F. Angelino, M.D. Foreword by John G. Bartlett, M.D. The Psychiatry of AIDS: A Guide to Diagnosis and Treatment. pp. 82, Fig. 4.2 and Fig. 4.3; pp. 83, Fig. 4.4; pp. 103, Fig. 5.1; pp. 104, Fig. 5.2; and pp. 106, Fig. 5.3. © 2004 The Johns Hopkins University Press. Reprinted with permission of Johns Hopkins University Press)

pleasant, imperturbable, and “laid-back.” When these elements are disordering, the patients are identified as sociopathic, narcissistic, flaky, irresponsible, and shallow. Given the lower salience of the future and the greater salience of the present, these individuals tend to be optimistic (or naïve) about the potential consequences to their behaviors. They are able to shake off consequences. Physicians may find them difficult because they are undisturbed by their HIV infection, gonorrhea, or elevated blood sugar. A patient who persistently lied to us about taking his medications despite falling T-cells and a rising viral load finally confessed when we got blood levels that showed he was not taking his medications. When we asked him why he had told us that he was taking his medications when he was not, he said: “it seemed so important to you.” Additionally, their impulsivity may be in part driven by a lack of concern and put them at risk for infection with HIV, addiction, and other medical difficulties. While not as difficult for clinicians as unstable extraverts, stable extraverts are a notable presence in addiction and/or chronic disease treatment centers.

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Unstable Introverts Introverts that are unstable tend to be anxious, moody, and pessimistic. They are described in the Greek terminology as melancholy. They are inwardly focused and ruminative about the hopelessness of their futures. When these elements are disordering, the patients are identified as melancholy, avoidant, pessimistic, dysthymic, paranoid, and obsessive-compulsive, dependent, and neurotic. Although they are actually relatively protected from infection by worries about consequences, the future, and avoiding illness, they may seek relief from their negative feelings by sex or drugs. They are concerned about their futures and averse to negative outcomes, but their pessimism can leave their view of their future as bleak. This negative view on life can make them feel hopeless or like they have little control over what will happen to them, sometimes allowing substance use or riskier sexual behaviors to become options. Additionally, they are often ambivalent, constantly trying to decide which is worse, this choice or that choice. They make long lists of pros and cons, arguing with their caregiver about every recommendation. They may go on medication and then off of it and then back on it while convincing themselves that maybe a better treatment is coming, and the drugs have toxicities, but their T-cells are falling and they are getting sicker. One such patient knew that the T-cell assay varied by 50 cells after checking his levels several times in a week. He then reasoned that if he had 200 T-cells, it might be 250 and when he had 150 T-cells, he might have 200. He managed to go on and off medication enough times to develop resistant virus for several classes of medication. His physician was at her wits end about how to persuade him to take his medication. What finally succeeded was showing him photographs of terrible HIV-related skin conditions combined with daily directly observed therapy. The fatalistic sense of powerlessness they can develop can interfere with their ability to direct their behavior at self-­ protection, like using condoms consistently.

Stable Introverts The least likely to be seen in our clinics, stable introverts are controlled, reliable, and even tempered. In the Greek terminology, they are phlegmatic. They are also often aloof, disengaged, and isolated. They are less likely to engage in risky behaviors than other personality types and are less likely to engage in any behavior. When these elements are disordering, the patients are identified as odd, schizoid, and reclusive and may develop isolated and dysfunctional circumstances. They are often difficult to persuade as they may have little distress. They are consequence averse, and this element can be used to try to engage them in treatment, but they are also relatively emotionally unresponsive to distressing ideas and may avoid treatment and even diagnosis. Of course, personality does not determine all behaviors nor does it protect from accidental exposures to disease, mental illness, or behavioral anomalies. As patients, these individuals are not as affectively reactive or impulsive; they are able to be motivated by long-term considerations of the future, risk aversion, and thought-based interventions, but can be difficult to engage.

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 ummary: Practical Implications of Working S with Personality Personality and temperament play a profound role in risk-taking behavior, health-seeking behavior, engagement with clinicians, compliance with treatment, and sustaining healthy behaviors. More importantly, problematic personality and temperament confound clinicians who react to the personality vulnerabilities of patients with anger and frustration due to their lack of understanding of how to effectively help these patients. In the integrated care model of treatment, all of the clinicians must understand how to effectively deal with difficult temperaments. They must also guard against counter therapeutic behaviors often seen in these patients, such as emotional manipulation, splitting, inconsistency, and even emotional provocation. These patients are often unaware of their behavior and the effect it has on others, and it is “natural” to them to engage with people in these ways. They will admit they try to “get their way” and that they “didn’t understand” when confronted, but they do not see their behavior as bad, wrong, or even problematic. The most effective way to initiate engagement with these patients is the role induction in which we tell patients what is good about their temperament but also how it makes them vulnerable. Instead of jargony terms like “superego lacunae” or “lack of ego strength,” we tell patients that they do not suffer from not enough of something, but from too much of something. We describe them as having more feelings than most people and compare them (correctly we think) to great figures that are relevant to them (Martin Luther King, Tina Turner, Bill Clinton) and point out to them how the very assets that can make them great can derail them. This initiates a conversation about change, how we will accomplish change, and about working together. The role induction conversation must contain the “firm limits” that everyone speaks of when working with personality-disordered patients but also explains why these limits are helpful, necessary, and therapeutic. The clinician can “model” the behaviors required by letting patients know that they too get frustrated and angry, but they do not “allow their feelings to run their life.” Patients of this type often know exactly how you feel, and by telling them that it is okay if they like you one day, hate you another day, and then like you again in the future, it will still be okay to work with you helps set up a productive relationship and allows you to confront “acting out” when it occurs. Successfully addressing personality disorders is one of the most difficult but also one of the most rewarding elements in care of difficult patients. Their response to treatment occurs over months to years, but is profound in its impact on the course of their lives. As one patient said, “I didn’t know you was gonna change my whole world.” Patients need to be kept on track, will come in and out of treatment, and will need a clinician who can take the long view of patient care to accomplish changing the patient’s whole world, but in the integrated healthcare setting, these patients will continue to benefit over years from the kind of care our team can provide. 5  The Four Facets of Patient Conceptualization

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Maladaptively Conditioned Behavior The “behaviorists” of the early twentieth century (such as Pavlov, Watson, and Skinner) sought to explain how behaviors are formed and maintained and came to view the behavioral perspective as a total of explanation for human behavior and dysfunction. For the purposes of this book, we focus on theories that relate to conditioning behavior (association, reinforcement, and punishment) that provoke and maintain certain select types of psychopathology. These ideas are particularly relevant to addictions, eating disorders, paraphilias, and some types of risk taking. In the early 1900s, behaviorists tried to understand human behavior through models in animals and simple experimental paradigms. One of the first and most profound ideas was espoused by Thorndike’s law of effect; simply put, if we are rewarded for a behavior, we will do it more, and if we are punished for a behavior, we will do it less. The commonly (mis)quoted line from Thorndike, “the probability of a behavior can be increased or decreased depending on its immediate consequence,” is probably a paraphrase of this statement from his actual text, “those (actions) which are accompanied or closely followed by satisfaction to the animal will… be more likely to recur; those which are accompanied or closely followed by discomfort to the animal will… be less likely to occur” [11] (Fig. 5.8). The behaviorists were not interested in conscious desires or drives, but focused on the way previous experiences “shape behavior” through repeated association with experience. Seemingly simplistic, these processes help us to fit into society, read people, determine what paths we take, and define our roles. When we step outside what we “should” do, a negative social consequence decreases our chances of doing it again. When we do what we are supposed to do at work or in our peer groups, positive consequences (praise, social inclusion, and even our paychecks) increase the likelihood we will choose that behavior again. We are profoundly influenced by

Increase Environmental exposure

Behavior

Decrease

Positive Environmental response

Negative

Figure 5-8.  Illustration of Thorndike’s law: something in the environment causes a behavior, which then elicits a response from the environment. If the response is positive (the top of the loop pictures), then likelihood of the behavior repeating increases. If the response is negative (the bottom of the loop), then it decreases the likelihood of the behavior repeating [3] (Reprinted from Treisman, Glenn J., M.D., Ph.D., and Andrew F. Angelino, M.D. Foreword by John G. Bartlett, M.D. The Psychiatry of AIDS: A Guide to Diagnosis and Treatment. pp. 82, Fig. 4.2 and Fig. 4.3; pp. 83, Fig. 4.4; pp. 103, Fig. 5.1; pp. 104, Fig. 5.2; and pp. 106, Fig. 5.3. © 2004 The Johns Hopkins University Press. Reprinted with permission of Johns Hopkins University Press)

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the outcomes of our behaviors, repeating behaviors that get rewarded and avoiding behaviors associated with undesirable consequences (Fig. 5.9). Pavlov describes a kind of conditioning we refer to as “classical” or “Pavlovian” but is best called “associational conditioning.” He described the passive pairing of unrelated stimuli (a bell and food) as causing a generalized response (salivation). After repeated association of the two stimuli, the dog salivates to the sound of the bell in the absence of food. This type of conditioning does not require the animal to “do” anything; it is passive. The patients we see can be conditioned in this way to avoid places associated with discomfort (medical offices) and to return to places associated with pleasure (such as places associated with rewarding drugs). BF Skinner described operant conditioning, in which the subject does something, a behavior, which is then “shaped” by reliably associated consequences. Countless experiments involving pigeons pecking at keys for pellets or rats pressing bars for food studied reinforcement contingencies and taught us that animals, and people, are easily conditioned to do behaviors even if they are unaware of the processes at play. There are a number of interplays between behaviors and consequences that shape behavior (Table 5.2). An important fact in conditioning is that the person may be unaware of what is happening; this does not lessen the influence of the rewards or punishment. Consider this anecdote of the one of the authors’ patients: + Environmental exposure

Environmental response

+ Behavior –

–

Internal “drive” (craving)

Reward-Reinforcement

Satiation Figure 5-9.  Positive feedback loop of reinforcement [3] (Reprinted from Treisman, Glenn J., M.D., Ph.D., and Andrew F. Angelino, M.D. Foreword by John G. Bartlett, M.D. The Psychiatry of AIDS: A Guide to Diagnosis and Treatment. pp. 82, Fig. 4.2 and Fig. 4.3; pp. 83, Fig. 4.4; pp. 103, Fig. 5.1; pp. 104, Fig. 5.2; and pp. 106, Fig. 5.3. © 2004 The Johns Hopkins University Press. Reprinted with permission of Johns Hopkins University Press)

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Table 5.2  Operant conditioning terms Type of contingency

Type/mode

Impact on behavior

Example

Positive reinforcement

Add a positive reward for a behavior

Behavior increases

A patient yells at the staff until they give in to her demands is rewarded for her behavior. Next time she wants something, she yells because she has been positively reinforced for this behavior

Negative reinforcement

Take away a negative stimulus when someone does a behavior

Behavior increases

A person is feeling sad, so he drinks alcohol and no longer feels sad. Because his drinking took away his emotional pain in that moment, he is conditioned to drink again the next time he is sad

Punishment

Add a negative consequence for a behavior

Behavior decreases

Extinction

Discontinuing reward or punishment

Reinforced behavior will slowly decrease

When he stole money from his friend, his friend punched him. That punch made him stop stealing from the friend He had been given tokens each time he came to his drug treatment program, which made him come every week. Once the program stopped giving out tokens, he stopped showing up for his appointments

A patient was noted to walk with a limp in the clinic. He had been on and off opioid pain medications for years. I saw him walking down the street and noticed his confident and strong gait, free of any limp. At his next visit, I asked him about his limp. He looked at me incredulously. “What are you talking about? I don’t limp!” I pointed out that he had walked into my office with a limp that day and told him about positive reinforcement. When he went to leave, I pointed out his limp. When he noticed his limp, he stared at me. “Doc,” he said, “I am never touching those pills again.”

In this case, conditioning had a powerful effect, impacting a behavior the patient didn’t even know was present. Every time he came into the office with a limp, he was more likely to be given painkillers. The more times he

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limped, the more times he was given rewarding drugs. When he did not limp, he was not given rewarding drugs. The effect was so subtly reinforced that he developed a limp without even noticing. Discovering that he had been manipulated by the drugs without even noticing scared him enough to give them up. His well-meaning doctors, who were trying to alleviate his pain, were conditioning a limp in their patient without realizing it themselves. In contrast, a person can be perfectly aware that they are being conditioned or reinforced and it does not negate the power of the conditioning. In fact, for some, knowing a reward may be coming can serve as a motivator to engage in a behavior on a more conscious level. When the reward is achieved, it reinforces the behavior just as much as if it were being done on an unconscious level. What is most important is that the behavior and the reinforcement are linked; this link is what creates the change in behavior. The behavioral paradigm is particularly useful in developing a model for addictions and paraphilias. Ultimately, positive reinforcement is mediated to a great extent by the ascending mesolimbic dopamine reward pathway, and almost all the actions of addictive compounds can be related to actions on this circuit. Some behaviors are directly linked to the reward pathways of the brain such as eating, sleeping, and sex. These behaviors activate reward centers when people engage in them. In the figure below, this sets up a positive feedback loop, and such loops are dangerous because they can easily get out of control. The purpose of this kind of loop is to amplify behavior. This enhances behaviors necessary for survival and prevents accidents like food poisoning, adverse experiences while sleeping, and negative romantic experiences from extinguishing behaviors needed for survival. Because this circuit amplifies behaviors, it has the potential to get out of control and disrupt function. There is a “turnoff” in all circuits of this sort to protect from this happening. After dinner, food is no longer “salient.” Before dinner in a restaurant, one might read the entire menu with great interest, but after dinner the menu does not hold your interest. The circuit is off. After sleeping we are rested and sleep has little salience until the next time to sleep. Sexual activity becomes unappealing after sufficient sexual activity. Errors in the “turnoff” mechanism can lead to obesity, hypersomnolence, and hypersexual behavior, but inadequate amplification can lead to genetic failure and therefore is selected against. Addictive drugs act at the reward pathway, but because they were not present in the environment during evolution, there is no “turnoff” for them built into the system so they can overwhelm the system and create a reverberating positive feedback loop. This is normally resistable because the appetite-driven activities of normal life (sleeping, eating, and sex) and the normal function-related activities of work, hobbies, and exercise compete with the addictive cycle and prevent it from capturing all behavior. The cycle is “open” to the environment, that is, it is affected by what choices we make, our temperaments, our life experiences, and even disorders. Depression turns off or mutes normal rewards from appetite-driven behaviors, but addictive compounds can still activate the reward pathways, making depressed people particularly vulnerable to the cycle getting out of control and “capturing” their behavior. Extraverts are more willing to take risks and are more sensitive to rewards, making them more vulnerable to addictions. People 5  The Four Facets of Patient Conceptualization

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Temperament life experience disease Environmental exposure

Environmental response Behavior

Internal “drive” (craving)

Temperament life experience disease

Reward-Reinforcement

Satiation Figure 5-10.  Reinforcement cycle with additional factors [3] (Adapted from Treisman, Glenn J., M.D., Ph.D., and Andrew F. Angelino, M.D. Foreword by John G. Bartlett, M.D. The Psychiatry of AIDS: A Guide to Diagnosis and Treatment. pp. 82, Fig. 4.2 and Fig. 4.3; pp. 83, Fig. 4.4; pp. 103, Fig. 5.1; pp. 104, Fig. 5.2; and pp. 106, Fig. 5.3. © 2004 The Johns Hopkins University Press. Reprinted with permission of Johns Hopkins University Press)

raised in environments with frequent exposure to addictive drugs and in social circumstances that accept intoxication are more likely to have their behavior captured by addiction (Fig. 5.10). Lastly, there are social, genetic, and environmental circumstances that increase or decrease the risks for addiction. Genes affect risk-taking behavior, as well as the degree of positive reinforcement from alcohol. Having an engaging occupation that requires investment protects people from addiction, as do religion, social connections, family connections, marriage, fraternal organizations, and other factors (Fig. 5.11). The body learns through association. When people consistently use drugs in the same place every time they get high, their bodies will actually begin to prepare for the effects of the substance before it has been administered or consumed because the place becomes so strongly associated with the drug reaction. This is a non-physiological piece of what builds up tolerance as the place becomes an internal cue that elicits the body’s protective mechanisms that are necessitated during drug use. Because the body is prepared,

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Environmental exposure

Environmental response Behavior

Internal “drive” (craving)

Genes Social connections Religion Occupation Class Geography Social conventions

Reward-Reinforcement

Satiation Figure 5-11. Reinforcement cycle with more additional factors [3] (Adapted from Treisman, Glenn J., M.D., Ph.D., and Andrew F. Angelino, M.D. Foreword by John G. Bartlett, M.D. The Psychiatry of AIDS: A Guide to Diagnosis and Treatment. pp. 82, Fig. 4.2 and Fig. 4.3; pp. 83, Fig. 4.4; pp. 103, Fig. 5.1; pp. 104, Fig. 5.2; and pp. 106, Fig. 5.3. © 2004 The Johns Hopkins University Press. Reprinted with permission of Johns Hopkins University Press)

it may take more of a drug for the person to achieve the same effect in that place. This may contribute to an overdose when using in a new place for the first time. People who consistently withdraw in a particular environment develop conditioned withdrawal and will describe getting “sick” when they visit certain places, an effect easily produced in animals and that in animals can be indistinguishable from physiological withdrawal. Both people and animals will gravitate to certain places when they crave drugs or start craving when they visit certain places that are cues for drug use. Finally, we must consider what happens when already existing appetitive behaviors are linked with conditioning. Using drugs is positively reinforcing because of the release of dopamine, but it takes away the negative stimulus of craving or withdrawal. Positive and negative reinforcement are at play in conditioning addictive behaviors like using drugs. In less extreme examples, eating, sex, or other behaviors that trigger the pleasure center can have similar addictive cycles that create voids and cravings for a behavior, thus increasing their occurrence in a person. Behaviors get amplified instead of sustained and they can become unmanageable. The utility of the behavioral view of addiction is that it explains why simply giving people medications like methadone or buprenorphine has been ineffective for treating addiction (more on medications in later chapters).

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Treatment of addiction requires one to interrupt the cycle that is out of control, understand the cues and conditioners that trigger the cycle, reestablish normal reinforcers into the person’s life, and set up a program of relapse prevention. Interruption of the cycle may require removing the person from the environment where they have been using. Many treatment strategies focus on changing “people, places, and things” as a primary step in addiction rehabilitation. Reestablishment of connections to family, community, employment, friends, and religion all help decrease the risk of relapse. Treatment of the other elements of the person, such as personality issues and life story issues, and treatment of psychiatric diseases such as depression and bipolar disorder are necessary elements of successful treatment.

Deficit from Disease The disease model of characterizing dysfunction is perhaps the most often used in describing illness. This approach considers the many types of diseases that affect a person. Medical conditions may include both chronic and acute conditions. Similarly, psychiatric diseases disorders may be episodic, like major depression and bipolar disorder, or more pervasive, like schizophrenia or obsessive-compulsive disorder (OCD). Addiction is complicated in that it is best understood behaviorally, but is usually conceptualized as a disease. In fact, acknowledging the disease aspect of addiction is highly important in the larger advocacy world of reducing the stigma around addiction; it is not simply a choice. Some advocates of nomenclature for understanding psychiatric conditions like to describe a disease as a “broken bodily part.” (See [1] for further discussion of this topic.) This helps clarify that some psychiatric conditions, such as altered life course or personality, are more responsive to certain kinds of therapies, such as guidance-based therapies for problems of personality and rescripting-based therapies for disrupted life stories, while for diseases we seek remedies for the broken part, brain lesion, genetic defect, or the like. The development of clinical nomenclature using operationalized criteria for disease classification relies on the concept of a broken bodily part producing a reliable downstream set of clinical symptoms that are characteristic of that condition. In psychiatry, using diagnostic guidelines such as the International Classification of Diseases, Tenth Revision [12], and Diagnostic and Statistical Manual of Mental Disorders, 5th Edition [13], allows clinicians and researchers to use a common language to try to investigate and understand the basis of these conditions. While no diagnostic guide is perfect, the existing systems are the result of intensive deliberation and research. Whichever system the clinician chooses, it is vital that they are careful and thorough in understanding the potential artifacts of the method being used to develop guidelines and the rules used in determining

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diagnostic labels. Despite their imperfections, systems such as the ICD or DSM provide a common language for providers to collaborate and communicate about patients, as well as an opportunity to group patients to use comparative therapies in trials to determine best treatments for certain diseases. The understanding that, just like in a liver or a kidney, diseases occur in the brain has had a destigmatizing effect for patients suffering from diagnoses like bipolar illness and schizophrenia. The idea that patients with these conditions got them because they were “cursed” or had sinned against a religious commandment has been ameliorated by our increasing understanding of these conditions as illnesses like hypertension and diabetes. It also helps mitigate against the old concept that patients suffering from mental illness are morally inferior or flawed. Although this is an old concept, it permeates many of those who comment on the mentally ill. In the mid-twentieth century, an “antipsychiatry” movement developed, partly due to the economics of caring for chronically mentally ill and partly because of the postmodern rejection of scientific ideas. The people generating this movement felt psychiatry was a politically based effort to control behavior and to use doctors to try to maintain the status quo of society. They saw the mentally ill as misunderstood, labeled, and unfairly hospitalized in what were essentially sanctuaries for people with illness. The famous book by Thomas Szasz at the time, The Myth of Mental Illness, was required reading for anyone who was socially conscious [14]. Unfortunately, if mental illness as a disease is a myth, the default explanation becomes the morally flawed view. Szasz (1974) said “Mental illness is a fraudulent imposition on the public perpetrated by psychiatrists seeking to preserve their privileged professional status by forcing care on involuntary patients who in turn sought handouts from society because they were too shiftless or criminal to earn their own way” [14]. In the end, this supposed “friend” of the victims of the mental illness hoax saw his patients as shiftless and criminal and left a damaging legacy that continues to plague patients.

Conclusion The four facets of conceptualization of a person—personality, behavior, disease, and life story—illustrate the complex factors that interplay to influence the functioning and well-being of any person. Conceptualization requires not only that the clinician be able to identify each facet but that they consider the interplay of each on the others. Noting just one facet is insufficient in understanding a person, yet teasing out each aspect can be increasingly complex. Fortunately, the multidisciplinary approach to integrative medicine allows for diverse perspectives to come together in painting a more thorough and complex picture of each patient that can allow for meaningful, rich work to be done in helping patients to heal.

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References 1. McHugh PR, Slavney PR. The perspectives of psychiatry. Baltimore: The Johns Hopkins University Press; 1999. 2. Meyer A. The material of human nature and conduct. Am J Psychiatry. 1935;92:271–4. 3. Treisman GT, Angelino AF. The psychiatry of AIDS: a guide to diagnosis and treatment. Baltimore: Johns Hopkins University Press; 2004. 4. Browning CR, Laumann EO. Sexual contact between children and adults: a life course perspective. Am Sociol Rev 1997;62(4):540–560. https://www.jstor.org/stable/2657425. Accessed: 25-11-2018. 5. McCrae RR, Costa PT Jr. Toward a new generation of personality theories: theoretical contexts for the five-factor model. In: Wiggins JS, editor. The five-factor model of personality: theoretical perspectives. New York: Guilford; 1996. p. 51–87. 6. Zimbardo PG, Boyd JN. Putting time in perspective: a valid, reliable individual-­differences metric. J Pers Soc Psychol. 1999;77:1271–88. 7. Cloninger CR. A systematic method for clinical description and classification of personality variants. Arch General Psychiatry. 1987;44:573–88. 8. Eysenck HJ, Eysenck SBG. Manual of the Eysenck personality questionnaire. London: Hodder and Stoughton; 1975. 9. Weinstein I. Learning and lawyering across personality types. Clin Law Rev. 2015;21(427):427–53. 10. Freyd M. Introverts and extroverts. Psychol Rev. 1924;31(3):74–87. 11. Thorndike EL. Animal intelligence. New York: Macmillan; 1911. 12. World Health Organization. International classification of diseases, 10th revision, 5th ed. 2016. Online version retrieved from http://apps.who.int/classifications/icd10/ browse/2016/en. 13. American Psychiatric Association (APA). Diagnostic and statistical manual of mental disorders. 5th ed. Washington, D.C.: American Psychiatric Association; 2013. 14. Szasz T. The Myth of Mental Illness: Foundations of a Theory of Personal Conduct. New York: Harper & Row; 1974.

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6

Diagnostic Decision-­Making Processes Julia Hodgson, Kevin Moore, Trisha Acri, and Glenn Jordan Treisman

In clinical care, the goal is accurate diagnosis. A diagnosis distinguishes the condition the patient has from other conditions and therefore guides the treatment. Ideally we can say that a patient who comes with a fever, dyspnea on exertion, cough with yellow sputum production, and malaise has a specific condition such as bacterial pneumonia. We can assume that bacterial infections of the lung cause pus, while viral infections do not. We can then say that a percentage of bacterial pneumonia responds to a particular antibiotic and develop a treatment algorithm that gives direction to the next steps in treatment. The algorithm is usually based on clinical trials that generate recommendations from population-based studies with the best outcomes. Deductive logic is an argument where a set of information is processed to produce a single answer given a potential set of possible answers. A deductive argument produces a single correct answer, but the accuracy of the answer is dependent on the assumptions of the argument. The answer is correct within the context of the assumptions but can be incorrect because of a flaw in the assumptions. Our argument about pneumonia assumes that all patients fitting the description above have an infection of the lung and that infections of the lung are bacterial or viral. Practical and efficient medical care prefers deductive logic because it produces a single answer and allows patients to be placed in a specific category which can then be used in a clinical trial, in epidemiological surveys, in treatment algorithms, and in prognosis predictions. The problem with deductive logic is that in medicine the assumptions are never comprehensive enough to cover all cases. Medicine is too complex for the level of reductionism that is desirable to make deductive logic as simple as we wish. There are “pathoplastic” factors that change the way symptoms appear, and there are endless conditions that have yet to be discovered.

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Patients who died of HIV and Lyme disease before they were discovered were usually given a diagnosis, but it was wrong. Inductive logic takes an open-ended data set and applies it in a reiterative way to either support or refute a hypothesis. It never gives a certain answer; it only is more or less supportive of a hypothesis. However, it is a more accurate approach to the best diagnosis. Inductive logic generates a list of possible diagnoses, referred to as a “differential diagnosis,” and allows one to say the most likely diagnosis but reserves the rest of the list as potential alternatives. The evaluation of the patient leads to a set of information: signs, symptoms, and historical course as well as associated history such as other conditions and family history. Unfortunately, this process requires practice and expertise and is therefore time-consuming and expensive. The need to categorize patients for treatment guidelines, research, outcome studies, and prognosis led to a certain necessary reliance on deductive logic to some extent. In easy cases with a single diagnosis, this yields results that are correct almost as often as the more complex process of inductive reasoning, but in complicated cases, it is far less successful in getting to the correct diagnosis. Diagnostic uncertainty is the clinical norm, especially for the most common complaints such as headache or fatigue. Literally thousands of known diagnostic entities can manifest with these symptoms, but the human mind requires shortcuts to create a small list of possibilities to consider. Even the most capable thinkers err toward simple explanations (A caused B) over complex explanations (C, D, and E caused F) despite the likelihood of multiple causalities in most situations. In the example of pneumonia, a patient presenting with bacterial pneumonia without any other history or complicating features usually has a diagnosis of “community-acquired pneumonia,” but a person with immune dysfunction (such as IgA deficiency) may be much more likely to get pneumonia, and this diagnosis might be missed in many people. Correctly diagnosing common complaints is best done by considering the patient’s complete history with the skillful shortcuts of professional disciplines. A primary care physician presented with headache and fatigue may first consider migraine and hypertension as diagnoses. A psychologist presented with headache and fatigue may first consider relational and occupational stress. A physician and a psychologist coordinating care of a patient with headache and fatigue will generate more possibilities and arrive at more comprehensive and accurate explanations. Solo-practicing clinicians are less effective for people with complicated and chronic conditions because more professional minds outperform solo clinicians in case conceptualization over patients with multifactorial conditions that interact, such as IgA deficiency and community-acquired pneumonia. Accurate diagnoses—not simple ones—provide superior healthcare. The term “diagnostic formulation” is a description of how all of the clinical data in the case can be accounted for by a single condition or set of conditions. It uses a whole case approach to each patient that includes aspects of the biological, psychological, and developmental disorders that explain the whole case and not just a single problem. As we discussed previously,

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Ockham’s principle of parsimony states that unlikely events generally do not occur at the same time, and therefore the simplest explanation is the most likely. In more complicated cases, the statistical fact that some patients will have two or even three unlikely events at the same time needs consideration. An aphorism ascribed to Einstein “Everything should be made as simple as possible, but not simpler” points out that sometimes things are more complicated and require a complex explanation. The best diagnostic formulation “explains” all the clinical elements of the case and provides the basis for a treatment plan that will result in the best outcome.

Reliability vs Validity Evaluation and diagnosis are “expert activities.” The development of operational criteria, a set of defined criteria that allow anyone using them to decide whether something is included or not included in that category, can be used to place patients into a category of having a condition. This allows for “reliable” diagnosis. In this case the term reliable means that if a large group of people use the criteria, they will all get the same answer. The measurement of reliability rests on developing a set of criteria and then seeing how often using that list will generate the same diagnosis across a targeted group of users. Validity is a measurement of how often the diagnosis is correct, a measurement complicated by how well the “correct” diagnosis can be determined. To perform clinical trials and to develop treatment recommendations, it is necessary to have a method of identifying a group of patients with the same condition. Checklist-based diagnostic tools and rubrics increase the reliability of diagnosis but not necessarily the validity. Again, back to the pneumonia example, the valid definition of bacterial pneumonia is the presence of a bacterial infection in the lungs. To make sure the diagnosis is accurate, one might need to do a bronchoscopy and get samples from the lung. In a large research study, one could “operationally” define pneumonia as a fever greater than 38.5 °C, a cough producing green- or yellow-colored sputum, and breathing faster than 24 breaths a minute while walking. These criteria will miss some pneumonia and will call some bronchitis pneumonia, but nearly everyone will be identified the same way for the study. The criteria are reliable, and the researchers may accept the degree of validity based on the goal of the study. Thinking this way gets one a deductive schema of defining a condition. Expert clinicians think in terms of a “differential diagnosis,” a list of possible explanations for the disorder afflicting the patient. The method for generating the list is referred to as inductive reasoning or logic, as compared to deductive logic. Students begin with deductive logic and in easy cases come up with the correct answer most of the time. This form of logic can be seen as moving backward from the existing hypotheses to compare to the data at hand [1]. One hypothesis condition is tested at a time. In diagnosis, deductive thinking is one where comparisons are made to existing possibilities until a match is found. Deductive logic comes to a 6  Diagnostic Decision-Making Processes

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definitive conclusion. In determining a psychiatric diagnosis, for example, one would go through the possibilities step by step, comparing existing symptoms to the first list of criteria, then the second, and the third and so on. Hopefully, the clinician arrives at the correct diagnosis. This is common in early trainees and less developed diagnostic sophistication (Fig. 6.1). Inductive logic is an alternative approach in which we iteratively refine a differential diagnosis. Schemas are the basic method of inductive reasoning. The clinician has a set of data from which they develop a list of possibilities working to exclude some and include others as the information supports or refutes each hypothetical candidate diagnosis. This approach requires greater knowledge and allows new knowledge to be added to the schema. Schema-based inductive reasoning is considered forward reasoning, moving from the existing signs and symptoms to the disease; this system is based upon “a hierarchical knowledge structure” [1] (Figs. 6.2 and 6.3). In a paper regarding medical student learning [1], in easy cases, the deductive and inductive methods were not significantly different, while in difficult cases, expert clinicians using inductive logic were five times more likely to get the correct diagnosis. If they recognized the condition by pattern, they were ten times more likely to get the correct diagnosis. The use of the method of developing and refining a differential diagnosis underscores how difficult diagnosis can be. In psychology, where there are no specific laboratory tests for most conditions, we rely entirely on clinical experience and evaluation to get to the correct diagnosis. Diagnosis is not just about what or how much the clinician knows, but how that knowledge is organized and understood by the clinician [2].

Criteria List A 1 of 6

Clinical Data Set

Criteria List E 4 of 6

NO

Criteria List D 2 of 8

NO

NO

Criteria List B 2 of 7

Criteria List C 1 of 5

YES

Diagnosis E

Figure 6-1.  Deductive process

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Additional data set

Clinical Data Set

Differential A,B,C,D,E Additional data set

Differential A,C,D,E,G Additional data set

Differential A,C,H

Probability is the rule of life-especially under the skin. Never make a positive diagnosis William Osler

Figure 6-2.  Inductive process

Reciprocal Processes in Diagnosis Diagnosis is further complicated by the many reciprocal cycles of one condition exacerbating another. Obesity leads to diabetes which leads to insulin use which increases appetite which leads to worsening obesity which leads to worsening of diabetes. Smoking can lead to lung disease which can lead to hypoxia which can lead to air hunger which can lead to severe anxiety which makes patients want to smoke more. These comorbidities overlap and worsen each other, and the formulation must take into consideration all elements of the patient. Major depression turns off the reward circuits in the brain rendering patients more vulnerable to the rewarding properties of addictive drugs. Normal behaviors driven by appetite, such as eating, sleeping, social interactions, and sex, lose their rewarding properties during depression. Other function-related activities also release some reward transmitters such as work, hobbies, and exercise, and these are less rewarding as well. Reinforcing (addictive) drugs will still produce a brain reward even in major depression, and therefore patients are more likely to get addicted if they have major depression. This is complicated even more by the finding that addictive drugs make major depression worse in many cases. Also, because addictive drugs work via the dopaminergic reward system of the brain, patients become quite refractory to rewards from normal behavior. Addicted patients are often demoralized by their life circumstances, and demoralization can also be confused with major depression. The clinician needs to treat the addiction but also needs to treat the major depression and demoralization simultaneously. Patients with this rubric will often have lost social 6  Diagnostic Decision-Making Processes

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Example Differentials -Bladder cancer -kidney disease

RBCs lost in urine

RBCs being destroyed by immune system

Example Differentials -Hypersplenism -Autoimmune hemolytic anemia

RBCs being fractured by turbulent blood flow

Example Differentials -Arteriovenous shunt -Arteriovenous malformation -Heart valve disesase

Example Differentials -Psychological disturbance (cutting) -Excessive blood donation -Vampire bats -Excessive phlebotomy

RBCs lost through blood extraction

RBCs being degraded

Damaged or lost bone marrow

Example Differentials -White blood cell cancer -Drug induced Aplastic anemia

Low iron

Example Differentials -Autoimmune gastritis -Poor dietary iron -Chronic blood loss

Example differentials -Sickle cell disease -Thalassemia -Hereditary spherocytosis

RBCs are fragile

Example Differentials -kidney disease -Multiple myeloma -Anti-erythropoetin antibodied

Not enough erythropoietin (hormone for making blood cells)

RBCs not being made

Figure 6-3.  An oversimplified schema for developing a differential diagnosis in patients presenting with anemia. Each of the three primary causes of decreased red blood cells (RBCs) has examples of causes below it and short examples of differential diagnoses for each. Although this is by no means conclusive, as young doctors learn new causes of anemia, they fit them into this schema

Example Differentials -Colon cancer -Bleeding polyp -Internal hemorrhoid -Stomach ulcer

RBCs lost from bowel

RBCs being lost

Anemia: Blood does not have enough healthy red blood cells (RBCs)

Figure 6-4.  (a, b) Addiction and depression

A Behavior

Reward

B

Behavior

De pre ss ion

Addiction

Reward

connections and family connections, may be homeless and unemployed, and may have legal charges or a legal record. These problems must be addressed as part of the rehabilitative process and need to be part of the formulation and understanding of the patient and their illness. The culture the patient lives in may reject the idea of psychiatric illness, and this may interfere with treatment of depression, and this is also an important element in formulating the patient and developing the treatment plan (Fig. 6.4a and b). In summary, the need for clear diagnostic categories for use in epidemiology, clinical trials, prognostic data, public health efforts, and efficient evaluation requires an emphasis on deductive “checklist” diagnostic methods for patient care and public health. On the other hand, complex patients with complex comorbidity and interacting conditions require an inductive “expert evaluation and formulation” to receive successful treatment and have recovery from their illness. Integrative medicine improves the ability to generate a complete and more accurate formulation and improves the outcome for our patients. In settings like ours, it is necessary to have expert input for patient care from several disciplines and an integrated treatment plan shared by all of the clinical team members.

References 1. Harasym PH, Tsai T, Hemmati P.  Current trends in developing medical students’ critical thinking abilities. Kaohsiung J Med Sci. 2008;24(7):341–55. 2. Mandin H, Jones A, Woloschuk W, Harasym P. Helping students learn to think like experts when solving clinical problems. Acad Med. 1997;72(3):173–9.

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PART III

Treatment Within an Integrative Medicine Model

Addictions work is difficult and requires patience and is, at times, incredibly frustrating. It can also be incredibly rewarding. Any practitioner who commits themselves to working with chronic and vulnerable populations must be willing to work with people suffering from addiction. This is not an affliction that can be ignored nor pacified. Addictions work requires a nuanced knowledge of the disease and a variety of interventions to work with a difficult population. This section offers an introduction to the topic and issues that arise in addiction treatment. Rather than a comprehensive guide to the treatment of addiction, this chapter is an introduction and outline of the issues related to addiction treatment and the comorbidities that contribute to the development of addictions and complicate the treatments. As opioid addiction is currently one of the primary causes of death in our patients and is a driving force in the HIV epidemic and the Hepatitis epidemics, we will focus on opioids to illustrate the demands of addiction, how the disease of addiction interferes with treatment, and what recovery can look like in an integrative medicine setting.

7

Behavioral and Psychological Interventions for Addiction Julia Hodgson, Kevin Moore, Trisha Acri, and Glenn Jordan Treisman

Individual long-term integrated primary and psychological care are the cornerstones of our integrative medicine approach, especially in the context of treating addiction. There is no “cure” to addiction. It is a chronic and relapsing disease that requires years of comprehensive and complex treatment from an interdisciplinary approach. As we discuss in Chap. 8, medications are an important tool in the process of recovery. Even more so, however, therapy is necessary in order to help the patient to address their addiction as well as the myriad of psychological, relational, and personal issues that threaten their recovery. This chapter introduces the framework from which integrative medicine can intervene in addressing addiction in patients. There is widespread pessimism in drug treatment research and among drug treatment policy-makers that individual psychotherapy is an ineffective and inefficient treatment for addiction. Because psychotherapy and psychological interventions add to cost, insurers and policy-makers are eager to deny effectiveness of an integrated approach. An example is the citation by policy-makers in Pennsylvania of a randomized clinical trial of 653 opioid addicts that found no added benefit in added individual drug counseling to standard medical management of opioid addiction [1]. In the referenced study, in either arm, patients did poorly because the study placed everyone on opioids and then tapered them after either 2 or 12 weeks. The 2-week success was 6.6%, and the 12-week success post taper was 8.6%. These deplorable outcomes reflect a lack of understanding of the nature of addictions; they are chronic, and therefore treatment must be chronic, they require rehabilitation, and they require a multidisciplinary approach. This study showed that subjects with a history of heroin use did more poorly, in keeping with the increased comorbidity seen in heroin addicts. They also excluded subjects if they had used heroin >4 days in the past month, had a lifetime opioid dependence diagnosis due to heroin alone, had ever injected heroin, © Springer Nature Switzerland AG 2020 J. Hodgson et al., Integrative Medicine for Vulnerable Populations, https://doi.org/10.1007/978-3-030-21611-5_7

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required ongoing pain management with opioids, had experienced a major pain event within the past 6 months, were prescribed methadone >40 mg a day for pain, were psychotic, or were otherwise psychiatrically unstable. Essentially, they excluded any patient any of the authors have ever seen clinically in any setting. Although the refusal to pay for psychotherapy saves money in the short term, it contributes to the widespread pessimism regarding addiction treatment and always involves the oversimplified view that you should be able to “cure” addiction with a pill. This does not just reflect the reality of real-world interventions in addiction. Although group therapy is a powerful treatment for addiction and other behavioral conditions, individual therapy is often a necessary element of treatment for patients with complex psychological disorders that may underlie their addictions. The “one-size-fits-all” focus on group psychotherapy that is “efficient” or “cost-effective” and therefore saves money decries the high rate of treatment failure and poor outcomes when treatment depends solely on group therapy. Consequently, the oversight of researchers and the biases of policy-makers make current treatment dollars less costeffective than appropriate intensive multimodal treatment. In integrative medicine practices, training over years and long-term investment in patients develops high-quality psychotherapy skills and advanced clinical sophistication that allows for more effective treatment of people with addiction.

Rethinking Treatment Contracts Many in the field of addiction treatment support the use of patient contracts because this specifies roles and obligations of the patient. Unfortunately, our patients have often experienced family members and authority figures who have defaulted on their obligations, including the experience of violence, betrayal, sexual misuse, and abandonment. They also often have a long history of defaulting on promises and contracts as part of the chaos of their addiction. Despite the enthusiasm for contracts in our field, we avoid the use of treatment contracts. Because developing an ability to keep promises and to see the importance of obligations is a long-term gradual process that we help patients develop through treatment, we have found treatment contracts often place us in the difficult position of having either to give people a second chance and suggest that the contract is not meaningful or to discharge a person who might be able to do better with more treatment. We use the building block of individual therapeutic relationships as the primary intervention, and as such there is a mechanism to clearly present information and for the patient to clearly understand their roles and obligations as well as way of assessing how clearly they retain the information. We want to respect the different levels of literacy, comprehension, and cognition that our patients present with both in their addictions and in recovery. It is easy to imagine how someone who is high is not easily able to retain information. We can all remember having the flu and how we will not process information as easily as we normally would; opioid withdrawal is very parallel to having the flu in terms

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of cognitive functioning. Many of the patients we see have very low literacy levels. Even when a patient is stabilized on buprenorphine (often referred to by the brand name, Suboxone™) and has adequate language proficiency, mental illness and other comorbid conditions impair memory, information processing, and comprehension. Patient understanding and engagement in their own treatment is a progressive pursuit and far more than a once and done patient contract. We think a treatment contract may hinder patient engagement and many of our patients have spent a lifetime defaulting on other written agreements. We strongly advocate for an evolving conversation, and the contract that we develop with patients is based on the relationship between the patient and the clinician, modeling the more successful social contracts that our patients do fulfill. In their addiction, most of our patients have shared drugs and resources with others despite their limited resources and will “pay back” the person who has shared with them. These forms of social contracts have more traction with our patients, and we utilize this strength in developing the therapeutic relationship as a better and more successful form of social contract than the written form we often employ. We are clear about expectations and limits, but usually give the patient a choice of more intensive treatment if they are unable to keep commitments. An example is a patient who failed to respond to multiple rounds of antidepressant treatment. He finally admitted he had never taken the medications we had prescribed after many perplexed conversations. When asked why he had told us he was taking the medication, he replied “it seemed so important to you.” This “misinterpretation” of the contract both gives us an insight into the way this patient thinks about interactions (the importance of making the other person feel a certain way) and also allows for a psychotherapeutic intervention in the form of pointing out how this may not be a successful problem-solving approach. We use contracts when required by third parties, like probation or insurance companies, or as an adjunct for the occasional patient who reads about recovery and engages in more intellectual aspects of recovery. When we have to use a contract, we model our contracts on the SAMHSA recommended patient contract published in SAMHSA’s TIP 63: Medications for Opioid Use Disorder (Treatment Improvement Protocol (TIP) Series 63 [2]) (Fig. 7.1). In our practice of integrative medicine, we prefer ongoing conversations and evolving engagement with our patients.

Sustaining Long-Term Treatment In the past, drug treatment was based on the idea that addicts can be “cured” of their addiction by a “course” of treatment. An understanding of the basic elements of addiction shows that addiction treatment must be long term, ongoing, and evolving. Drug treatment in the United States is currently episodic. The length of treatment, even in outpatient treatment, is assumed to have an endpoint measured in days or weeks that “fix” the problem. There is also a general

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Date:

Witness:

Date of Birth:

Figure 7-1.  Sample treatment contract. (Reprinted from SAMHSA’s TIP 63 Medications for Opioid Use Disorder [2])

Date:

Signature of Patient:

For women of childbearing age: Pregnant women treated with methadone or buprenorphine have better outcomes than pregnant women not in treatment who continue to use opioid drugs. Newborns of mothers who are receiving methadone or buprenorphine treatment may have opioid withdrawal symptoms (i.e., neonatal abstinence syndrome). The delivery hospital may require babies who are exposed to opioids before birth to spend a number of days in the hospital for monitoring of withdrawal symptoms. Some babies may also need medication to stop withdrawal. if I am or become pregnant, I understand that I should tell the medical staff of the OTP right away so I can receive or be referred to prenatal care. I understand that there are ways to maximize the healthy course of my pregnancy while I am taking methadone or buprenorphine.

I understand that it is important for me to inform any medical and psychiatric provider who may treat me that I am enrolled in an opioid treatment program. In this way, the provider will be aware of all the medications I am taking, can provide the best possible care, and can avoid prescribing medications that might affect my treatment with methadone or buprenorphine or my recovery. I understand that I may withdraw voluntarily from this treatment program and discontinue the use of these medications at any time. If I choose this option, I understand I will be offered medically supervised withdrawal.

I understand that, like all other medications, methad one or buprenorphine can be hamful if not taken as prescribed. It has been explained to me that I must safeguard these medications and not share them with anyone because they can be fatal to children and adults if taken without medical supervision. I also understand that methadone and buprenorphine produce physical opioid dependence. Like all medications, they may have side effects. Possible side effects, as well as alternative treatments and their risks and benefits, have been explained to me.

[insert name of program] to I authorize and give voluntary consent to dispense and administer medications—including methadone or buprenorphine—to treat my opioid use disorder. Treatment procedures have been explained to me, and I understand that I should take my medication at the schedule determined by the program physician, or his/her designee, in accordance with federal and state regulations.

Patient's Name:

CONSENT TO PARTICIPATE IN METHADONE OR BUPRENORPHINE TREATMENT

lack of research to support these treatment episodes and no organized way of knowing the long-term outcomes of people treated at that particular facility. Typically, the only outcomes that are known are when a person relapses and returns to the same drug treatment facility. This lack of systematic data combined with only episodic care disallows any drug treatment provider from adapting to improve outcomes. Our model stresses the concept of rehabilitation and is based on our assumption that an addiction is a chronic condition, like diabetes or hypertension, and that their disorder will evolve and needs ongoing monitoring and adjustment. A person with an addiction is a patient for life. We have had success treating chronic conditions with integrative medicine over many years, including HIV and addictions. Even if the patient eventually only needs primary care and occasional mental health check-ins, the patient’s longterm outcome is known. This allows the treatment team to have data to learn from and adapt treatment practices to become more effective. The power and strength of ongoing psychotherapeutic and primary care relationships capitalizes on the continuity of the team’s comprehensive knowledge of the individual’s clinical history and current functioning. We know our patients extremely well. Our approach is in contrast to how substance abuse treatment is typically provided. In both inpatient and outpatient substance abuse programs, time-limited group interventions are seen as the cornerstone of treatment with the philosophy that by listening to other recovering people, patients can learn how to recover themselves. While groups are efficacious for behavioral disorders, and the most successful group-based therapies recognize that you are a member of the group for life, groups lack the capacity to address comorbid conditions that may interfere with recovery. They cannot address the individual comorbid conditions nor correctly diagnose and skillfully present timely interventions tailored to the needs of the individual. Twelve-step fellowships such as Alcoholics Anonymous or Narcotics Anonymous also see groups as a cornerstone intervention but place great emphasis on a recovering person working the steps with a sponsor and promote long-term group participation. We find the individual attention and indefinite duration of 12-step fellowships as analogous and additive to our treatment, so long as other treatments such as antidepressants, antipsychotics, or adjunctive addictions treatments are not stigmatized. We encourage our MAT patients to engage in whatever 12-step fellowships or other recovery supports that we see as helpful. Patients with schizophrenia have very high rates of addiction and yet may not derive any benefit from a 12-step program. Treatment should be prescribed and directed based on the assessment of the whole person, not just a single element or problem.

 ecovery Therapy Versus Traditional R Psychotherapy The traditional method of long-term psychodynamic psychotherapy is a collaborative, noncoercive process in which the therapist collaborates with the patient to explore the life of the patient. Insight is valued, and processes are 7  Behavioral and Psychological Interventions for Addiction

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around exploration and eliciting from the patient. The therapist may guide and engage at a conscious level, but they also spend their time listening to the underlying or unconscious processes that may be at play. The job of the therapist is not to be directive, but to collaboratively help the patient to engage in autonomous growth in their life. In contrast to traditional psychotherapy, recovery-oriented therapy is a process that is often much more directed. Addicted patients have lost much of their autonomy, and the nature of addictions requires a redirecting of the behavior, thoughts, and goals of patients. Early in the process, it is necessary to orient the patient in their role, the process, and the demands of engagement in treatment. Blunt conversations about the rules and consequences are necessary in order to set expectations for change and growth. Early therapy is the time to help the patient confront the distortions and untangle the lies they have been telling themselves about their use. Very overt behavioral changes must be made in day-to-day and week-to-week lifestyle. A new path must be created for patients who have been programmed or conditioned to behave automatically and therefore make bad choices in their lives. Attaining employment or daily pro-social activities, shifting social contacts to those who are not using, and staying away from environments that are triggering are all important changes that the patient must develop. In these early phases of treatment, the therapist must aggressively guide the patient in acknowledging what changes must be made and in carrying out said changes. Even motivational interviewing and other so-called indirect techniques are targeted and help the patient to confront self-deception and to see themselves as agents in their own recovery. With a directive stance to therapy, there is an inevitable struggle that arises between the previously programmed behavior and the new behavioral paradigm. The patient may feel like the addictive behavior is their “choice” at times and then at other times be completely committed to treatment. The therapist is acting jointly with the patient and is tolerant of the chaotic lives, mistakes, and relapses that inevitably occur. However, when the therapist leads, patients may resist because it is difficult for them to differentiate their goals and interests from the programmed behaviors and the feelings provoked by that programming. Terms like autonomy, self-respect, and being in charge of their own lives may be used by patients driven to return to a life that they have admitted earlier permitted no autonomy, no self-respect, and no sense of being in charge. At these moments they perceive the therapist as working in opposition, and the process feels coercive instead of collaborative. Skillful therapists learn techniques to confront these distortions and accept the reality that the therapeutic process in recovery therapy has an element of paternalism in it that can be coercive. We will often concede this point to the patient but point out that being coercive does not imply that it is not in service of the patient. A common point that we make is that this confrontation is harder for us than just going along with the patient but would be a disservice to them. Both traditional and recovery therapies are a long-term process that becomes increasingly helpful as investment and trust in the process increase on the part of the patient. Lasting improvements may take significant periods of time. However, there are clearly different frames of understanding required in order to engage in each. The two types of therapy are not necessarily

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mutually exclusive; rather one gradually gives way to the other. Early recovery therapy must focus on addiction, behavior, relapse, recovery, rehabilitation, and direction. This must remain the focus as long as relapses are occurring and troubles around recovery disrupt engagement. Over time, therapy must continue to build up supports, skills, and abilities that will allow recovery to continue. The patient must have solid long-term goals that they will ongoingly do the things that they need to do in order to prevent relapse. However, once sufficient stability has been established and addiction is not an active issue in their life, the therapeutic process and dynamics begin to shift. If relapse occurs or addiction becomes an active issue again, the therapy will revert to being recovery-focused and more directive and change-­ focused in order to address the problem. In the course of recovery, shifts to more explorative and collaborative work follow on success and occur once stability has been firmly established. Ideas about their worth, fear, anxiety, avoidance, and hopelessness all contribute to addiction, and addressing these ideas aids recovery. Eventually, when a person is more stable, the nature of therapy may change. While relapse work will always be in the background as a safety net, the therapy moves away from it over time and toward issues in a person’s life that have not been addressed yet such as trauma-related work, deeper understanding of the person’s assets, better definition of their personal goals, and, finally, helping the person to realize and achieve their highest potential. Good therapists help the patient gradually address internalized self-destructive patterns of thought provoked by their experiences, often in ways that have furthered their addiction in the past.

Relapse Prevention Within recovery work, recognizing the nature of relapse is of utmost importance in order to assist patients in building up skills to combat it and to foster a mind-set that is understanding when relapses do occur. Reactions tend to be the person either thinking they made a mistake or feeling hopeless about their abilities to ever recover. In the latter case, it is important to remind the patient (and clinician) that relapse is a part of the recovery process and is a learning process. It is widely known across the recovery community the relapses tend to occur in three main situations, as supported by the work of Grimm et al. [3] in animal models and well described in the recovery literature (e.g., [4]): 1. Triggers, the colloquial phrase for environmental cues associated with drug use 2. Re-exposure to the drug, even in subtle or small amounts 3. Stress Each of these situations is known to induce relapse and is thus elaborated upon below. Helping patients to understand this not only normalizes when these happen but can build up the knowledge and skills necessary to prevent the likelihood of relapses. 7  Behavioral and Psychological Interventions for Addiction

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Identifying Triggers In order to build up relapse prevention skills, it is vital to help the patient in overtly identifying triggers. These are conditioned cues in the environment that become associated with use, thus increasing a desire or likelihood to use when re-exposed to them. Unfortunately, triggers are vast and sometimes unknown, so significant time may be spent in learning to identify what may be risk factors. Examples include certain places where they used to use, friends they used with, certain emotions like anger or sadness, particular activities, or even foods or drinks they used to consume while using. Triggers can be negative, like the anniversary of the death of a loved one, or positive, like birthdays, New Year’s Eve, and the 4th of July, but are all potential triggers. Many patients have said to us, “Well, certainly I can have one (drink, beer, toke, joint, jolt, tab, bag, pill, line, etc.) for my (birthday, New Years, president’s day, the election, toe nail clipping day etc.).” Any event in which a person experiences strong emotions will bring up memories and temptations to use, and for many patients boredom is the single worst trigger. Triggers are personal and unique, so the patient must identify them for themselves. Once triggers are identified, a scripted program to replace the previously scripted program needs to be described, initiated, and practiced. It is not enough to recognize high-risk situations, but the person needs to learn to work to change their automatic response to them. This means separating from “friends” they used drugs with or who create feelings that trigger use, building up positive supports with sober people, like friends who are clean or solidly in recovery, a sponsor, or supportive family members. Research has shown that the addition of a sober partner in recovery greatly facilitated successful recovery [5, 6]. If a person knows that going to a bar, even if they don’t drink, will make them want to get high, they need to avoid that situation. A helpful technique for some patients is to identify the things that are anti-triggers in their life. What are the low-risk people, places, situations, and things in a person’s life? What has never been associated with using? The patient must determine how to build up these low-risk pieces of their lives as one strategy to counter the power of triggers.

Re-exposure Being re-exposed to drugs is simpler than the patient might acknowledge. What we have found in our practice is that it is not enough for a patient to want to stay away from using. The people who were, or are, in their life who are still using will not let them go easily. Dealers, even if they are supposed friends, are aggressive about re-recruiting the people who they used to bring them money. With current technologies, calls, texts, messaging via social media, and countless apps make it increasingly difficult to get away from people who are trying to sell. Free samples (“tasters” or “testers”) are common tricks, especially when someone has been away at jail or rehab; there are some neighborhoods where people will toss a bag of something at you as you walk by. Despite their best intentions, it is incredibly difficult for patients to say no when something is in their hands that their addiction drives them to use.

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Supports in a person’s life might re-expose them in attempts to be helpful as well. It is common for a patient to come in reporting use of something a friend or family member gave them because they saw that the patient was in pain or anxious; for someone who is not in the recovery mind-set, offering a painkiller or benzo might seem like a kind thing to do. However, within the context of recovery, this is clearly inducing a relapse. Even having friends, partners, coworkers, or family members who use, which is a common phenomenon, creates an ongoing exposure to seeing people using or under the influence, at times highlighting the positives of use and creating additional temptations. While the person will need to learn the skills to refuse such offers, it is unsurprising that being exposed to drugs or use can lead to relapses.

Stress-Induced Relapses The literature repeatedly asserts the connection between stress and self-­ administration of drugs, i.e., relapse, in humans and in animal studies (e.g., [7–9]). Of course, it is an oversimplification to assume that stress alone can predict or cause addiction, but it undeniably plays a role in the maintenance of use. Some theorize that stress and addiction are linked because patients self-medicate with drugs of abuse to deal with stress, negative affect, or events in their lives, while others note the physiological activation of internal systems in the presence of triggers, cuing a craving for a drug or increasing sensitivity to stressors [7, 9]. While the literature is inconclusive about the exact mechanism, it is growing in its acknowledgment that there is a link between stress and addiction. As it is impossible to eliminate stressors from society or from the lives of patients, a piece of recovery therapy must include building up the person’s ability to tolerate and cope with stress, as well as a rehearsed and scripted behavioral plan to engage in when stress is encountered.

Strategies There are endless strategies that the patient and clinician may develop together in order to address cravings and triggers and prevent relapses. The following list illustrates some of our favorites: • Make a list of triggers and come up with replacement behaviors for each, like exercising at 8 pm, a time associated with high. • Make a list of low-risk situations, behavioral scripts, or friends. • Come up with a list of people who are positive supports. • Create a relapse plan, writing out who the patient will call, where they will go, and what other behaviors they can do when they want to get high. Have multiple steps and options in case one doesn’t work and rehearse the plan. • Identify different types of cravings, like differentiating between somatic (heart racing, upset stomach) and cognitive (drug dreams, ruminating on thoughts about getting high).

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• Urge surfing: teach patients to mentally detach from their thoughts about using, taking a step back to visualize their cravings as an ocean wave, riding it to its rise and crest, then as it falls. • Plan time to engage in non-drug-related behaviors, or pro-social behaviors, intentionally throughout each day. Patients often have chaotic lives, so planning for positive behaviors is important. • Increase routines and scheduled lives, decreasing chaos. Structure in life is critical to recovery. Write out a daily schedule that includes appointments, eating, sleeping, and other positive activities. • Check out different 12-step meetings, looking for a group that the patient can connect with, does not have people who are using the meetings as a place to sell or use drugs, and feels safe and supportive. Every meeting has its own personality, so they may need to find one that is a good fit. LGBTQ and women-only meetings are options for specialized groups as well. • Find a sponsor or a go-to support who can engage regularly in person and over the phone in times of temptation. • Seek out a job, volunteer, or other activities to fill their days. Structure is a key to recovery. • Continue with therapy and support groups, even when past the initial crisis of detox, frequent relapses, or overt recovery-based work. • Use religion/spirituality as it fits with the patient’s beliefs; going to worship services or praying can be a powerful support for many. • Learn assertiveness skills for saying no to offers to use or triggering situations. Rehearse trigger situations. There is no one right way to engage in recovery and relapse prevention. The patient must discover what is effective and helpful for them as an individual. The most important thing is to shift thinking away from what the patient will not do (e.g., “I will not use drugs, I will not talk to my dealer”) to what they will do (e.g., “I will go to a meeting on Tuesdays, I will get a sponsor, I will apply for 3 jobs this week”). Active, positive, observable steps toward recovery must be an ongoing process. This not only requires and encourages commitment on the part of the patient, but it builds up important skills necessary to make recovery a long-term success. As the clinician, it may be difficult to get patients to make changes that are best for them. When someone is depressed, telling them to get out of bed and go for a walk seems counterintuitive and, at times, impossible from the patient’s perspective. In these cases, the clinician must act as a behaviorist. Feelings become less important, and behavior is the focus of the treatment intervention. The patient must change how they behave in order to get better; feelings will follow, but they are outside the realm of what we can change directly. We will often say “you don’t have to believe me, or to believe that this will work, but if you do it anyway it will get you better.” Another common phrase in our work is “it’s not how you feel, it’s what you do.” It feels paradoxical to tell someone that they don’t have to believe the strategy will work and that they have to do it because they likely have to believe you on some level before they will attempt your instructions. However, it works. Saying “you don’t have to believe me. In fact, I want you

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to think it won’t help. But you still have to cooperate” may be more effective than saying to someone “try it. What do you have to lose?” even.

 ombatting Ambivalence with Motivational C Interviewing Ambivalence is ever present in addiction work. Defined as having two opposing feelings about something at the same time, ambivalence is a concept all of us experience. How often do we find ourselves avoiding things we know are good for us? Not flossing after every meal, smoking cigarettes, or speeding in our cars? Ambivalence is the nature of the human condition, and it runs rampant in addiction. Many people come to treatment both desperately wanting to change their lives and fiercely clinging on to the lifestyle that has caused them so much pain. Think of the two sides of ambivalence as the two sides of a seesaw. When someone begins to push down on one side convincing us to make a choice, we run to the other side to create balance. If someone tells us we can’t do something, it makes us want to do it all the more. In therapy, it is tempting to tell people what to do. However, this approach can actually foster behaviors in exact opposition to what the clinician wants the patient to do. However, motivational interviewing is an approach to therapeutic work that embraces ambivalence and helps patients to make changes in their lives. Motivational interviewing (MI) is an approach to having conversations in a way that elicits and strengthens motivation and evokes a commitment to change [10]. This approach addresses resistance and ambivalence in a collaborative manner, assuming that the patient has the motivation and means to work toward a goal within them [10, 11]. There is a substantial body of research at this point on the effectiveness of MI that finds that MI influences the outcomes of treatments and produces lasting change [11]. In fact, many studies show that a minute number of sessions using MI (e.g., as few as one session) can create change in behavior [12]. In order to create change, Miller and Rollnick [10] espouse that the patient and clinician must work through the four main processes of MI: engaging, focusing, evoking, and planning [10]. Engaging refers to the process of establishing the therapeutic relationship, comparable to many approaches to therapy. Focusing is the stage where the clinician and patient clarify the goals and changes that will be the target of sessions. Once goals have been established, evoking is the process by which the patient’s own motivations are explored. Finally, planning involves eliciting a commitment to change as well as developing the steps needed to carry out said change. While each of these processes builds upon the one prior, conversations using MI often flow in and out of each process as needed to best aid the patient in developing change [10] (Table 7.1). MI assumes ambivalence in every person considering change, so it aims to elicit “change talk” and move away from “sustain talk” [10]. Change talk refers to statements that are in line with change, and sustain talk refers to statements a person makes against change; both of these are commonly 7  Behavioral and Psychological Interventions for Addiction

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Table 7.1  The main processes of motivational interviewing [10] Process name

Description of process

Engaging

The process of establishing the therapeutic relationship, comparable to many approaches to therapy

Focusing

Clinician and patient clarify the goals and changes that will be the target of sessions

Evoking

Process by which the patient’s own motivations are explored

Planning

Eliciting a commitment to change as well as developing the steps needed to carry out said change

heard in a person who is considering making a change [10]. When the clinician aligns with one side of the ambivalence, the common reaction is for the patient to defend the other side of their ambivalence. Thus, if a clinician tries to force the change, the patient will retreat toward sustaining the status quo [10]. Therapist behaviors that are inconsistent with MI include confronting the individual, giving advice, or falling prey to the “righting reflex” to try and fix the problem; these behaviors are harmful to the process of MI, pushing to individual to fall back to sustaining their current behaviors [10, 13]. Miller and Rollnick [10], there are a number of skills that the MI practitioner may use to help move conversations forward and avoid arguing one side or the other of ambivalence [10]. Open-ended questions encourage the patient to explore and elaborate as opposed to eliciting short answers. Affirmations build upon the idea that the patient’s strengths are what facilitate change; looking for and pointing out strengths, good intentions, and even small efforts can be a powerful tool. Reflective listening and statements serve to affirm that the clinician is listening and to move the conversation forward by making the patient confirm or clarify their meaning. Summaries not only compile information that has been explored thus far but can encourage the patient to fill in missing details and serve as a transition in conversation to another task. Finally, there are some times when providing information or advice is important within MI, but it must be done with the patient’s permission and the clinician cannot dictate what the patient does with the provided information. While these skills are an important part of practicing MI, it is important to clarify that MI is not intended to be a composite of techniques, but rather a style of conversing with and being with people contemplating change. The use of MI is much more nuanced than the above description, but this information provides a foundational understanding to the use of MI in clinical work [10] (Table 7.2).

Trauma Within a Recovery Context Most patients who come to integrative medicine settings come with life stories full of painful, scary, and life-threatening events. Many have unresolved traumas or may even have developed post-traumatic stress disorder. Even

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Table 7.2  Motivational interviewing (MI) skills [10] MI skill [10]

Definitions [10]

Open-ended questions

Encourage the patient to explore “How might attaining a sponsor help you in your and elaborate as opposed to recovery?” eliciting short answers

Example

Affirmations

Looking for and pointing out strengths, good intentions, and even small efforts

“You smoked half as many cigarettes this week as last; that is a great improvement”

Reflective listening and statements

Affirm that the clinician is listening and move the conversation forward by making the patient confirm or clarify their meaning

“You’re afraid that your efforts to change your eating won’t help your diabetes”

“You brought up exercise, Compile information that has nutrition, and seeing the been explored thus far, but can doctor. Where should encourage the patient to fill in we start?” missing details, and serve as a transition in conversation to another task Done with the patient’s “May I give you some Providing permission and the clinician information about information or cannot dictate what the medications to help quit advice patient does with the provided smoking that we information prescribe here?”

Summaries

without the PTSD diagnosis, trauma is very impactful on a person and their functioning. For some, it led to drug use; for others addiction is very tied in with the trauma that occurred in their life in other ways. Trauma may be very disorienting and can lead to impulsivity, aggressive behaviors, hostility, or other defenses against the terror of feeling unsafe that may occur in the wake of trauma. Often in the healthcare system, these patients are seen as unpredictable, inappropriate, and undesirable; they are understood to be a nuisance or a threat instead of struggling to get a grasp on what is going on in their world in that moment. Seen as non-compliant or badly behaved, they are blamed and punished for their trauma reactions. Thus, integrative medicine sites must have the competencies to deal with trauma and to treat these patients with the patience and understanding that is necessary to deal with unpredictable or scary behaviors. While this section does not serve as a comprehensive guide to the treatment of trauma as a whole, it elaborates upon the framework from which integrative medicine providers may view trauma treatment when working with patients. There are many components to trauma. The core diagnostic features of PTSD are also the features that produce the most disorder in the person’s life, namely, hyperarousal, avoidance, negative alterations in mood and cognitions, and reexperiencing [14]. Addressed below, many of these symptom clusters come

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back to the idea of fear and feeling unsafe in the world. While many people experience traumatic events and do not have PTSD because of resiliency, environmental supports, or countless other reasons, those who do experience trauma reactions are not to be considered weak or at fault. Coming from a place of compassion, the clinician may begin to address a number of factors in trauma even when the patient is not in a stable place (Table 7.3).

Table 7.3  Overview of PTSD Cluster of PTSD

Symptoms [14]

Hyperarousal

Disturbances in sleep Relaxation and anxiety management skills Aggressive or self-destructive (diaphragmatic behaviors breathing, progressive Startling easily, struggles muscle relaxation, and concentrating mindfulness)

Avoidance

Intervention strategies

Being hyper-aware of one’s surroundings

Exposure Response prevention

Avoiding physical people or things that bring up memories of their trauma

Identify when avoidance occurs

Pushing to (safely) do and face fear-provoking situations Not allowing PTSD to isolate, Physical avoidance prevent them from living Numbing through substance lives use Avoiding thoughts, emotions, or feelings related to the trauma

Dissociating from the self Negative alterations in mood and cognitions

Re-experiencinga

Warped views of the world and of the self (including believing that the world is an unsafe place, they are to blame for their trauma, or they are broken)

Bring balance and normalcy back to worldviews and emotions Identify extreme thoughts/ emotions Identify safety

Changes in mood, like having fear, anger, guilt, shame, or horror

Introduce self-care and self-regulation

Losing interest in regular activities, feeling alienated from others, and struggling to have positive emotions Spontaneous memories, nightmares, and flashbacks where the person feels drawn back to the trauma

Moving away from black-and-white thinking/ see the shades of gray Re-exposure activities Delving deeply into the story of the trauma Medications for nightmares

Therapeutic interventions for this cluster of symptoms should only be done in stable/safe stage of recovery to help protect against relapse

a

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It is noteworthy that many other psychiatric comorbidities will amplify the destructive response to trauma. Major depression is the most common and the most easily identified and treated. The comorbidity is so great with major depression that it is often hard to find cases where it is not present. It is, nonetheless, a key comorbidity that should be identified and treated separately. Psychotherapy for patients with major depression that is untreated is ineffective and even destabilizing.

Hyperarousal Arousal-related symptoms refer to disturbances in sleep, aggressive or self-­ destructive behaviors, startling easily, struggles concentrating, and being hyper-aware of one’s surroundings [14]. This symptom cluster may be overtly addressed in therapy early on, helping to teach and implement relaxation skills and anxiety management, such as diaphragmatic breathing, progressive muscle relaxation, and mindfulness. However, it is incredibly important that the patient practice these newfound skills frequently, in and out of session, and even at times when they are not experiencing anxiety or stress. The patient may think that managing anxiety through these techniques seems impossible, but reassurance and insistence of the utility of the skills is necessary by the clinician in order to build up enough buy-in that the patient will practice enough to see the benefits. Without making these skills regular parts of the routine, they will not be effective in managing arousal and anxiety. Once they have a solid grasp on relaxation skills, they can increase their practice by doing something that raises their anxiety a little bit and then using their new skill to calm themselves down. This is essentially exposure and response prevention work, borrowed from CBT approaches to therapy (Box 7.1).

Box 7.1: Interventions for Panic Attacks

Diaphragmatic Breathing When people are experiencing anxiety, they tend to use shallow chest breaths. However, more effective and helpful are fuller breaths that fill the lungs and engage the diaphragm, pushing the stomach out with each inhale. Guiding the patient to place a hand on their stomach and a hand on their chest, we can coach the person to take deeper breaths, giving their bodies and their brains the oxygen they need to help with calming themselves in time of anxiety, panic attacks, and stress. Our bodies are meant to breathe this way, but our anxiety often overtakes the body’s natural instincts. Through practice, the person can relearn their natural and healthiest breathing practices. Progressive Muscle Relaxation PMR is a technique that guides the person through progressively tensing and relaxing each muscle group in their body. People often do not realize that they are even tightening muscles until they are instructed to

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intentionally tense them more and release. Moving progressively from the feet up to the face, then the whole body, we guide patients to tighten muscles, hold, and release and hold, noticing the difference. Of course, care must be taken if there are pre-existing injuries or pain, refraining from using this technique in the case of muscle injury, for example. Guided Imagery Using mindfulness or meditation techniques in which the patient is walked through imagining themselves in a peaceful and safe place, whether it be the beach, the forest, or a memory from their life. They are instructed to imagine the setting, using every sense: sight, smell, sounds, touch, and taste. There are guided scripts or videos available online for those who struggle to generate these scenes on their own. The clinician and patient may co-create a serene setting together as well, talking through what the place is like in every way. When encountering stress or anxiety, the patient can call upon this image to remove themselves mentally from their present anxiety and into a more peaceful mind-set.

Avoidance As the name implies, this symptom cluster refers to when the person is avoiding physical people or things that bring up memories of their trauma or are avoiding thoughts, emotions, or feelings related to the trauma; physical avoidance, numbing through substance use, and dissociating from the self are all strategies used in avoidance of trauma [14]. Addressing avoidance may be done before complete stability with recovery has been accomplished as well, helping the person to achieve feelings of freedom and mastery in their lives. Treatment around this area involves pushing the patient to do things that they have fear about but also have an awareness that the fear is irrational. Careful attention must be made not to overly push the patient or encourage them to do things that may actually harm them. However, if someone is resistant to going into a certain store, for example, because it reminds them of what they had been doing earlier in the day their trauma happened, actively pushing against that fear and going to the store will help them to reclaim back a piece of their life. The patient must consider what they are avoiding, what they can actually do, and how to face their fears. Unless it’s actively pushed against, avoidance will creep back into the patient’s life and hold them hostage in a web of their own fears.

Negative Alternation in Mood and Cognitions Following a trauma, it is common to have warped views of the world and of the self, including believing that the world is an unsafe place, they are to blame for their trauma, or they are broken. Changes in mood, like having fear, anger, guilt, shame, or horror regularly as well as losing interest in regular

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activities, feeling alienated from others, and struggling to have positive emotions, are all possible effects of trauma [14]. The final cluster that may be addressed in someone who is not yet stable, the goal of work in this area, is to bring some balance and normalcy back to worldviews and emotions. Remembering that thoughts are likely more extreme, the patient needs to discover that while there is danger in the world, there is also safety. While the person has had something happen to them that makes them feel broken, they also have the power to do things to take care of themselves and re-­ regulate their emotions. Moving away from black-and-white thinking, the patient learns to see the shades of gray in their world again.

Re-experiencing/Intrusion Spontaneous memories, nightmares, and flashbacks where the person feels drawn back to the trauma are unsettling and scary symptoms of trauma [14]. Treating this cluster of symptoms is best done through re-exposure activities and delving deeply into the story of the trauma. Highly destabilizing for even the most stable of people, this is intensely difficult and triggering work. For this reason, this piece of trauma work is reserved for after significant stability has been achieved within recovery. Even once it is addressed, the clinician must be very careful and cautious in monitoring for potentials for relapse or destabilization that may occur in patients. Until the therapeutic work is able to address this component of PTSD work, there are some medications available that have been researched and established to target PTSD nightmares when used in the correct dosages (e.g., Prazosin, [15, 16]), which will allow the medical provider in the integrative medicine practice to offer some relief from this specific symptom.

Safety In discussions of trauma treatment, the idea of safety is repeatedly returned to in described the mind-set of the patient. Not a formal diagnostic criteria, the result of many of the above symptom clusters is a sense of feeling unsafe. Thus therapeutic work must help the patient to learn realistic appraisals of safety and danger and to realize that they are safe and have established safety in their own lives already since the initial trauma. The person may be experiencing bodily sensations, like heart racing or being startled easily, which does not make sense to them. Especially in the earlier stages of trauma, it is more important to establish what the person can do to make themselves feel better and feel safe than to figure out why they are feeling unsafe. How does the person use anxiety management, grounding, distraction, calling a trusted friend, or other techniques to feel calmer in the moment? Furthermore, it is important to realize that safety is complex and multifaceted. The patient must consider how they may establish safety in any and all of the following areas of their lives: physical safety, psychological safety, safety in intimate relationships, and social safety. 7  Behavioral and Psychological Interventions for Addiction

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Confounding Issues in Treating Trauma As was discussed above, trauma therapy is complex and potentially destabilizing work. While some aspects of trauma may be addressed earlier on, deeper level trauma work must be postponed until patients are in a stable enough place to engage in the work without being put at risk. Some patients want to deal with their trauma right away and struggle with this postponement. Others may deny the effect trauma has had on their lives, a phenomena magnified by certain cultures, like war-related trauma for those in the military. For some, they may have attempted to tell others about their trauma before and have not been believed or have been shamed for their experiences, as is common with child abuse, sexual assault, and rape; not being believed can be just as traumatic if not more than the event itself. These experiences can make it harder to trust the therapist or bring up trauma; it may also add layers of shame, confusion, and stigma to the trauma itself. The very nature of trauma that may breed a sense of fear or mistrust in the world unfortunately creates barriers in establishing trust and rapport between the therapist and patient as well. Medical and behavioral concerns overlap with PTSD and trauma in patients. It is common to discover that people with addiction have relied on substance use to cover up or cope with their trauma for years. When the addiction and trauma are so intertwined, it can increase the difficulty of treating both. Furthermore, co-occurring medical issues that arise from the trauma may have gone untreated or may have caused chronic pain or other ongoing reminders of the trauma, thus necessitating medical intervention as well as adding repeated triggers for the person dealing with this trauma. Furthermore, certain medical discussions may trigger or relate to the trauma, such as conversations around sexual health, fear around the body, or other linked conditions. Thus, it behooves the physician and therapist to collaborate in considering how to tactfully and thoroughly address the medical or physical concerns that may be exacerbating traumatic experiences. Finally, there are recommendations for different medical interventions for certain aspects of PTSD. Patients may seek out benzodiazepines or opioids that they have felt successful on in the past, but the integrative medicine team knows that these medications cover up symptoms instead of allowing healing to occur. Seeking out current medical recommendations and being able to have conversations with patients about these choices provide clarity and effectiveness around medical decision-making. There are realities of ongoing trauma that may need to be addressed in therapy. Long-time survivors or victims of intimate partner violence may still be with their partners, or may not have a healthy understanding of what a relationship should look like. Sex and aggression get tied up with one another, and it can be confusing to sort out what is excitement, what is fear, and what rights the patient has to their own body or the choices that are allowed to make about their lives. People who have been traumatized sometimes have poorer boundaries or have distorted ideas about what healthy relationships are; recognizing when relationships are toxic or healthy, and potentially ending the relationships if needed, is a new skill that may need to be acquired.

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Understanding the nature of the trauma as well as the ongoing messages and impacts it may be having on the person are vital for treatment, especially if traumatic events continue or resurface during therapy.

References 1. Weiss R, Potter J, Fiellin D, Bryne M, Connery H, Dickinson W, et  al. Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: a 2-phase randomized controlled trial. Arch Gen Psychiatry. 2011;68(12):1238–46. 2. Substance Abuse and Mental Health Services Administration (SAMHSA). Medications for opioid use disorder. Treatment improvement protocol (TIP) series 63, full document, HHS Publication No. (SMA) 18- 5063FULLDOC. Rockville: Substance Abuse and Mental Health Services Administration; 2018. 3. Grimm JW, Hope BT, Wise RA, Shaham Y. Neuroadaptation. Incubation of cocaine craving after withdrawal. Nature. 2001;412(6843):141–2. 4. Stewart J. Psychological and neural mechanisms of relapse. Philos Trans R Soc Lond Ser B Biol Sci. 2008;363(1507):3147–58. 5. Kidorf M, Brooner RK, Peirce J, Gandotra J, Leoutsakos JM. Mobilizing community support in people receiving opioid-agonist treatment: a group approach. J Subst Abuse Treat. 2018;93:1–6. 6. Kidorf M, Latkin C, Brooner RK. Presence of drug-free family and friends in the personal social networks of people receiving treatment for opioid use disorder. J Subst Abuse Treat. 2016;70:87–92. 7. Goeders NE. The impact of stress on addiction. Eur Neuropsychopharmacol. 2003;13(6):435–41. 8. Groblewski PA, Zietz C, Willuhn I, Phillips PE, Chavkin C. Repeated stress exposure causes strain-dependent shifts in the behavioral economics of cocaine in rats. Addict Biol. 2015;20(2):297–301. 9. Piazza PV, Le Moal M. The role of stress in drug self-administration. Trends Pharmacol Sci. 1998;19(2):67–74. 10. Miller WR, Rollnick S. Motivational interviewing: preparing people for change. 3rd ed. New York: The Guilford Press; 2012. 11. Lundahl B, Burke BL. The effectiveness and applicability of motivational interviewing: a practice-friendly review of four meta-analyses. J Clin Psychol. 2009;65(11):1232–45. 12. VanBuskirk KA, Wetherell JL. Motivational interviewing with primary care populations: a systematic review and meta-analysis. J Behav Med. 2014;37(4):768–80. 13. Magill M, Gaume J, Apodaca TR, Walthers J, Mastroleo NR, Borsari B, Longabaugh R. The technical hypothesis of motivational interviewing: a meta-analysis of MI’s key causal model. J Consult Clin Psychol. 2014;82(6):973–83. 14. American Psychiatric Association (APA). Diagnostic and statistical manual of mental disorders. 5th ed. Washington, D.C.: American Psychiatric Association; 2013. 15. Koola MM, Varghese SP, Fawcett JA. High-dose prazosin for the treatment of post-­ traumatic stress disorder. Ther Adv Psychopharmacol. 2014;4(1):43–7. https://doi. org/10.1177/2045125313500982. 16. Dierks MR, Jordan JK, Sheehan AH. Prazosin treatment of nightmares related to posttraumatic stress disorder. Ann Pharmacother. 2007;41(6):1013–7. Epub 2007 May 15.

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8

Adjunctive Pharmacotherapy for Opioid Addictions Julia Hodgson, Kevin Moore, Trisha Acri, and Glenn Jordan Treisman

We often hear people—patients and providers—talk about medication-­ assisted treatment as a cure to addiction, likening it to penicillin and assuming a simple prescription could end this epidemic. The president of Physicians for Responsible Opioid Prescribing and an early advocate for buprenorphine, Dr. Andrew Kolodny, admits that he initially (mistakenly) thought “this cures all addictions” [1]. On the contrary, we align with people long in recovery, who have told us the desire to cure their ailments and their pain with a simple pill was what got them into their addiction in the first place. Indeed, a desire to prescribe away complex conditions like pain or addiction is the exact mentality that will lead to these medications becoming problematic instead of a tool in a larger treatment program. Psychopharmacological interventions are incredibly successful in conjunction with rehabilitative treatment for opioid addiction; pharmacology plays an important role, but is insufficient alone. A multidisciplinary team is an important part of treatment in order to address the behavioral and psychological elements we have described in this book (see Chap. 7). Together, the team can implement comprehensive treatment and hold patients accountable in their recovery while simultaneously addressing psychiatric and medical comorbidities that contribute to their addiction.

Adjunctive Pharmacotherapy for Addictions Treatment of addictions is primarily behavioral and psychological. Simply giving pills for addiction ignores the need for rehabilitation, relapse prevention, and social re-engagement. While most of addiction treatment involves psychological treatment directed at engaging patients, getting them to © Springer Nature Switzerland AG 2020 J. Hodgson et al., Integrative Medicine for Vulnerable Populations, https://doi.org/10.1007/978-3-030-21611-5_8

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“convert” (accept the addiction as a disordering medical problem), detoxify, rehabilitate, and prevent relapse, a number of medications can be helpful in the process of treating addictions. The term opioid substitution therapy or opioid maintenance describes using opioids with particular pharmacological properties to as part of the treatment for opioid addiction. In truth, any opioid can be used in theory to stabilize opioid addicts and help them to stop getting illicit opioids, but some opioids appear to be superior to others. While many drugs may be helpful in treatment of opioid addiction (such as clonidine and many others), there are three current types of adjunctive pharmacotherapy for opioid addiction treatment that act directly at the opioid receptor and are shown in Table 8.1. Additionally, the short-acting drug naloxone is used to reverse overdoses. While it is not a pharmacotherapy for addictions, we prescribe it for all our opioid using patients to try to limit overdose deaths and have included it here. It is short acting and may have to be readministered, and it is parenteral and cannot be given orally but must be injected or intranasally inhaled (Table 8.2).

Methadone While there are five major subtypes of opioid receptors in the brain, the mu opioid receptors are thought to be the principal pathway that creates the euphoric “high.” Methadone is a full opioid agonist that has high intrinsic activity to the mu receptor site and is thus able to prevent withdrawal and provide a long-acting activation of opioid receptors which become less sensitive to other opioids (tolerance) due to constant stimulation. Methadone metabolizes far more slowly than other opioids and gives the patient a much more constant opioid-induced state than morphine/heroin and other shorter-­ acting opioids. If a patient adequately dosed on methadone takes another opioid, it can have a small additive effect but lacks the intensity of the effect opioids usually produce. Thus, it diminishes the pleasurable and reinforcing effects of other opioids. This partial blockade of the reinforcing effects of opioids decreases behavioral associations between using opioids and the desired feeling state, which in turns reduces urges and cravings and supports nonaddictive social and occupational functioning. Currently, methadone can be utilized for addiction treatment only in specialized settings and with rigorous licensing requirements. Strengths of methadone are a long duration of action and long half-life, meaning it can be dosed once a day for addiction treatment (it needs greater frequency as a pain medication). Methadone is also very inexpensive (although the monitoring of use and restrictions add cost burden). It comes in both oral forms (liquids and pills) and parenteral forms for injection but for opioid treatment is almost always used in the liquid form, making it harder for patients to sell it later. Patients take their methadone as a liquid in the clinic, although they may be able to earn “take home” doses and come to the clinic less frequently as an incentive to make progress in treatment. Methadone also has a variety of problems when used illicitly and for chronic pain treatment. We will limit our discussion of methadone because of the specialized nature of methadone treatment.

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Dolophine

Naltrexone

Mixed opioid agonist/ antagonist

Full opioid agonist

Mechanism

Opioid Vivitrol oral antagonist Vivitrol monthly injectable

Buprenorphine Suboxone, Subutex (daily oral) Sublocade (extended-­ release buprenorphine) monthly injectable Probuphine implant (6-month extended-­ release buprenorphine implant)

Methadone

Common brand name

Block mu receptor without activation (blocks effects of opioid, does not help with withdrawal/cravings)

Full activation of mu receptors Eliminate the need for illicit opioid use and stabilize people on a daily dose Partial activation of mu receptors. Causes dependence so as to encourage use, and blocks “high” if opioid used on top of medication

Effect

Table 8.1  Adjunctive pharmacotherapies for addiction

Any licensed medical provider can prescribe

Medical providers with special DEA license can prescribe, even in primary care settings

Special clinic with unique licensing requirements

Availability

Table 8.2  Naloxone pharmacotherapy for addiction Common brand name

Naloxone

Narcan

Mechanism Effect

Availability

Opioid antagonist

Most states do not require prescription, can acquire from pharmacy or clinics

Reverses overdose by blocking mu receptors

Buprenorphine Buprenorphine is a partial opioid agonist and thus produces less euphoria than full agonists. Buprenorphine has a very high affinity for the mu opioid receptor and binds tightly, a property that is effective in minimizing the reinforcing effects of other opioids, including heroin. Patients report, “I couldn’t get high,” “I didn’t feel anything,” and “it was a waste of money to try.” Even more effectively than methadone, adequate doses of buprenorphine very much decrease reinforcement and the subjective high associated with the use of even injected heroin and morphine. While really huge doses of full agonist opioids can overcome this effect (such as might be needed in emergencies or surgery), patients can usually not afford street drugs in quantities adequate to overcome the effects of buprenorphine and the blockade of the behavioral associations between using the opioid of choice and the desired feeling state. There are some caveats to the use of buprenorphine. The most important effect is the precipitation of withdrawal in people physically dependent on other opioids which are full agonists (most addictive opioids). A patient being transitioned to buprenorphine from other opioids must be almost completely off these drugs or in severe withdrawal from them before starting buprenorphine. This can be a tricky part of transitioning a patient to buprenorphine, as some patients with chronic pain as a comorbidity are on high doses of opioids. The transition to buprenorphine for these patients can be quite tricky. Additionally, the dramatic decrease in the wholesale price of illicit heroin has made it possible for some people (particularly people selling illegal drugs) to become dependent on high doses of opioids. Patients with excessive heroin habits can also be very difficult to transition to buprenorphine without a specialized setting. The availability of such settings can be challenging for a treatment facility that has limited access to inpatient beds and may be thwarted by the emphasis on short lengths of stay in hospitals. Buprenorphine can be injected or can be absorbed transdermally or sublingually (under the tongue) into the blood. It is metabolized by the liver when taken orally (called the first-pass effect) and so is not very effective when swallowed. It can be used for pain relief and sometimes is used for opioid detoxification. When used for opioid substitution therapy, it is usually given as a sublingual form in a combination with naloxone, an opioid antagonist that

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is not absorbed well sublingually. The naloxone has no significant effect when taken sublingually, but if a patient injects the buprenorphine/naloxone combination, the naloxone will precipitate withdrawal and block the effects of buprenorphine. This prevents people from injecting their sublingual medication. The drug is supplied as films or as pills that go under the tongue. The original combination product was called Suboxone, but there are now several marketed forms. The drug is usually given three times a day. Buprenorphine also be delivered in two long-term formulations. One form is a slow-release injected subcutaneous monthly injection called Sublocade. The other is a set of implants that slowly release buprenorphine and need to be changed every 6 months called Probuphine. In both of these, the active agent is buprenorphine and essentially provides the same treatment as the sublingual type but has some special properties such as long duration of action and decreased ability to sell or divert the drug. There is concern about the use of Naloxone in pregnant women using opioids as the naloxone in the formulation could precipitate withdrawal in the fetus. (To be clear, toxicity to the fetus will only occur if the medication is taken illicitly via injection, not if it is taken sublingually as prescribed, formulated, and intended.) Therefore, an alternate form of sublingual tablet containing only buprenorphine (brand name Subutex) is available for use in pregnancy. (Methadone is also a safe option for treatment during pregnancy.) Any physician or mid-level clinician can obtain the certificate that allows them to prescribe buprenorphine with modest training requirements. It is available from pharmacies and does not require the special handling of methadone.

Naltrexone Naltrexone binds to the mu opioid receptor site without any activation. This essentially produces very few direct effects in the patient. The full blockade of opioid receptors prevents patients from experiencing any effects of opioids unless given in very large doses. Problems with initiation of naltrexone are the same as those with buprenorphine in terms of precipitating withdrawal in patients dependent on opioids. One of the advantages of naltrexone is the lack of any opioid action. Patients with a desire to maximize function and decrease any opioid effects (clouded thinking, constipation, dry mouth, nausea, and many others) find this medication free of those effects. Naltrexone can be given daily in an oral pill or monthly in a long-­acting injection.

 se of Agonist and Partial Agonist Therapies U for Opioid Addiction Pharmacotherapy interventions in the treatment of opioid addiction have become more readily available and used in the United States [2]. The idea for methadone, one of the first drugs to be extensively used, was that the

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presence of a long-acting potent agonist would prevent self-administration of opioids and therefore decrease the conditioned behaviors of seeking opioids, using them in stereotyped ways, committing crimes to get opioids, and injecting. The hope was that after an extended period of time on methadone, patients would no longer be conditioned to the behaviors associated with addiction and could gradually be tapered off and that the structure in their lives they had developed while on methadone would prevent returning to illicit use. The concept of “harm reduction” and that methadone was a “substituted addiction” came later with more popular use. Methadone is an effective adjunct to rehabilitation, and many models of methadone provision have been developed. Some focused more on the harm reduction concept of substituted addiction, and this model allowed easy access to methadone with a minimum requirement so as to decrease crime, sexual misuse, and injecting that were all associated with ongoing opioid addiction. Other models emphasized recovery and rehabilitation and required patients to attend group therapy, to make progress in their recovery, and to develop a structure for life that would help them maintain their functioning. These programs were more burdensome to patients and more expensive for providers but focused on cost savings of restoring function in patients for the society at large as well as improving the quality of life for the individual patient. Methadone used for maintenance is provided as a liquid and is usually observed at administration. Used this way it has few medical consequences and few issues of diversion. Problems include the cost of monitoring programs, the need for specialized licenses and training, and the limited availability of the treatment. The more recent treatments developed using buprenorphine depend upon its action with partial agonist and antagonist properties of the drug. Opioid-­dependent people with addictions will experience profound withdrawal if they use buprenorphine, and this limits diversion and sale. There is a ceiling effect where taking more drug produces very little additional “high” and this decreases the “saving up” of the drug to use late in the month. The use of other opioids is relatively ineffective due to the tight binding of buprenorphine to the receptor. Furthermore, buprenorphine decreases cravings and prevents withdrawal [2]. Without urges and cravings, the patient is able to build up behavioral skills and make changes in their life to move away from addiction without the competing influences of physical addiction. Buprenorphine has been found to decrease overdoses, decrease the use of opioids, help patients stay in treatment for longer, and preserve cognitive functioning more than other opioid substitution options [2, 3].

Contrasting Buprenorphine to Methadone A current vigorous debate in the addiction community, there are many perspectives on the use of different medications with people dealing with addiction. Buprenorphine has many clear advantages over methadone. Unlike methadone, buprenorphine produces less intoxication and preserves more

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cognitive functioning, decreasing the nodding, or cognitive fog seen with other opioid agonists. Furthermore, buprenorphine has the advantage in its ability to be prescribed in an office-based setting by an individual physician who has obtained additional mandated training. In contradistinction, a state-licensed methadone clinic is run by a staff of addictions counselors who are supervised by a physician who may see the patient only infrequently. In addition, patients can dose buprenorphine at home, allowing people who take the medicine to avoid reporting to a clinic daily for maintenance; increased flexibility increases access and the ability for patients to pursue jobs or engage in other activities important for their recovery [3]. Some criticize buprenorphine programs and clinicians who use it without the requirement of therapy or involvement in more recovery-based treatment. Similar criticisms have been leveled at some methadone clinics as well. Patients in methadone and buprenorphine clinics may take the opportunity to sell their medications when they have little accountability holding them to high standards of rehabilitative and recovery directed treatment. This can be overcome by focusing on effective treatment and studies of outcome for different models of treatment. We feel that the use of integrative medicine programs for care of the whole patient is the best and most effective model for the use of these medications. It is clear that medication-assisted treatment of opioid addiction with either buprenorphine or methadone requires a commitment to recovery, and clinics that prescribe must demand a commitment.

Dosing of Buprenorphine There is also debate among professionals in the field about appropriate dosing of buprenorphine, namely, if 16 mg daily (two tablets or films) is sufficient for everyone or if some patients need 24 mg (three tablets or films). Beyond this, there is the question of whether some patients require even higher doses and whether it is better to manage some patients with very low doses if low doses are adequate for their treatment. The function of buprenorphine is threefold: preventing opioid withdrawal, removing urges and cravings to use opioids, and preventing getting high or overdose in the case of using opioids. In our experience, 16 mg is sufficient to keep patients from experiencing withdrawal symptoms. Approximately half of our patients do not have urges and cravings to use opioids on 16 mg of buprenorphine. However, the other half requires 24 mg to receive this benefit. Further, some can still feel some effect from illicit opioid use on 16 mg. This is important because preventing getting “high” is often what severs the tie of behavioral association between addictive behaviors and euphoric intoxication. Extinction of addictive behaviors is, of course, a primary goal of recovery psychotherapy, and this is part of what makes buprenorphine and psychotherapy so effective in combination. To support our clinical experience, SAMHSA and the FDA both acknowledge that 16 mg and 24 mg are both appropriate interventions for some patients [4, 5]. The largest argument against the 24 mg dose of buprenorphine stems from fears of diversion. While buprenorphine is diverted, it is usually avoided by addicted opioid users because of precipitated withdrawal. If buprenorphine

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is diverted and used recreationally, it is a far safer drug than any other opioid. Arguments for the use of buprenorphine at 24 mg a day is that some patients clearly benefit from the higher dose. Opioid addiction is a disease every bit as infectious and fatal as HIV. Buprenorphine is also a life-­sustaining medication. More than 50,000 people died of opioid overdose in the United States in 2016 [6], and that is more than who died in the entire 13 years of the Vietnam War and more than who died from AIDS at the peak of that crisis. With access to appropriate buprenorphine dosages, more people are likely to be effectively treated. Methods to monitor levels and appropriate use are discussed below. Finally, we have found that most people who are using buprenorphine bought on the street are using it to stave off withdrawal symptoms and not to get high.

Naloxone for Emergencies Gaining media attention has been the availability of a medication called naloxone (brand name Narcan) that is used when someone is having an overdose from opioids. An antidote to overdose from opioids (though not stimulants, benzodiazepines, barbiturates, or other drugs), naloxone blocks the effects of opioids at the opioid receptor by binding tightly to the receptor but not activating it. However, it is of note that if a person is overdosing from a combination of drugs or it is unclear what is causing the overdose, naloxone should still be administered and can be helpful [7]. When naloxone is administered, the patient will go into immediate withdrawal as the opioids are suddenly displaced from the receptors in their brain. A person is suddenly angry, irritable, and sick; they want to use more drug to make the withdrawal go away. In an emergency overdose, 911 should always be called, especially as naloxone is short acting and does not block other drugs that may be present and further medical interventions, including more naloxone, may be necessary. Some states have Good Samaritan laws that protect people who call 911 from law enforcement when someone is overdosing; many jurisdictions will not prosecute for drug crimes discovered when emergency personnel respond to an emergency. Recently, more retailers have been pledging to carry Naloxone in their stores. In some cases, a prescription is not needed, though insurance will cover the medication if a person cannot afford it. Because naloxone is poorly absorbed orally, it must be administered via injection or a nasal spray. Furthermore, it is both advisable and permissible to use a prescription on anyone who needs it, not just the person to whom it was prescribed. Patients should not only be taught how to use this medication, but they should teach their family, friends, and loved ones so that anyone may administer the emergency medication if needed. Naloxone is being used variably across the country. Our county (Delaware County in Pennsylvania) has already seen great impacts from implementing programs of naloxone administration by first responders. In 2014, there were 118 overdose deaths in Delaware County, an area west of Philadelphia, 56 of which were heroin specifically [8]. However, the District Attorney of Delaware

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County, Jack Whelan, shared in a speech in November of 2015 that the 1st year he had his police officers carry naloxone showed great success. From November of 2014 to November of 2015, police administered 141 doses of naloxone, only 2–3 of which were repeat people. In other words, they stopped about 140 people from potentially dying. This number does not even include naloxone administered by paramedics, the hospital, or individuals that may have reversed overdoses as well [9]. There is some resistance from people getting trained to use naloxone. In training sessions we have provided, questions such as “Why would we reward an addict for overdosing?” and “Doesn’t saving them just encourage them to use again?” come up over and over. We have a variety of responses that emphasize the core issue: “a dead person can’t recover.”

 ccountability Through Observed Urine Drug A Screens It is common in substance abuse treatment counseling to ask the patient about their use, urges, and cravings. Even skilled interviewers of addicts can be incorrect about present use. Although patients may come intoxicated, they may also time their visits and appear sober despite ongoing use. We inform patients that we will screen them for drug use through the duration of their treatment as part of our standard care. Patients (and professionals) are concerned about trust issues during recovery, and patients may expect to be rewarded for simple attendance and perfunctory participation in treatment. We inform patients that we do routine toxicology screens for two reasons. First, if they relapse, the behaviors associated with drug addiction will likely return, and they will have difficulty telling us the truth. By doing standard screens, we do not jeopardize the evolving trust between us. The second reason is that a record of successful sobriety documented in the medical record can come in very useful later if problems from their old life surface or if they have a brief lapse that places doubts about their sobriety up to that time. The sensitive and selective objective measurement of substances in the body helps align the patient’s appearances and behaviors as well as ground the psychotherapy in much needed bedrock. We warmly nudge patients with a smile and say, “Let’s get real.” Few clinicians or programs use observed urine drug screens. It violates social norms to watch someone urinate. Staff and patients are creative in finding reasons to elude this recommended supervision. However, even in clinics comprised totally of voluntary (i.e., non-court-mandated) patients, the authors have routinely discovered people attempting to fake urination, swap urine cups, or otherwise beat the tests. As many strategies for “fooling” drug screens may involve switching out urine for purchased or borrowed “clean” urine, adding something to urine, or watering down results so they are unreadable, observing the person in providing urine samples can be very helpful when working with patients who have habitually tried to avoid detection while using drugs. These behaviors and attitudes become habitual and are

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often not a considered action but rather an automatic stance against “authority.” Being in the bathroom with the person may not be enough as some patients will still attempt to tamper with their urine necessitating close monitoring. The clinician or therapist should not be the one to observe because of the dual roles it entails, but the presence of an observer can be an essential part of treatment for some patients. Awareness of deceptive behaviors is vital to continued opioid treatment success. We use this information to enrich the ongoing conversation about the patient’s ambivalence to recover. We do not use it as proof of the patient’s inherent deceptiveness toward others; instead, we see it as an example of arrested or impaired development. Addiction impairs a patient’s previously achieved stage of development. The rationalization of addictive thinking often sees drug use as a “right” or as a form of self-expression and independence. The recovery process is a rediscovering of the capacity for continued personal development and for the development of relationships that model those that promote health and success. Information that a patient tried to fake urination is an opportunity to discuss the nature of truth in service of deepening the patient’s commitment to recovery. Rather than use information of deceptive behaviors to terminate treatment, we use it as a point of helping a patient to see their addiction in a clearer light. We seldom discontinue integrative medicine treatment, offering therapy and medical services per the White et al. treatment philosophy [10]. We usually increase the intensity of treatment when the patient is struggling with lapses or deceptive behaviors. Eventually, we may discontinue buprenorphine treatment if the tool has repeatedly failed to help the person become clean from opioids and therefore might be diverted to fund an opioid addiction, but we actively try to keep the patient in psychotherapy and primary care for their chronic condition of opioid addiction regardless of their recovery status. We have seen success after discontinuing buprenorphine treatment with or without subsequent buprenorphine trials. Success in drug treatment is a product of change, and change is resisted by habit. Successful change occurs when clinicians persuade patients to heal by increasing self-awareness, building new habits that move them toward health, and are able to help patients past the deception that addictive drugs produce during the evolving process of becoming an addict.

 onitoring Buprenorphine Levels Using Urine M Drug Screens Quantitative information from toxicology screens is tempered by variability in metabolism due to many factors. We use statistical information to look at the overall picture and patterns, noting variances in an individual patient from their norm instead of a single piece of data to determine compliance. Trends in drug screens tell us what our patients are doing. The more data we have, the more accurate a picture we have of how our patients are doing. In looking at buprenorphine levels in observed urine drug screens, we are able to look at the buprenorphine and its breakdown product

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(norbuprenorphine). Typically, the ratio of buprenorphine to norbuprenorphine is about 1:2 or 1:3 with proper adherence to the medication. However, when we look at buprenorphine levels and ratios between buprenorphine and norbuprenorphine, we have to consider any number of factors that are impacting what shows up: creatinine levels, time of day, how long the test was administered after they took their buprenorphine, what level they are prescribed, and what else is going on in their bodies at any time. Also, the metabolic variables within an individual patient will impact drug screens. For some, the ratio and relative levels will stay fairly consistent from week to week. On others, it may appear that they have ups and downs and inconsistent levels, and it does not appear like they are taking their buprenorphine correctly at first glance. However, over time, we can see that the variable metabolism is the consistent pattern for a person, and we are able to judge their urine drug screen results accordingly. Without understanding these patterns, clinicians may jump to assuming that patients are tampering with or misusing their buprenorphine, which may be inaccurate. However, given the need to hold patients accountable, learning each patient’s patterns is vitally important for interpretation of their individual patterns and use. Below are examples of charted levels of buprenorphine/norbuprenorphine in patients on Suboxone™ in order to illustrate the variability in results and why clinicians need to look at results over time and in an individual nature. Note that each graph is not scaled the same, nor are all patients receiving the same dosages.

Stable, Consistent Metabolism The following chart is actually one of someone with fairly consistent metabolism. She is prescribed three tablets per day (Fig. 8.1a, b). As you compare to later examples, you will note that her absolute values of buprenorphine and norbuprenorphine may appear low in comparison. However, having watched her for 7 months and worked with her at least twice per week, the team is fairly confident that she is taking all three tablets. We have learned that this is just what her ratio and levels look like given her individual metabolism.

Stable, Variable Metabolism The next three charts belong to one person and are being used to illustrate the importance of data over time. The first chart shows his levels over 2.5 weeks, then 1 month, and then over 8 months to show the difference more time makes in seeing trends in a person’s metabolism and medication use. If we just looked at a few drug screens, we might think that his levels were decreasing or that he was not taking his medication the right way. However, looking at the pattern over a long time, it is clear that this pattern of appearing inconsistent is actually the norm for this patient. This patient has an inconsistent metabolism, but his inconsistent metabolism is his norm; this is his consistent pattern. This very fact is why it is so important to track data over time, looking at the trends and getting to know the norm for each person. 8  Adjunctive Pharmacotherapy for Opioid Addictions

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Looking at just one lab result, or even a few in a row, can be highly misleading (Fig. 8.2a–d).

Tapering Off of Buprenorphine The next graph shows someone who had been taking three strips of buprenorphine per day for 6 months (Fig. 8.3). There are one or two points in the graph that look like blips, suggesting that she might have taken her buprenorphine differently that week or that her body might have just been metabolizing differently because of illness or other metabolic factors. After 6 months, the team tapered her off of her buprenorphine over a month, slowly decreasing her dose each week so she would not experience physical withdrawal from stopping her buprenorphine. As can be seen in this chart, her levels started to decrease as expected as she was given less and less, indicating she was

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Figure 8-2.  Stable, variable metabolism. (a) Three strips/day 2 weeks; (b) three strips/day 1 month; (c) three strips/day 17 months; (d) ratio of buprenorphine to norbuprenorphine over 17 months 8  Adjunctive Pharmacotherapy for Opioid Addictions

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6 months @ 3 strips/day, then one month taper off 1800 1600 1400 1200 1000 800 600 400 200 0 Buprenorphine

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following her taper as prescribed. In some patients, we are unsurprised to discover that extra doses have been saved at home or are acquired to slow down the taper. We look for levels to decrease overall, expecting them to last in the system longer than we may have given them, but to ultimately disappear from results soon after the end of the taper.

Inconsistent Use and Relapses The following graph shows a patient who was not consistently taking his medications. At first, the team attributed the inconsistent use to the patient’s inconsistent work and sleep schedule (Fig. 8.4a, b). This patient would sometimes work third shift (10 pm to 6 am) and other times be awake during the day to come to his appointments and watch his children. However, about halfway through this graph, it was revealed that he was not taking his full dose most days, and the team decided to decrease from 24 mg per day to 16 mg per day to reflect what was actually working for him in terms of dosing and to discourage selling or otherwise diverting his extra buprenorphine. However, he soon began relapsing after he lost his job in order to cope with the stress of the situation. He was skipping some doses of his Suboxone™, so he would be able to get high on Percocet. These relapses are shown in the points where both buprenorphine and norbuprenorphine are low. When buprenorphine levels are higher than norbuprenorphine, it shows that they may have taken a dose recently, but they have not been taking it long enough for the breakdown product to have built up in their system. This can reveal missed doses and inconsistent use. More importantly, as some clinics just test for the presence of buprenorphine in their drug screens and not levels, it shows someone who might be trying to beat the test for some reason (often diversion).

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Figuring Out What Is Going On There have been times when UDSs have stumped our team, leaving us uncertain about if patterns were normal or if they were revealing dangerous patterns. At these points, we not only looked back at the long-term data, creating the charts above, but also looked at the numbers and the patterns over time. When we were still uncertain, we reached out to the company who does our labs for us and discovered that a toxicologist there was able to 8  Adjunctive Pharmacotherapy for Opioid Addictions

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interpret and explain trends in data for us. They were able to pull up results for the patients who bewildered us and verify what a “normal” result was and what might indicate improper use of the buprenorphine. It is important to recognize that urine drug screens are a tool, not a solution. Clinical judgment, conversations with patients, and other evidence help inform our interpretation of the results and what we can discern regarding patient behavior. We are sometimes tempted to dismiss inconsistencies because we are fond of a patient or believe that the patient is making progress, but an advantage of the team approach and the presence of the data is the opportunity to debate the most likely explanation of the data.

Revealing Labs to Patients A final note in how an integrative medicine team uses laboratory data is in how much we reveal to patients. As the goals of UDSs are to hold patients accountable and foster the development of skills like honesty, being forthcoming, and breaking old habits of trying to “trick” the tests, it is sometimes more useful not to reveal the labs. Insisting on improving honesty requires that the patient tells the clinician what might show up in their results. Providing them information about what does, or does not, show up on our tests allows them to learn the test parameters. This works against the goals of the patient in their recovery. The clinician, at most, may say “there are inconsistencies in your urine drug screen. What do you need to tell me?” Patients may deny, come up with excuses, lie, get angry, cry, and avoid admitting the truth as this is the behavioral programming of addition. The lack of knowledge about what their labs have revealed can be a powerful factor in allowing for a change. Sometimes patients will reveal things our tests haven’t caught because they assume we know what they have done. The ones who ultimately admit to what has happened are the ones who move forward in their recovery. The ones who time and time again refuse to acknowledge what substances they are using are not upholding their end of the agreement to engage in therapy and by being unwilling to admit relapse, even if the drug they used doesn’t seem “that bad” (like taking someone else’s medications), they are making the choice to not completely commit to their recovery and the rules of the program. Either the patients who refuse to comply with the program may have escalation of the frequency of their visits, or they may be tapered off buprenorphine until they are ready to increase their engagement. To do otherwise is just to collude with the addiction, which is not a good position for the integrative medicine team to take.

Treating Chronic Pain Any discussion of addiction, opioid addiction in particular, would be incomplete without a note on chronic pain. Acute severe pain, such as the case of a kidney stone, broken bone, surgical procedure, or physical trauma is usually best treated with a short course of opioids. This type of pain is a bodily

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response to acute tissue injury. Opioids block the subjective emotional response to pain and dull the sensory experience of pain. Chronic pain such as that seen with back pain, osteoarthritis, neuropathy, phantom limb pain, and complex regional pain syndrome are pain syndromes that have very little evidence for successful treatment with opioids. In this type of pain, the bodily tissue is not being injured, or the pain is disproportionately worse than the degree of tissue injury. In this type of pain, the nervous system is producing pain unrelated to dangerous injury, but that feels like dangerous injury. Although opioids may initially improve symptoms, over time pain actually is often amplified by the opioids and increases. The patient gets into a vicious cycle of taking increased doses, having temporary relief, and then having worsening pain. There is a type of acute pain that is chronic, such as in patients with burns, cancer, ulcers, chronic wounds, and other conditions. This last group are the hardest conditions to treat. Opioid treatment for chronic pain is a common pathway to addiction. Patients frequently report initiating opioid pain medication after surgery or some other acute injury. They may take more medicine than prescribed or for a longer duration than would be necessary for a similar injury, but they may also be encouraged to take opioids by clinicians committed to the idea that all pain is bad that has been prevalent for the last 20 years in medical practice. Many patients report escalating use of the medication due to increasing pain and ultimately finding new sources for the medicine, either through new or multiple doctors and later from friends and even from drug dealers. In recent years, as prescribed opioids have become hard to obtain and illicit prescription opioids have become expensive, many patients describe switching to use of heroin or other illicit opioids. Statistics show that 1 in 4 patients treated with opioids for chronic pain develop an opioid use disorder following some variation of this pathway [11]. We refer to the CDC’s Guidelines for Prescribing Opioids for Chronic Pain when considering the options for medications for pain [11]. When considering treatment of chronic pain, it is important to consider non-opioid treatment options and non-pharmacologic modalities. Treatment of chronic pain requires a thorough evaluation of the etiology and causes of the pain. This requires a team approach and often considerable patient advocacy. Patients with addictions and poor socioeconomic status may be dismissed as “drug-seeking,” and the team may find resistance to getting careful evaluation and testing done by outside experts. Careful evaluations for causes of neuropathic pain, central pain sensitization, complex regional pain, compression radiculopathy, autoimmune pain, and chronic GI pain require a great deal of experience to delineate and treat. Low back pain is an example that has many potential causes that may require different treatment interventions. The evaluation of pain necessitates collecting a comprehensive history of the pain, conducting a thorough physical examination, requesting and reviewing old records from previous medical providers including radiologic studies, and consideration for obtaining new imaging studies or other tests. The psychological evaluation of the patient is an important part of this work-up as well. Understanding the underlying personality structure and psychological history of the patient with the pain is just as important as the physical causes of the pain. After a thorough evaluation of the patient 8  Adjunctive Pharmacotherapy for Opioid Addictions

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is conducted, the team, together with the patient, can plan a comprehensive intervention to treat the pain. A 2012 National Health Interview Survey [12] shows that about 25.3 million US adults (11.2%) had pain every day for the previous 3 months. Nearly 40 million adults (17.6%) have experienced severe pain. Individuals with severe pain have worse health, use more healthcare, and have more disability than those with less severe pain. Chronic pain may result from underlying diseases or health conditions, injury, medication treatment, surgery, inflammation, and problems in the nervous system (“neuropathic pain”) and may even have an unknown cause. Regardless of cause, however, pain has a huge impact on quality of life and productivity, can impede movement and sleep, and increases anxiety and depression and a host of other issues. Because opioids block the ability to detect pain, the pain sensory apparatus adjusts to increase pain sensitivity, which requires higher levels of opioids to block, and so forth. This opioid-induced hyperalgesia upregulates the pain system, and normal pain sensations are magnified. Physical dependence to opioids increases, and the pain is never truly treated. Addiction is a likely outcome in addition to ongoing pain. Furthermore, patients have come to believe that they “need” opioids to manage their pain. They have often been told this by well-intentioned “pain” specialists who were encouraged for the last three decades to be more liberal with opioids: that pain is a “vital sign” and that pain needs constant evaluation on a pain score which is the immediate focus of attention at a visit. The Joint Commission demanded that hospitals assess and manage pain in all settings, and hospital administrators were quick to “educate” clinicians on evaluating pain. The advent of “patient satisfaction ratings” as a tool for evaluating quality of care (something with no evidence to support it) and Medicare adopting a policy of using patient satisfaction ratings in determining reimbursement only further fueled this problem and encouraged administrators to further pressure doctors to provide opioids to patients. More recent recommendations have moved away from long-term prescription of opioids (with the exception of cancer patients, burns, non-healing wounds, and traumatic injuries) and to other medications and interventions for chronic pain. Initiating care for chronic pain may initially increase pain. Physical therapy and working on the body are uncomfortable. This can be a trigger for opioid use or craving due to past experiences and conditioning, even as the body may be healing. When people try to lower their opioid consumption and initially feel more pain, it’s hard to maintain the resolve and motivation to avoid use. However, to avoid this discomfort is often to feed an addiction and sustain chronic pain. Integrated teams need to work with patients to shift the focus from the goal of comfort and elimination of all pain to functionality in life, including learning to tolerate some amount of pain. The goal is to manage pain and improve functioning, all while decreasing risks of overdose and addiction. There are a number of alternative options for treating chronic pain. These options address the issue medically and psychologically. First, exploring non-­ opioid medication treatments, including aggressive treatment of depression symptoms, is important. Use of antidepressant medications that also help with

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chronic pain is helpful. The SNRI antidepressants (venlafaxine, duloxetine, desvenlafaxine, milnacipran, and levomilnacipran), tricyclic antidepressants (such as nortriptyline along with others), and some other antidepressants are very useful in some types of chronic pain. Additionally, anticonvulsants (e.g., gabapentin, pregabalin, lamotrigine, valproic acid), calcium channel blockers (such as verapamil), and numerous other medications are helpful for certain chronic pain syndromes. Nonsteroidal anti-­inflammatories (e.g., naproxen or ibuprofen) can also be helpful. As with other medications, staying aware of abuse potential is important as recent reports have seen an increase in abuse of gabapentin. Consideration of non-medication interventions is important as well. Chronic pain is often tied to more global issues, such as weight, health concerns, and daily activity, so considering what activities the patient may pursue is also essential. Most chronic pain is made worse by inactivity. It’s important to find activity that works with pain. Graded activation is important, as overuse can worsen pain and injure deconditioned body systems. Because our patients often “overdo it” on good days and are inert on bad days, specific activity prescriptions are often necessary. Low back pain, for example, may be made worse by gardening but improve with walking or water aerobics. For every 24 h spent in bed, a person loses 7% of their muscle mass which causes more pain. Sedentary lifestyles make pain worse. Additionally, a day without any activity or distraction only increases focus on pain, making it worse as well. Physical therapy, orthopedic doctors, acupuncture, yoga/pilates, massage, and topical treatments or ice and heat are all options to be explored with the patient. The point is that it is vital to work with the patient to explore alternatives and help build motivation to try new, different, and difficult things. Getting started on these strategies is often the hardest piece, but once behavioral activation begins, and the patient begins to see some improvements, it is easier to sustain.

Other Pharmacotherapies In patients with opioid-medicated hyperalgesia, even buprenorphine may amplify pain. Naltrexone can be used to prevent opioid use as it prevents any reinforcing effects of opioids. Additionally, there is an extended-form naltrexone injection, brand name Vivitrol, that is given once per month. Naltrexone extended-release injection is sometimes used upon discharge from inpatient settings and with patients who need the longer-term effects and has the benefit that no daily maintenance or medication is needed. Prior to naltrexone injection, the patient must have detoxified so that all opioids are out of a person’s system, making its utility more difficult for those who are actively using because of the long period of time, typically at least 10 days, needed from the last use to prevent an adverse reaction upon receiving the injection. In practice, we will initially administer short-acting naloxone to patients without signs of withdrawal or recent use and, if they tolerate it well, then administer naltrexone an hour later. The idea is that the potential withdrawal from naloxone will last only a short time in comparison to that from long-acting naltrexone. 8  Adjunctive Pharmacotherapy for Opioid Addictions

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We have extensively discussed opioids in this chapter because they are the biggest problem we face geographically and our experience with opioid addiction treatment has been extensive. We have not discussed the use of medications to support gradual withdrawal from opioids (such as hydroxyzine, dicyclomine, methocarbamol, clonidine, and numerous others) which can often play a role in managing opioid addiction. We also face alcoholism, benzodiazepine addiction, stimulant addiction, nicotine addiction, and other drug use. The treatment of addictions in general involves the same steps of engaging patients and persuading them that they have a disorder (sometimes referred to as conversion), detoxifying patients, rehabilitating patients, and preventing relapse. It is also critical to treat psychiatric comorbidities. There are other adjunctive pharmacotherapies used for addiction, such as aversive conditioning for alcohol using disulfiram and decreasing drive for substances using varenicline, naltrexone, and bupropion. While the use of these medications goes beyond our scope, our experience is that these treatments are also adjunctive and that addiction treatment is mostly about the integration of care, a focus on the whole patient, and a psychological approach to comprehensive addiction treatment.

References 1. Sontag D. The double-edged drug: addiction treatment with a dark side. November 16, 2013; The New York Times. Retrieved 1/31/2019 from https://www.nytimes. com/2013/11/17/health/in-demand-in-clinics-and-on-the-street-bupe-can-be-savior-ormenace.html. 2. Center for Substance Abuse Treatment. Clinical guidelines for the use of buprenorphine in the treatment of opioid addiction, DHHS publication no. SMS 07-3939. Rockville: Substance Abuse and Mental Health Services Administration; 2010. 3. Mendelson J, Flower K, Pletcher MJ, Galloway GP. Addiction to prescription opioids: characteristics of the emerging epidemic and treatment with buprenorphine. Exp Clin Psychopharmacol. 2008;16(5):435–41. 4. Substance Abuse and Mental Health Services Administration (SAMHSA). Medications for opioid use disorder, Treatment Improvement Protocol (TIP) Series 63, Full Document. HHS Publication No. (SMA) 18- 5063FULLDOC. Rockville: Substance Abuse and Mental Health Services Administration; 2018. 5. U.S. Food & Drug Administration. Approved Risk Evaluation and Mitigation Strategies (REMS): Buprenorphine-containing Transmucosal products for Opioid Dependence (BTOD) REMS Programs. 2018. Accessed November 2018 from https://www.accessdata. fda.gov/scripts/cder/rems/index.cfm?event=RemsDetails.page&REMS=9. 6. National Institute on Drug Abuse. Overdose death rates. 2018. Access November 2018 from https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. 7. Substance Abuse and Mental Health Services Administration. SAMHSA opioid overdose prevention toolkit: safety advise for patients, HHS publication no. SMA 13-4742. Rockville: Substance Abuse and Mental Health Services Administration; 2013. 8. Quinn R. Heroin deaths in Delco at record high; fed study ranks county fourth in state for fatal overdoses. Delaware County Daily Times. 2015. Retrieved from http://www.delcotimes.com/article/DC/20151118/NEWS/151119573.

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9. Whelan, J. Update on county response to opioid overdoses. 2015. Speech presented in PA, Sharon Hill. 10. White WL, Scott CK, Dennis ML, Boyle MG. It’s time to stop kicking people out of addiction treatment. Counselor. 2005;6(2):12–25. Retrieved from http://dbhids.org/wp-content/ uploads/2015/07/2004-Possible-Resource-Papers-StopKickingPeopleOutofAddictionTreatment.pdf. 11. Morbidity and Mortality Weekly Report (MMWR). 2016, March 18. Accessed November 2018 from https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm?CDC_AA_refVal= https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1er.htm. 12. Blackwell DL, Lucas JW, Clarke TC. Summary health statistics for U.S. adults: National Health Interview Survey, 2012. National Center for Health Statistics. Vital Health Stat 10. 2014;260:1–161. https://www.cdc.gov/nchs/data/series/sr_10/sr10_260.pdf.

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9

Contemplating Integrative Medicine Skills with a Case Example Julia Hodgson, Kevin Moore, Trisha Acri, and Glenn Jordan Treisman

Sara1 first came to our clinic over 10 years ago at 37 years old. Diagnosed with HIV, hepatitis B, and hepatitis C during one of her incarcerations and feeling overwhelmed after 20 years of major depression, she was suicidal, terrified, and hopeless about her life. She spent over two decades as a sex worker, getting arrested and locked up countless times. A history of multiple traumas, unstable family and relationships, and bouts of homelessness permeated her history. Recently having found a religious community, she came in for medical services at the urging of a friend from her new church. The medical intake staff was baffled by the complexity of her story and referred her to the psychologist, one of our authors, to oversee her care, and he continues to work with her over a decade after their first encounter. The complexity and longevity of these patients can be difficult to comprehend for those are not doing this type of work. Our patients feel unique in how chaotic and absurd their lives can be at times. Weekly, someone asks, “do any of your other patients have this many problems?” The answer is always yes. In fact, the simple case in our clinic is the exception and, usually, just a sign that someone is hiding significant pieces of their life and their history. Sara, a long-term and ongoing patient, has allowed us to use her story to show the impact that chronic and complex conditions and life stories can have on a person and within treatment. We will explore the integrative processes at play with our patients that are so integral to successful treatment in the most difficult circumstances. Case conceptualization occurs through consideration of life story, personality, behavior patterns, and disease models. Then treatment of each element of the diagnosis addresses her 1

 Sara gave permission for her story to be used in this text; identifying information changed.

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complex and chronic mental, behavioral, and medical health concerns. Finally, throughout, the gold standard of coordination of care is illustrated. To be clear, our intention here is not to show you how we solved a complicated case, especially as coming up with a final answer is nearly impossible with these patients. In fact, we are happy if you have more inquiries than answers as you read this. This is the reality of the work. Most frustrating and most exciting in integrative medicine is that there is no right answer; the work is an ongoing and collaborative conversation among colleagues. The process of integrative medicine—of psychology and medicine—is not a problem with an easy solution. Furthermore, there is no end to treating these patients. Addiction is a lifelong disease, and chronic conditions, especially incurable ones like HIV, need to be ongoingly monitored. As long as Sara is alive, which we hope will be for a normal healthy lifespan, her story and her involvement in treatment will continue.

Sara’s Background Sara’s parents were married, her father worked in landscaping and her mother intermittently as a waitress; when depressed, her mother would stop working, but would return when she felt better. Nearby, she had a number of aunts, uncles, and cousins who regularly spent time together. She lived with both parents in the suburbs of a major city until her family found out that her father had been molesting Sara and exiled him from the family. A few years later, her maternal uncle repeatedly molested her as well, but her family dismissed these actions as untrue, and they were allowed to continue into Sara’s teen years. To cope with her growing depression, she started using marijuana and alcohol at 13 years old. When Sara was 15, she dropped out of school and ran away from home. She relished the newfound freedom, independence, and sense of control she had over her body and her own safety. She started doing sex work to support herself, using cocaine and heroin as well. She got pregnant once, unintentionally, and on discovering that the pregnancy was too far along to terminate, she gave her child up for adoption. During her pregnancy, she used cocaine and heroin but cut back on the amounts she used. She was arrested by the police repeatedly and served numerous short sentences because of her sex work; by the time she came in for care, she had over 100 incarcerations. She was also involved in small time cons and stealing but managed to evade arrest for any of these behaviors. Despite all of this, Sara was well-liked and friendly and kept a group of friends although at a distance. She had no close connections in any of her relationships. She felt in-­ control in her life and had few complaints. In her late 20s, however, everything changed for Sara. She had prided herself in her ability to pick good clients while doing sex work. She felt she was able to tell who was safe when choosing clients. One night, a man held her up at gunpoint, raped her, and then shot her in the stomach and left her for dead in an alley. Fortunately, someone found her, and she was brought to the hospital where she was revived and saved with minimal lasting effects

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from the wound. The police ultimately caught the perpetrator after finding other victims’ bodies in his car and arrested him. Despite his being incarcerated, the life of control she had built started to crumble. She no longer trusted her intuition to pick safe clients, and her drug use escalated from recreational highs to attempts to completely numb herself. She began feeling suicidal and occupied her time planning how she might end her life. She continued to live this way for another decade, going through the same motions of sex work and suicidal planning before she reached out for any help.

Reaching Out for Help Exhausted by the life she was living and lacking any sense of joy, Sara discovered a church community in her late 30s where she received the support she had never really had. One member of the church discovered her medical issues and helped her to find our clinic, driving her to her first appointment where she met us. She knew she had been diagnosed with hepatitis C and HIV but had never had care for either diagnosis. A more thorough medical examination and blood work revealed hepatitis B, gonorrhea, and syphilis, as well as COPD to accompany her heavy cigarette smoking. Her distress was permeating her life. At admission to the clinic, Sara was not only suicidal, but had a plan and means to carry out her plan to kill herself. Her mood was low, her outlook hopeless, and her ability to organize her thoughts limited. Sara was jumpy and constantly on alert. She felt scared in her own apartment, yet she struggled to leave home. Sara had frequent panic attacks during which her hands would sweat and she would feel as though she couldn’t breathe and was having a heart attack. She had dreams and intrusive recollections of both her attack and instances of sexual abuse from her childhood that would be so intense that it would seem like she was almost re-experiencing these events. The little she did sleep was haunted with nightmares. To cope she depended on heroin, both emotionally and because she would go into withdrawal if she didn’t use every few hours. When she was initially evaluated, her addiction was dictating more of her life than she wanted to admit.

Integrated Diagnosis Integrated diagnosis goes beyond a checklist methodology. While diagnostic guides can reveal pieces of a person, the team considered Sara’s personality, behavioral influences, and life story in addition to thinking about her diseases. Additionally, the formulation of her case incorporates medical considerations. By developing a clear picture of Sara, treatment is able to be individualized and prioritized in the best way for Sara’s overall health. To start, we will walk through the thought process that went into determining diagnosis and at times, kept us from feeling like diagnoses that may have technically have been met were inappropriate. The conversations around medical 9  Contemplating Integrative Medicine Skills with a Case Example

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Table 9.1  Using the diagnostic concepts from the DSM-5, this chart illustrates the diagnostic criteria that Sara met, thus influencing her diagnostic formulation [1] Major depressive disorder

Post-traumatic stress disorder Opioid use disorder

Depressed mood

Exposure to life-threatening event

Intrusive recollection/ Decreased re-experiencing of the event interest/pleasure in activities

Drugs taken more or over longer period of time than intended Tolerance (need more drug to get same effects)

Weight loss (decrease in appetite)

Avoidance of thoughts/feelings connected to memory/event

Withdrawal

Insomnia

Negative alterations in mood/ cognition (distorted sense of blame, stuff in severe emotions, negative thoughts/beliefs about self and world)

Cravings to use

Loss of energy/ fatigue

Increased arousal (hypervigilance, Failed attempts to easily startled) stop/cut down

Feelings of worthlessness

Large amounts of time/effort spent to obtain, use, and recover

Suicidal thoughts and plan

Ongoing use despite:  Physical hazards  Known physical or psychological conditions caused/ exacerbated

and psychological diagnosis took time to develop and were the springboard for both mental health and physical health concerns. Sara’s symptoms are presented in the context of the DSM-5 criteria in the table below, but this is only the beginning of the conversations about her conceptualization (Table 9.1).

Depression Sara’s symptoms seem to map onto major depressive disorder very easily. She has low mood, is not experiencing pleasure in her life, can’t think, can’t sleep, can’t eat, has poor memory, and is having extreme

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experiences of ruminating on whether or not she should exist or if there is a point to her life. However, given her comorbidities, there are more factors that must be considered in assigning this label. For example, she has been using cocaine for over 20 years. Cocaine harms the reward pathway in the brain, so is her depression the result of cocaine or a more organic cause? To that point, does the cause even matter if her depression has persisted once the effects of cocaine are out of her system? Similarly, cocaine and amphetamines can cause a psychotic or paranoid state; could this explain her fear at home and hyperarousal? Regarding the latter question, we looked at the onset of the paranoia. For Sara, it is a newer symptom that did not start at the time of cocaine use and was not temporally related to use. Cocaine-induced psychosis/paranoia may last for months or years, but the onset occurs during the drug use and not after the fact. Sara had stopped cocaine years prior to her paranoia. Similarly, Sara’s depression originated in her early teen years before her use of cocaine. While cocaine and other drug use, and their withdrawal effects, undoubtedly exacerbate her depressive symptoms at times, her depression predates these potential causes. In considering the impact that her HIV, hepatitis C, or other diagnoses might be having on depression and other mental health symptoms, the DSM provides some clarity. The DSM-5 specifies that depression that does not appear to be a direct physiological impact of a medical or substance-­ related effect is better described as major depressive disorder [1]. The DSM also specifically notes that consideration of this diagnosis in the presence of a major medical condition must be done with caution as symptoms will sometimes overlap, such as fatigue associated with cancer or weight loss associated with untreated diabetes [1]. For Sara, her symptoms were occurring outside of her medical diagnoses, some before the onset of any medical issue at all. Additional evidence for her depression diagnosis is a consideration of her life story. Family history is a risk factor for depression, as are adverse childhood events, both of which are true for Sara with her mother’s history of depression and her repeated childhood abuse. A development of a substance use disorder is not uncommon for those with depression, similar to Sara’s experience. Furthermore, chronic medical conditions, particularly those involving inflammation in the central nervous system (HIV and hepatitis C), may exacerbate the likelihood of depressive episodes, causing the depressive symptoms to become chronic instead of episodic [1].

Traumatic Reactions Sara’s mental state at the beginning of treatment is best characterized as one of constant terrors. There were constant internal contradictions about her reality, safety, and what was actually going on. Even when Sara was able to tease apart what was real, the fear did not alleviate at all. First of all, Sara’s fear of leaving the house and panic attacks ring of agoraphobia or even psychosis. Given her presentation, these classifications miss the truth of her experience. Sara developed an agoraphobia secondary to

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her trauma and depression. She reacted with panic attacks to exaggerated fearful situations. These fears manifested from her life-threatening experience of being attacked. Additionally distressing was Sara’s sense of internal contradictions. She was having intense feelings that made no sense to her. Sara felt like there was someone who was literally and physically outside of her window trying to stab her in the back and kill her. The preoccupation was always there for her. She had varying levels of insight about whether the experience was based in reality, but the person’s threatening presence was constant. At the same time, Sara was having nightmares about the actual attacker who had almost killed her. She was able to acknowledge that the real attacker was in jail for life and that she would be alerted if he were to go up for parole. She knew that the attacker after her wasn’t the real attacker from her past but it was unclear who this new attacker might be. In teasing out whether this was a delusion (indicative if a psychotic state), it was unclear what to make of the difference between her fear of being attacked and her lack of clarity around who the attacker might be. Delusions are fixed, false, and idiosyncratic beliefs and are part of the trilogy of psychotic symptoms (hallucinations, delusions, and thought disorder). They are fixed (absolutely real to the patient), false (contradicted by better explanations and superior information), and idiosyncratic (unique to the patient and not shared with a cultural or religious group). Despite her feeling of terror, Sara was sometimes able to cognitively overcome her fear and acknowledge that no one was there, supporting the view that she was not psychotic but was simply very preoccupied and overwhelmed, but the experience still felt real at all times. When she pushed herself to overcome her fear and leave her house, she had panic attacks because she was so frightened. If she then managed to get in her car and travel elsewhere, she had another fearful feeling that her normal route would take her through a graveyard that had the bodies of victims from the killer that was after her; she could see the graveyard in her mind’s eye and would go out of her way to avoid it. In the wake of her trauma, Sara became intensely hypervigilant in her life and developed a viewpoint that the world was an unsafe and terrifying place. To cope, she did not leave her house. This agoraphobia did not develop independent of her trauma, nor did it persist once the trauma was addressed in intensive psychotherapy. Sara’s experience of the world is one of anxiety, fear, irritability, hypervigilance, and constantly feeling on alert. Her world is full of shadows and malice. She was avoiding leaving her house, relationships, certain roads in her neighborhood, and even being asleep. PTSD is a diagnosis that could explain most of her symptoms. The symptoms map onto the DSM-5’s diagnostic characterization of this disorder. This diagnosis also helps to guide the therapist in developing an effective psychological intervention. However, this is diagnostically very complex. The debate of whether she was having delusions and some of her symptoms were psychotic manifestations of depression or an extreme PTSD is unclear. That most of these symptoms disappeared once her trauma was dealt with in therapy supports the attribution of these symptoms to PTSD.

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The purpose of diagnosis is to describe and conceptualize what you are dealing with as a clinician. It can inform treatment and help the clinician to plan how to work with the patient. The development of a good differential diagnosis that includes the possibilities allows ongoing collection of data to refine the most likely formulation for the patient. The clinician takes the time to think about the patient and moves forward in treatment. An additional consideration with PTSD is that it is a psychological diagnosis that ends up being behaviorally maintained. Through avoidance of negative situations, like places or people that induce fear, Sara is reinforced to stay home because her fear is alleviated, a classic negative reinforcement that increases her experience of agoraphobia secondary to her trauma. The more things in her life feel intolerable in the aftermath of her trauma, the more she avoids, and the more these events act as reinforcing or punishing agents in shaping her day-to day behavior. Classification of PTSD as a behaviorally maintained disorder as well as a disease has important implications in treatment (discussed below).

Substance Use Disorder Looking at Sara’s heroin and cocaine use, the disorders are fairly straightforward. However, as is discussed in chapters on addiction and on trauma, treatment as a whole becomes more complicated in the presence of addiction. The powerful grip addiction holds on patients can interfere significantly with treatment efforts. It exacerbates her other conditions (depression and PTSD) particularly while intoxicated or in withdrawal and can create the illusion of diagnoses like mania or psychosis. Like Sara, people who inject heroin often have higher rates of diseases like hepatitis C and HIV. Smoking (nicotine addiction) certainly exacerbates conditions related to her respiration, like her COPD which in turn contributes to her anxiety. Additionally, COPD can increase her risk for respiratory depression from heroin and death from overdose. Additionally, substance use disorders are very behaviorally maintained as well. Sara described her heroin use as becoming problematic after she was attacked. She started getting high regularly to try to avoid her negative feelings and escape the distress she was experiencing. Temporarily, this was very effective for Sara. Beyond physical dependence, Sara was continuously reinforced for using heroin as it helped numb the pain she was feeling; when she was high, she did not care about how terrible she felt her life was anymore. Withdrawal was punishing because of both the physical symptoms and the reassertion of her dismal reality.

Medical Concerns Sara presented with a number of medical diagnoses, some chronic and some curable but all of them treatable. Her sexually transmitted conditions were easily treated and her HIV and hepatitis C options were explained and

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she was reassured that these conditions were not a meaningful threat to her and were matters of routine treatment. The case manager in the clinic was able to track down some treatment records from an old doctor who Sara had briefly seen shortly after finding out that she was HIV-positive. These records provided the physician with initial information about the diagnosis as well as a few months of records detailing how Sara had responded to an HIV medication regimen, thus adding more personalized information to the physician’s decision-making about which medications to prescribe. The physician was able to avoid a regimen that she had not responded well to in the past, thus speeding up the process of controlling her HIV and getting her to healthy levels of immune system functioning and a suppressed viral load. These medical reassurances helped her to feel like the clinic was addressing her as a whole person and that there was a hope for something better than her previous condition.

Considerations of Personality Although Sara does not meet the DSM-5 criteria for a personality disorder, this does not mean that her personality is not an important part of her formulation. Her personality style has played an important role in her illness, both directly and indirectly. Sara is very present-focused, spending minimal time worrying about the future or potential consequences. Consider her arrest record. Despite a history of repeated arrests, she did not spend time ruminating about that part of her past or avoiding aversive consequences in the future. She did not like being in jail, but did not think about the possibility of going there when she was making her choices. Similarly, she contracted multiple sexually transmitted infections but continued to engage in riskier sex practices and sex work. Instead of being consequent-averse, Sara is motivated by rewards. Consider the continuous reward of cocaine use; bursts of energy and a euphoric high are much more motivating for Sara’s personality than the threat of intermittent punishment of jail. Sara is motivated by feelings, by rewards, and by operating moment to moment. Her extraversion is undeniable. How Sara reacts to emotional stimuli in her life plays a vital role in understanding her personality functioning as well as the above. She has faced an incredible amount of adversity in her life, yet her emotional reaction seems disproportionate to her experience. Outside of recent events, Sara has shown a consistency in her core personality throughout her life. Overall, she is somewhat limited in her emotional excursion across the board, especially given how others might react to even one of the things Sara has been through. She is very consistent in her reactions and is not affectively unstable or prone to large reactions from everyday events. Similar to many sex workers, Sara can be classified as a stable extravert. Arrests and negative events are not enough to prevent Sara’s behavior. She seeks emotional stimulation in intense circumstances that not everyone would be able to tolerate. Furthermore, she will tolerate a lot of distress in order to feel some of that emotion. Sara’s relatively recent experience of PTSD is the result of an accumulation of distressing events. This sort of reaction is actually outside of Sara’s stable

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nature. So, she might not be experiencing a lot of emotion from the PTSD or the events, but it is all the more distressing for her because of this incongruence with her core self. A stable extravert is a fair description, but it may be more accurate to describe Sara as pathologically stable and pathologically extraverted. We have included the term “pathological” in her descriptions of being extraverted and stable because her personality is extreme to the point that generates some of her circumstances and illness. In considering how her personality has come to be disordered, it is important to consider how it makes her vulnerable, where it may have come from, and the setting within which she is operating now. Historically, Sara developed her personality in a setting of constant abuse. She was programmed early on to be reinforced in relationships that are characterized by pathological attention; for her, negative attention is rewarding. To get that same attention as an adult, she seeks out dangerous relationships, works in a risky occupation, and relies on drugs like cocaine and heroin. Her pathological stability and extraversion made it difficult for her to have long-term relationships anyway, but being sexually abused by trusted people in her life, people she would want healthy love from, had made it all but impossible for Sara to engage in healthy or meaningful relationships. Sara operates without a net, taking risks without concern of her own safety or what might happen to her. She is vulnerable because of her impoverished support system, her career, her disregard for her physical or psychological safety, and her inability to think about potential consequences or dangers in her decision-making. Sara’s personality made her vulnerable, and her history and current setting put her in extreme danger of relapse.

Behavioral Reinforcements Impacting Sara We have touched upon the impacts reinforcement has had on Sara’s life, but it is important to consider how behavioral principles have specifically shaped her sex work, occupation, relationships, and a recent religious conversion in order to understand what is driving Sara to repeatedly engage in destructive patterns and why she sought out treatment.

Drugs Sara was able to acknowledge the coping mechanism that drugs started to play for her after she was attacked in her 20s. However, she used substances of various sorts for over 15 years before she identified it becoming a problem, so what kept that behavior going? As was described in Chap. 5, behavioral processes are often at play in addiction. At its simplest level, drugs like cocaine feel good; they activate pleasure centers in the brain, which are appealing and reinforcing for the person. In fact, cocaine is more reinforcing than anything the person can produce naturally. If joy from a piece of chocolate or kissing a loved one lights up the pleasure center in the brain at the magnitude of a lightbulb, cocaine lights it up in the magnitude of the sun. 9  Contemplating Integrative Medicine Skills with a Case Example

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Behavioral reinforcement comes into play. When people are rewarded with something positive, they will increase the likelihood and rate of the behavior associated with that pleasure. Furthermore, with the negative feelings of withdrawal added in, an aversive stimulus is present that is reinforcing to avoid, again by taking more cocaine.

Sex Work Despite its risks, there is something rewarding about sex work for Sara. One possibility might be that the cocaine became a reward for the sex work; cocaine had already been conditioned to be reinforcing for her, so its link to sex work was an easy reinforcer. However, she engaged in sex work for years before using the highly reinforcing cocaine. Another possibility is that she was rewarded by the physical and appetitive drive of sex. Yet Sara says that she actually felt very indifferent about sex; sex did not give her pleasure or displeasure, she just did not care much about it. Physical pleasure seems an unlikely explanation for sex work in general. One consideration is the sense of power that Sara gained in her sex work. As a childhood victim and survivor of sexual abuse, Sara was very powerless over her life. Perhaps power and control is what is so appealing and rewarding about sex work for Sara. Indeed, according to Sara, sex work was so rewarding because it allowed her freedom in her life and a sense of control she did not get as a child. Furthermore, she held her ability to talk to anyone and blend in across situations in high regard; having diverse experiences through sex work allowed her to act upon this strength and show herself, and others, her abilities. Sara experienced a boost in her self-confidence and self-­ efficacy when she was functioning so effectively in a difficult role as a sex worker. Sara’s insight, as well as our own perceptions of the connection between her life story and her work, is an important part of her understanding of her choices as a sex worker. However, this is not the entire story that we need in order to conceptualize Sara’s behaviors. Often, sex workers will have a preference for regular customers because they are known and thus safer. Having patterns and routines is protective in a potentially dangerous line of work; your support system will know when you’re missing, you are able to have repeated contact with people you know are safer or lower risk, and it requires less solicitation or exposure to unknowns that could lead to arrest or physical danger. For Sara, however, this was not the pattern of behavior. Sara did not allow regulars to develop, nor did she work in the same areas or with the same people for any long period of time. Sara consistently found new people, which might be riskier, but it is also more exciting. Remember her personality style; Sara needs higher levels of emotional stimulation to have an internal reaction. She is reinforced in highly stimulating situations and has little regard for potential negative consequences. Essentially, Sara needs the danger for emotional activation. She is driven by her feelings and reinforced by the larger emotional experiences, so a riskier sex work practice is more reinforcing for Sara. Most importantly in understanding the behavioral aspects of Sara’s sex work is the respective power of reward and punishment. Sara is only reinforced by

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the positives associated with her sex work, such as money, attention, feeling functional, and regaining power and control over her life that she lost in her childhood abuse. Her behavior is not extinguished by punishments, like incarceration or sexually transmitted infections. There is no reason for her to stop sex work. Consequently, she has never had any job other than sex work in her life.

Religiosity and Seeking Treatment Sara’s newfound religiosity in her 30s brought her to treatment but seemed somewhat incongruous with the choices she had made in her life up to that point. What led to this change in her life? By Sara’s report, her religious experience helped her to stop feeling bad about herself. She was repressing feelings and doing things that made her unhappy. However, once she experienced conversion, she did not have the problem of feeling bad about herself anymore. Sara’s belief that Jesus forgave her was what she needed. This released her of having to repress a variety of negative and self-critical feelings. There was more to this experience than Sara’s explanation for why her conversion happened when it did. At the time of her conversion, the reinforcing effects of drugs had given out. They were not pleasurable in the same sense as they had been, and it was not conditioning her behavior in the same way anymore. When the cocaine loses its power for pleasure, the PTSD became more activating and distressing. The depression was occurring off and on, causing distressing and perhaps psychotic symptoms that were so terrifying for her in her day-to-day experiences. Because cocaine was not giving her the positive effects it had been, it opened her up to the possibility of pro-social substitutions. Sara lost the pleasure and excitement of her life. Nothing she had been doing was working for her anymore. She could tell that things were wrong in her life and she wanted a change. A religious conversion is an opportunity for her to have an emotionally rich and intense opportunity. She was able to get a surge of experience that was different from the mundane numbness of her previous life. She was able to learn how to get the internal chemical reward and affective experience out of her religious experience that she used to get out of cocaine. Of course, she can still habituate to this experience. But she can also increase her religious enthusiasm and experiences as well, going to retreats, taking leadership roles, and feeling a reverberation if she induces religious conversion in others. Sara was getting from her religious experience what she used to get from cocaine.

Integrated Treatment Sara came to treatment with very severe medical and psychological diagnoses. This section will briefly address her HIV but then separates her work into four main phases based on her therapeutic progress. First, the first few years were very concrete and targeted work to address her suicidality and

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psychotic experiences. Second, work was able to shift into deeper processes around her depression and dealing with her worsening hepatitis. Trauma work is intensely dealt with in the third phase, until she was ready for long-­ term maintenance in the ongoing fourth phase.

Medical Treatment for HIV At the beginning of treatment, Sara had been referred from an HIV provider because she was suicidal. She had been diagnosed with HIV while incarcerated as part of a prison inreach program when service providers came in for testing. At that time, she was also diagnosed with addiction but did not care about either diagnosis. It was only at the point of her religious conversion and recovery journey that she sought out HIV medical care. For a year or two before coming to the clinic, she was on an antiretroviral medication treatment regimen that she was adherent to and controlled her HIV successfully. Once she came to the clinic, medical interventions for HIV only continued this treatment while periodically monitoring viral load and CD4 levels (a measure of her immune system functioning). Additionally, screening for STDs allowed for detection and treatment of a number of acute infections.

 hase One: Suicidality and Acute Symptom P Management Most pressing at the beginning was to deal with her suicidal urges and the fact that she was so afraid to leave her house that it was hard for her to come into the clinic for sessions. The team’s psychiatrist recommended using a combination of an antidepressant and antipsychotic to begin to dampen the impact of some of her symptoms so that she could even begin to engage in therapy. Interaction effects of her psychiatric and HIV medications were monitored via ongoing communication during team meetings as well as educating the psychologist about the expected effects of each medication, how to talk to Sara about their efficacy, and what side effects or signs to look for that might indicate a need to revisit medications or dosages. Initially, therapy was scheduled for two to three times per week. The therapist had to work actively to help her to fight against her fears. Sara had to work to behaviorally prove to herself that she could do the thing that she thought she could not do. At first, phone calls were a common occurrence, Sara crying in her home or in her car, terrified to drive to the clinic. Her therapist would attempt to calm her and encourage her to come in, telling her that coming in would allow them to get her better. This first intervention of overconfidence is actually an intentional choice despite rational doubts about the ability to “cure” any patient. However, for a patient who is terrified, the clinician can utilize the confidence from previous experiences or the confidence of their supervisor regarding being able to help solve the problems that the patient is experiencing. The clinician is essentially saying, “I can help with everything that you are experiencing. I have an endless number of options to use.” Many schools or thoughts say this is disingenuous or bad

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clinical method because you do not actually know that this is the case. However, our experience has allowed us to get familiar with these kinds of problems and to be confident that if the patient can continue to cooperate with treatment, we are extremely likely to succeed in helping them. We use this to inspire a level of hope to get the patient to do the things that we know that they can do. Similar to the placebo effect, the patient’s belief that they will get better can be as reparative as any other intervention. This may be called a placebo, but in this instance, it is a tool of our trade. We have to remember that Sara believed that people were following her, trying to break into her car, and trying to harm her. The paranoia and hopelessness are tied together. The confidence to inspire hope is what she needed to start treating her fear and get her to come to sessions. Another important note is the need for flexibility in working with Sara in this early stage of treatment. Many treatment centers would say that Sara had missed her appointment and would have to wait until the next scheduled time if she were late. There is a trade off in flexibility as a therapist. When the clinician can tell that she is trying, it is worth working with her to get her better. If the patient was not invested in the treatment, was blowing off appointments, or was not trying to engage, it would be important to have boundaries and insist upon adherence to scheduled times. A clinician will burn themselves out if they do everything for every patient, regardless of the patient’s effort level. However, if the patient is working hard, the clinician can work with them. The first few sessions were about skill building. The standard three interventions we use for people with panic attacks are diaphragmatic breathing, progressive muscle relaxation, and guided imagery (see Chap. 7, Box 7.1 for description of each). Taking the time to explain each skill and practice them in session helped Sara to have tools in the moments of panic attacks of fear. Sara did whatever she was asked to do without question. She was trying to get better and saw these skills as helpful. For a more resistant patient who doubts the utility of such intervention, we must insist as clinician that the patient do the behaviors even if they do not believe they will be helpful. We are fond of saying, “you don’t have to believe they will work, you just have to do them.” Once the behaviors change, the mind catches up. More importantly, they must practice these skills when they are not in the midst of a panic attack. Like training a muscle, it takes practice and repetition to build up strength, so it can be used when times are hard. A few months into her treatment, she was better able to consider reality in regard to her paranoia; she still felt like someone was after her, but was able to cognitively acknowledge it was untrue. Her medications were making a dent in her symptoms as well, allowing her to come into treatment. She was making slow improvements, still struggling but seeing her symptoms decrease. Then, a prior trusted client of hers she had stayed in contact with got drunk and attempted to rape her. Sara completely decompensated and wanted to kill herself; she did not relapse, but she needed to go into a psychiatric inpatient unit for a week or two to cope with her intense suicidality. Once she got out, the man claimed that he didn’t remember having tried to have sex with her and apologized. Sara was fairly hopeless but was actually clear in terms of her paranoia. This was also a point for her clinician to emphasize her 9  Contemplating Integrative Medicine Skills with a Case Example

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strengths, pointing out that she had avoided relapse despite her suicidality and that her symptoms were decreasing. She had only been in therapy for a few months and was able to take a significant step. Feeling empowered, Sara decided to move and found an apartment that was further away from her old life, physically and symbolically. When she was in the worst of her addiction, she surrendered some of her self-sufficiency, trading sex for housing and drugs, and making her feel dependent on others worse than she ever did when she was being paid in money and able to make choices about her life. Now, however, Sara was able to get jobs cleaning houses and started supporting herself again, something for which she was incredibly proud. Sara has been actively involved in a local church that was very recovery-­ focused throughout her treatment. With fellow parishioners, she would engage in bible study and work around the 12-step program. Yet despite her connection to this large group of people, she had thus far kept her psychiatric difficulties a secret. Once she was hospitalized, her mental health status became known, an event of which she had been terrified. Some of her fears were confirmed when some of her community members were pejorative, saying disparaging or unhelpful comments to her. With the help of her therapist, she stood up to them in a heroic way despite her hopelessness. In this experience, Sara started to feel emboldened. Therapy allowed Sara to begin recognizing her power to fight for herself despite her depression and hopelessness. In these moments of empowerment, treatment for Sara turned a corner. Her most distressing symptoms retreated. Some combination of the therapeutic intervention and a newfound will to get better converged to push her forward. She had occasional minutes or hours of paranoia come creeping back in subsequent years, but it never elevated to the level that it had been at the onset of treatment. Her panic attacks essentially disappeared.

Phase Two: Depression and Hepatitis C Treatment shifted into a second phase when Sara was able to eliminate her panic attacks and her most distressing symptoms were minimal and under control. Sara was still combatting depression and had symptoms of PTSD that were impacting her ability to function most effectively in her world. At this point, however, her hepatitis C was getting a lot worse and causing complications that were worrying the doctors. Sara’s ammonia levels were elevated, resulting in a condition called hepatic encephalopathy which causes cognitive confusion. In fact, the medical and psychological providers coordinated diagnostically at this point because of the delirium that hepatic encephalopathy can cause. At many times, it was difficult to tease apart the symptoms of her psychiatric conditions and her delirium from worsening liver disease. While the team was unable to tease out exactly what was going on in term of the etiology of Sara’s symptoms when her hepatitis worsened, they were able to coordinate treatment moving forward to keep her best interest in mind.

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Given the severity of her hepatitis, medical intervention was imminently necessary. Fortunately, the medications required for treatment of hepatitis C have improved dramatically since Sara was treated. At the time she was treated, not only were first-line medications rife with side effects, but treatment was lengthy, and insurance was slow to cover the cost. Now, hepatitis C can be treated in 2–3  months with minimal side effects. Like our recommendations for HIV, we encourage medical professionals to remain updated in current medical guidelines when deciding a medication regimen for any patient. For Sara, it was important to consider her history of severe depression and the potential for the medications that were available to her to trigger additional depression as a side effect. The integrative model of care allowed the physician and psychologist to coordinate to balance her medical and psychological needs throughout her treatment. The team was able to advocate with the insurance company for a more modern—and expensive—alternative that would not have the severe side effects for someone with a history of mental health concerns like Sara. The team’s patient navigator had to coordinate with the insurance company to determine what requirements were needed in order to pay for this incredibly expensive medication; unfortunately, given its cost (e.g., approximately $1000/day for at least 3 months), insurance companies required doctors and patients to leap through hurdles to get this medication approved. The physician and patient navigator worked together to complete appeal forms and write letters advocating for the patient, attaching updated lab work in order to successfully acquire this medical treatment for Sara. While there were minimal side effects from the treatment itself, Sara experienced a resurgence in her depression and anxiety symptoms at this time. Because of the complications her hepatitis C had caused medically, she began ruminating on whether the treatment would work. Despite reassurances on the incredibly high cure rate from her treatment team, she had known people who had horrific experiences in being treated with the old medication and was afraid she would become suicidal again or that this treatment would not work and she would have to use the old methods. Because she was so caught up in her worries and her sense of safety felt threatened yet again, Sara struggled throughout the 3 months of treatment. Blood work was drawn every 2 weeks to check viral levels and monitor the success of the treatment, the frequency of which is necessary for the treatment, but reminded Sara of her days of injecting heroin and increased her urges to use. She survived without a relapse, however, with supports from nightly church and twice weekly therapy sessions. Social supports appeared to be key. Sara was making her own money, feeling independent and self-­ sufficient again, a feeling she had lost years ago. She was taking her life back into her own control, and, despite the depression, she forged on. Once follow-­up lab work revealed that she was considered cured and her medications were stopped, her depression rescinded, and Sara’s energy and motivation returned. At this point, Sara had been in treatment for 3–4 years. Once Sara’s energy was back, even though she was still somewhat depressed, she started working full time as an aid taking care of older adults. She was still very attached 9  Contemplating Integrative Medicine Skills with a Case Example

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to a large social network through her church, allowing her to engage meaningfully in her life. She had aspirations to work with former sex workers to inspire them about the changes possible in their lives. She also aspired to go into jails and do similar work with inmates. Neither of these aspirations ended up panning out, but her hopefulness and forward thinking marked a significant shift in Sara’s view of the world. Considering the personality functioning described earlier, Sara’s extraversion is a protective factor for her in not being able to carry out these dreams. Extraverts do not get as derailed as introverts when there are bumps in the road. For Sara, this was a setback, it was not insurmountable, so she just kept moving forward in her life. Sara was symptomatically improving as well, experiencing only mild depression, as well as an absence of panic attacks and paranoia/hallucinations. She had some re-­ experiencing and avoidance directly related to her attack, but it was much less intrusive than it had ever been before.

Phase Three: Trauma Work When Sara was 9, her father molested her. She told her mother, and he was exiled from the family; she never had contact with him again. So many years later, Sara was still angry at him for what he did. In her 40s, she knew that her father was somewhere across the country and a severe alcoholic. She was furious with him, but wanted closure as well. She truly believed that someday he would return and apologize, acknowledging everything that he had done to her. Before we could get close to any kind of contact, he died. Sara was left without him ever acknowledging or apologizing to her. She had been doing better but she was unable to handle the news of not getting the closure she yearned for and Sara relapsed. To her credit, Sara was only gone from treatment for 5 days, but during her relapse, she not only used heroin and cocaine but immediately started doing sex work again and had been arrested. When she got out of jail and returned to her clinic, she was a little sheepish but was determined never to repeat these behaviors again. This was a turning point in her treatment, and she clearly got better over the next several weeks. Sara’s depression symptoms had remitted, and she decided that she wanted to work on her PTSD. The topic of her attack had come up a number of times over the years of therapy, but it was very different to relive and delve into the story of her trauma. Using a prolonged exposure approach, her therapist guided her in walking through her story. He prompted her to recall sensory details of the incident with great specificity, walking through it step by step. This man had tried to kill her; he had thought he was successful. Sara needed to keep processing her story again and again until the story made sense, until she was habituated to the pain and anxiety of the story. They had practiced and learned relaxation skills to use in conjunction with the story. Sara audio recorded her story in session, and she brought it home to listen to it, practicing her relaxation exercises as she listened to it daily at home. Long into this process, the therapist received a voicemail from Sara that simply said, “I listened to the tape again today. I have a real sense of freedom again. I feel like I’m getting myself back.”

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Phase Four: Maintenance Given Sara’s progress in decreasing her depression and PTSD symptoms, appointments with her therapist began to be more spaced out. Sara navigated some changes in her jobs and where she lived as well as a conflict that arose in her church that divided the congregation and led to Sara seeking out a spiritual home that felt more in line with her values. Ten years since the beginning of treatment, Sara and her therapist still meet about once per month. She determines her treatment schedule and will reach out when she needs extra support. She does not have the symptoms of PTSD or depression anymore. She will always be in recovery from her addiction, but she is now solidly in her recovery and has no urge to use. Sara is working full time as a caretaker, is active in her new church, and has reconnected with her mother and sister in another state, giving her an invaluable connection to family. The course of treatment with Sara has demonstrated the long-term, individualized, and coordinated care that needs to occur with patients with complex and chronic disorders. At first, the rigor and intensity of multiple sessions per week is needed because it psychically organizes her and intervenes when she is at her most vulnerable. As she recovers, she functions at a more typical level. She will always be somewhat vulnerable, but she has developed so many strengths that have allowed her to persevere in the face of her challenging life. Sara knows when she needs help from her therapist and, given their bond, is able to reach out to attain the said help. She knows how the therapist is able to aid her. Sara is someone who never functioned at a high level before her illness, so she was never working to return to a level of functioning that she had lost, but rather than being rehabilitated, she was habilitated. For Sara, treatment will likely be a lifelong process. While the length of time between sessions may get longer and longer, her therapist suspects that the two of them will work together until one of them dies. Given Sara’s stability and healthy life, due to her own personal strengths and tenacity as well as the support of coordinate medical and therapeutic care, Sara is going to live for a very long time.

Post-Script Since beginning the draft of this story, Sara actually relapsed on cocaine. She and her therapist increased their frequency of meeting again and are helping her to work through this resurgence in her addiction. While the details of this piece of her story are in flux, it is a vital illustration of the chronic and never-ending aspect of a lifelong disease such as addiction. Over their 10 years together, Sara and her therapist built such a strong relationship that she has managed to keep him as a constant and trusted source of support. She did not disappear when she relapsed, nor did she return to all of her old behaviors like what has happened in past relapses. She is using cocaine, but she is also maintaining her HIV medication and working with her therapist to help her to move forward.

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Integrative medicine with vulnerable and complicated populations does not have an end, it is not simple, but it keeps patients alive and gives them a chance at lives that would be impossible without a passionate and dedicated team fighting for her.

Reference 1. American Psychiatric Association (APA). Diagnostic and statistical manual of mental disorders. 5th ed. Washington, D.C: American Psychiatric Association; 2013.

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PART IV

Logistical Considerations of Integrative Care

The core competencies of integrative medicine are clear at this point, but the piece that is often challenged when we present our model is the logistics of actually implementing such a system. To have a successful group, there needs to be a shared value of integration and a training set up to facilitate the necessary skills to intervene collectively. The model we are proposing is often seen as the ideal in care, yet it is rarely used because of the perception that it is difficult and costly. While it seems to require more work in the short term, it is actually much more efficient because each expert on the team provides the care they are best at and other members of the team do not struggle with treatments outside of their area of expertise. This approach to patient care relieves the burden of siloed care by providing a more complete and whole picture of the patient, as well as more minds thinking about each problem as it presents itself. Quality of care and outcome are improved and more efficient. In this section, we discuss how to set up an integrative medicine team, including our recommendations for roles that are beneficial to include. We then talk about training people in the art of integrative medicine, considering deficits in current educational models. Finally, we use the example of our own clinic to illustrate how these dynamics all play out when a patient comes through our doors.

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Setting Up an Integrative Medicine Team Julia Hodgson, Kevin Moore, Trisha Acri, and Glenn Jordan Treisman

Integrative medicine demands practitioners work together as a team and requires common goals, good communication, and, for many, ongoing education and challenging changes in practice. Each member must be able to forego ego and individual interest in order to serve the team and the patient in a coordinated manner. The team must have unified goals and vision, operate efficiently, and be led by an effective leader. Shared vision does not mean an absence of disagreement, as the team must often make difficult decisions that provoke disagreement. In fact, this is an area fraught with politics and extreme points of view about issues of autonomy, freedom, lifestyle, paternalism, and other considerations. Because of these complexities, each team member is obligated to express their point of view and think critically about the practices that the team uses. It ultimately means that disagreements are worked out in the team meeting and a treatment plan is reached, not played out in conflicting messages and treatments given to the patient. There are countless arrangements that could work in assembling an integrative medicine team, and it depends on the specialization and needs of the practice in determining which composition makes most sense. In this chapter we review the general organization and components of a treatment team and contemplate how these interdisciplinary roles may be organized in the treatment of a complex patient. We will describe the processes and characteristics of an effective team and discuss ways to implement a team. Finally, this chapter explores the qualifications for and challenges of leadership within a team-based decision-making model. While we use our own model as a specific example, we urge the reader to extrapolate from our design to craft the most effective team for their patients.

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Roles in Integrative Medicine Teams Following organizational literature as well as the foundational assumptions of integrative medicine, teams must be set up in a way to maximize communication and collaborations in order to best treat and advocate for the patient. A wheel is a common metaphor used to illustrate the makeup of an integrative medicine team (see Fig. 10.1). On each spoke are the different roles of psychological staff, medical staff, and assisters. At the hub of the wheel is the patient. Holding together the outside of the wheel are coordination, communication, and integration. Every piece of the wheel is vital for the success of the system. The hub is what the system of the wheel is organized around, just as important a piece as each of the spokes. Without any of the spokes, the wheel becomes weak and cannot support its weight. The wheel is only able to hold weight and move forward when bound together by the collaborative processes of integrative medicine.

Integration

Figure 10-1.  Wheel metaphor of integrative medicine

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comprehensive medical evaluation ~Develop a diagnostic formulation of the patient ~Reconcile findings with those of psychological team

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maintain insurance/benefits ~Scheduling ~Coordinate with pharmacy ~Distribute and track medications ~Request records from other providers

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MEDICAL ASSISTANT(S) MENTAL HEALTH SPECIALIST ~Referrals and prior ~Complete a comprehensive authorizations assessment of the patient ~Phlebotomy, lab work ~Develop diagnostic formulation ~Support medical provider in that accounts for case visits ~Develop a treatment plan that ~Discuss medical adherence adequately addresses all (e.g. pill boxes) elements of the formulation ~Provide medical education to ~Provide the therapies (group, patient individual, and others) PATIENT ~Assess the patient ~Follow program for progress and (attend sessions, need for changes give UDS, etc.) in treatment ~Take medication as prescribed ~Engage in therapy ~Commit to making PATIENT NAVIGATOR(S) MEDICAL PROVIDER changes in life ~Help patients obtain and ~Provide a

While the individual makeup of a team may differ depending on the primary goals of the team, there are certain occupational categories that need to exist for a successful integrative medicine team.

Mental Health Specialist Taking charge of behavioral and psychological interventions, the mental health specialist plays several roles within an integrative medicine team. They are usually the initial contact for the team, conducting a comprehensive intake evaluation in which a thorough history is collected, preliminary psychological diagnoses are assigned, and the goals for treatment are developed. While not able to assess for medical concerns in a nuanced way, the mental health specialist can gather a basic medical history to guide the physician who will ultimately conduct a more thorough medical history. The mental health specialist is usually the primary contact person for a patient, bringing their information to the team for decision-making and meeting most regularly with the patient to work on goals that will improve quality of life. Interventions may include motivational interviewing, therapy, psychoeducation, planning, and monitoring of progress. In addition to hiring licensed providers such as psychologists, social workers, and licensed professional counselors, the use of psychology trainees can provide a rich added benefit to the program—and to the training of new people in the field—because of the high level of nuanced training we believe is needed for our patients. One of our clinics partners with a local university to provide the training opportunity, which allows us a long-term and intensive model of developing highly effective clinicians to work with our challenging patients. (See Chap. 11, for more on this topic.)

Medical Provider Medical providers are primarily responsible for the medical side of treatment in a patient. Prescribing medications, ordering tests, screening for and treating medical conditions, and providing regular physicals and OB-GYN services are among the tasks that our medical providers oversee. The medical provider must also understand the psychological formulation of the patient and plan to integrate care with the mental health team. Additionally, insurance companies will often require appeals, prior authorizations, or even phone calls to justify certain medical decisions and pay for necessary treatment. For example, within the world of addictions treatment and the use of buprenorphine (described more in Chap. 8), doctors often have to call the insurance company to advocate for the medically appropriate level of medication when they want to increase the dose of buprenorphine. This task represents a shortcoming in the healthcare system, making it all but impossible for an integrative medicine team to devote ample time to advocate for the patient receiving clinically necessary medications and treatments. Other interventions, like that for hepatitis C, require that the physician provide documentation of the condition before agreeing to pay for its treatment. These processes necessitate documentation and appeals by the physician trying to treat a 10  Setting Up an Integrative Medicine Team

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sick patient. While assisters can help with some of the documentation in these processes, the ultimate task is left to the physician to fight for the patient when insurance companies are particularly resistant to using expensive diagnostic and treatment modalities for patients.

Assisters The most often overlooked person in an integrative medicine team is someone who helps manage the organizational complexities needed to achieve maximum treatment effectiveness. Job titles include patient navigator, medical assistant, case manager, nurse, and social worker, among many others. Each assistor type has its own traditions, but all provide the cohesion needed to manifest the recommended interventions. An integrative medicine team needs more assistors than clinicians to deliver the best healthcare possible. Just as clinicians from different disciplines work synergistically for the patient, a diverse group of assistors maximizes the team’s ability to track appointments, provide motivational interviewing, request records, review pill boxes and support medication adherence, appeal insurance decisions, increase a patient’s health literacy, check glucose levels, send referrals, and know which food bank is stocked today. Different from a traditional clinic staff, these are not subordinate employees who only execute delegated tasks but full team members who are involved in case conferences and have input into clinical decision-making. Often, patients will divulge information to assisters that they might not share with their doctor or therapist, whether intentionally, through small talk, or when talking to other patients in a lobby or waiting room. This data can be as valuable as what is shared during formal sessions with clinicians, necessitating the involvement of assistors in team decisions and conferences. The more minds focused on the patient, the better the outcomes.

The Patient Finally, the most important member of the team is the patient themselves. In patient-centered approaches, the staff may be the experts in determining treatment, but no progress can be made without complete participation by the patient. Integrative medicine only occurs within the office; the other 23 hours of the day are the sole responsibility of the patient. The therapists and doctors can guide treatment, develop a program, and help set up supports. The patient is responsible for taking medication, following through on their commitments to the program and all plans, and being forthcoming with their providers. While it is understandable that no patient is perfect, patients of integrative medicine have more obstacles than most, and the patients’ attempts to follow through and their commitment to their recovery and treatment are the measures of their engagement. A patient may relapse, but it is their willingness to come in and talk through the relapse with their therapist that is vital. Another patient might not be taking their insulin as their doctor prescribed, but coming in and telling the doctor or medical assistant allows the team to work with them to overcome barriers that are getting in the way. In both of these scenarios, the patient is the catalyst for change and

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improvement. Thus, considerations of the integrative medicine team are incomplete without the inclusion of the patient. While engagement of the patient is the responsibility of the treatment team, the patient must be a partner in the process.

Effective Team Functioning Research in organizational psychology and business guide conceptualizations of setting up teams in integrative medicine settings. Katzenback and Smith (1993) define effective teams as “a small number of people with complementary skills who are committed to a common purpose, set of performance goals, and approach for which they hold themselves mutually accountable” [1]. Integrative medicine teams are the epitome of the definition, bringing together clinicians and assistors from different disciplines who work together to treat each patient. However, J. Richard Hackman, a professor of social and organizational psychology at Harvard University, shared in an interview for Harvard Business Review that “[r]esearch consistently shows that teams underperform, despite all the extra resources they have. That’s because problems with coordination and motivation typically chip away at the benefits of collaboration” [2]. Working in a team brings up unique challenges that do not arise in individual or private practice. Effective teams do not appear overnight, but require extended time working together and finding a balance of power and responsibility. Often, hierarchical habits initially impede effective team collaboration, so these patterns must be unlearned [2]. Furthermore, it can take time to learn the skills to effectively collaborate and use each member of the team to their maximum potential. It is a common misconception that teams become stale, but research and clinical experience do not support this fable [2].

Characteristics of Effective Teams Given the challenges that face teams in integrative medicine, attention must be paid to effective team processes. In his classic work that is still cited by business consultants today, McGregor (1960) proposes the following characteristics of effective work groups [3]: 1. Engaged and involved members, operating in a comfortable environment without tension, boredom, and frustration. 2. Focused and productive discussion, where every member is participating and clear on the goal of the discussion. 3. Members of the group understand and accept group objectives and tasks. 4. Members listen to one another, process each point of view, but do not prolong any one topic within a discussion. 5. Healthy disagreement that is able to be resolved and does not derail group functioning. 10  Setting Up an Integrative Medicine Team

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6. Constructive criticism occurs in the absence of personal attacks; ideas, feelings, and opinions are openly expressed, and there are no hidden agendas. 7. Group should reach a consensus on decisions after hearing all opinions; voting or making decisions based on the majority should be avoided. 8. Following decisions, action is planned, and clear assignments are made. 9. The leader is not authoritarian nor the sole decision-maker; relative involvement and expertise about an issue guide who may lead parts of a meeting. 10. The group is aware and self-reflective about the team process, devoting time to periodically check-in and adjust to improve functioning. Furthermore, successful teams must have goals that are specific and contextualized within the larger picture; increasing understanding helps members of the team to understand the decisions that are being made [2]. In line with the foundational assumptions of integrative medicine, collaboration and clear communication are key in effective team functioning.

Team Size Regarding the size of the team, in our clinic, we have found that an ideal outpatient team size is somewhere around six to eight people, e.g., three clinicians and four assistors. Larger teams create more challenges, not less, because of the additional links that must be managed and time that is inevitably wasted [2]. Research on effective team sizes in business varies, though agrees that teams become unmanageable once they become too large and are maximally productive in smaller numbers. A rule of thumb is to stay under double digits [2], while others specify that four to six people are the optimal size [4]. Ultimately, the exact number depends on the skill and experience of members as well as the tasks of the team. Larger integrative medicine teams cannot efficiently be fully collaborative, and smaller teams do not have enough collective skills. Of note is integrative medicine within an inpatient setting; these teams may be larger to incorporate specialists and additional supports that are required to function within the larger institution, although often the necessary specialists, e.g., gastroenterology or surgery, will participate only when their expertise is required.

Succeeding Within a Larger Agency A team functioning within a larger agency needs to have support [2]. In integrative medicine, teams are imperative so they have to be set up to succeed. The larger agency needs to provide the information and resources, as well as the managerial support, to allow them to operate in the way they need to. Simply setting up a team and leaving it to fend for itself is a recipe for failure. Instead, larger agencies cannot just elicit and set up teams, but must evaluate their effectiveness in an ongoing way and determine if they are being supported sufficiently within the larger context. A long-term

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investment is what allows integrative medicine teams the resources, both material and in terms of information and support, to succeed and be able to serve clients in the most effective way possible. The goals of an institution may differ from those of the team. Human Resources (HR) departments excel at managing individuals within an organization. HR departments may feel obligated to defend the views of an individual or wish to keep an unproductive member on the team because it is difficult to effectively move them elsewhere. However, like most traditional settings in a workplace, the focus on the individual may contradict the values and systems needed to support a team [2]. Instead, support of teams within an organization must move away from trying to individually coach members and devote energy on the group dynamics. Hackman clarifies that “[t]eam coaching is about fostering better teamwork on the task, not about enhancing members’ social interactions or interpersonal relationships” [2]. If the team loses, the patient loses, and ultimately someone needs to advocate for the team at the level of the organization.

Challenges of Leadership The shared clinical decision-making model of integrative medicine is challenging to the most open-minded. In traditional settings, the role of team leader tends to fall upon psychologists or medical doctors as the highest members of the behavioral medicine hierarchy. Integrative medicine diminishes the rankings of hierarchy; it is built upon the idea that every member of the team is equally important. However, despite the vitality of shared decision-­making, a leader is still a necessary role in any integrative medicine team. In any setting, teams operate best under some form of leadership to guide and keep the team on track. In integrative medicine, especially given differing levels of training among assistors, trainees, and the diverse members of the team, a team captain synthesizes the points of view. The leader must guide the team, keep the team on track, and provide clinical and organizational oversight. Furthermore, the leader has to make the members and boundaries of the team clear, specifically defining its members [2]. The leader shapes the team. Deciding who should lead the team poses challenges in any setting. Ideally, having a behavioral health director and a medical director co-­ leading the integrative medicine practice provides balance between the two major schools of thought that influence the treatment of the patient, medicine and psychology. Yet, having two leaders creates unique challenges. Bregman, CEO of a company that coaches leadership teams and contributing writer for Harvard Business Review, points out the challenges when strong individual leaders are working on a team together; each leader may be deeply committed to and advocate for their respective disciplines or subgroups, but they have to be able to be collectively strong as leaders for the overall group to succeed [5].

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Qualities of Effective Leadership Whether one or two people, leaders must define the objectives and goals for the team, making sure that they are clear and specific. Then, the leader must empower the team to accomplish them, refraining from micromanagement and denying team members power over their responsibilities [2]. There is a balance between being authoritarian and hands off; somewhere in the middle is the balance [2]. Even when the team is responsible for making decisions as a unit, the leader must continue to keep an eye on the larger picture of where the team is heading to make sure that the team stays on track [2]. Bregman (2013) identifies main qualities that are essential in leaders, especially in team dynamics. First, the leader must be gifted at being a leader; being a leader includes being smart, organized, prepared, and informed as well as being able to adapt, communicate effectively, and navigate conflict. Second, leaders need to have confidence; confidence allows leaders to take risks, to consider alternative solutions, and to manage negative emotions like blame or threat without become overly defensive. Third, leaders need to be generous; leaders need to see the overall good and put that before their individual or small group needs as well as being able to collaborate and take enough interest in the other members of their team to effectively collaborate with everyone [5]. Bregman further notes that it is challenging to find leaders with these qualities because they require an amount of vulnerability that can be uncomfortable, but being courageous enough to do so is imperative for developing a commitment and effective team [5].

Liability Beyond philosophical challenges of shared responsibility for decisions related to a patient is the challenge of who is held liable and responsible for the decisions being made about a patient’s care. Licenses are currently issued to individuals, not teams, so one physician’s name is ultimately associated with a given record or treatment for prescribing, billing, and liability purposes. A psychologist may be the other license that is held liable for treatment as well, for example, if a patient were to die by suicide and the team were sued by the family. Given the additional burden on these members of the team, how does an integrative medicine team navigate when there is not an agreement about the treatment of a patient? Should those with most liability get the final say? Consider the example of a social worker and a physician discussing treatment options for a patient based on their respective discipline’s philosophies for conceptualizing or diagnosing a patient. Suppose that the social worker presents a radically different treatment philosophy than that of the physician and the team as a whole agrees with the social worker; the social worker is arguing that therapy is the only intervention that should be used for a patient who is struggling from post-traumatic stress disorder (PTSD). The physician, on the other hand, sees the value in adding a medication like a selective serotonin reuptake inhibitor for anxiety symptoms and a medicine to address

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nightmares in PTSD to help the patient to sleep better at night. In a typical medical system where the physician is at the top of the pyramid, the physician has the option either to overrule or re-evaluate his or her own view; this decision requires them to balance their own perspective on the issue with the medico-legal responsibility that falls on them regarding prescription decisions. At this point, the team leaders can help the two camps to see each other’s perspective regarding the diagnosis and appropriate treatments and to come to a compromise. We have found that a lively discussion regarding the diagnosis or case conceptualization leads to a shared decision on the treatment plan for a complex patient and ultimately leads to better care. In addition, the social worker is likely to be the first team member the patient will approach when she has side effects from the new medication, and then the team can discuss the new information to adjust the treatment appropriately.

Conclusion There is no right answer for how to navigate the challenges of leadership and liability within integrative medicine. The quest for correct diagnoses and best treatments requires achieving the highest skill in one’s discipline while simultaneously challenging one’s professional assumptions and habits of mind. An integrative medicine team is a learning collaborative for all involved.

References 1. Katzenbach JR, Smith DK. The discipline of teams. Harv Bus Rev. 1993;71(2):111–20. 2. Coutu D. Why teams don’t work. Harv Bus Rev. 2009;87(5):98–105, 130 3. McGregor D. The human side of enterprise. New York: McGraw-Hill; 1960. 4. Mauboussin MJ, Callahan D. Building an effective team: how to manage a team to make good decisions. Credit Suisse: Global Financial Strategies, January 8, 2014. Retrieved November 23, 2018 from https://doc.research-and-analytics.csfb.com/docView?langu age=ENG&format=PDF&source_id=em&document_id=1027595371&serialid=WaID4bAg 2JGWEdmhE%2B5eJyJPYqIjGuJ8Sb8NUYoLmME%3D. 5. Bregman P. Three qualities every leader needs to succeed on a team. Harvard Business Review. 2013, July 29. Retrieved March 15, 2016, from https://hbr.org/2013/07/ the-three-qualities-every-leader-needs.

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An Integrative Training Model Julia Hodgson, Kevin Moore, Trisha Acri, and Glenn Jordan Treisman

The practice of integrative medicine is not in line with the majority of current practices in healthcare, thus rendering it counterintuitive and often in contrast with training that clinicians of all disciplines receive. Those who find themselves working in integrative settings often have to rapidly develop an entirely new set of skills to successfully navigate the demands of team-based and interdisciplinary interventions. Thus, an important member of the integrative medicine team that promotes sustainability and early buy-in to this approach to practice is that of the trainee. Whether it is a medical resident or a psychology student (we prefer to train clinical psychology doctoral interns), incorporating them into integrated settings early in their training and careers allows for maximum exposure to this system of care, creating a new generation of clinicians who are competent in coordination and integrative medicine from the onset of their careers.

Training in Professional Silos Before delving into the advantages of trainees in integrative medicine, a point should be made about the universality of application of this training model. Professional silos are the norm in healthcare, beginning early in educational models that separate fields like psychology, sociology, medicine, dentistry, and nursing into different degrees and different schools. As trainees advance in their education, they specialize more and more in their own discipline, and few programs overlap in training. Our discussion of coordinated care does not aim to dismantle or discredit the training institutions of

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professional silos. Instead, we propose that training in coordination is added into healthcare programs, though potentially in varying degrees for different specialties. To reiterate, integrative medicine is most necessary for the 5% of patients with the most complex, chronic, and comorbid conditions. While we believe that everyone in the healthcare system will come across these patients at some point, it is likely more necessary for those in primary care or community mental health to be well versed in integration than those in highly specialized procedural roles such as vascular surgery. For the majority of patients, fractured healthcare is sufficient. However, some degree of coordination is vital across all levels of healthcare. For some disciplines, professional silos are not only adequate the majority of the time but may be deemed necessary during training periods. A neurosurgeon, for example, whose job is highly dependent on specific and difficult skills, needs to focus education and training on developing those abilities. The neurosurgeon’s strengths lie in their interaction between the body of the patient and themselves. In this case, specialized training is an advantage, building up skills necessary for professionals who do a particular procedure. In surgery itself, a professional silo benefits the patient because it allows the surgeon to perform at a high level without distraction. However, all physicians need a basic degree of training in coordination of care in order to influence and aid patients in medical decision-making around surgery beforehand and to facilitate proper aftercare. To illustrate the need for even specialists to practice coordination and integration of care, we present the example of Michael1, a 28-year-old high-functioning man, who discovered he had a benign brain tumor that had to be removed. He was admitted to a prestigious urban hospital where his surgeon was able to remove the tumor. This surgeon had a very precise specialty that he excelled in, allowing him to perform at a high level in his domain and treat Michael expertly. Michael had told the surgeon that he was a recovering opioid addict and that he had to be very careful about access to opioids. After the procedure, Michael was in the hospital for 4 days and was discharged to return to his home in the suburbs outside the city. During his hospitalization, he was given high doses of opioids for his postoperative pain. At discharge, the busy resident gave him a prescription for a month supply of hydromorphone, as was the usual practice for discharging patients from that service. The prescription was included in a packet of other medications given to Michael at discharge. Michael began using the hydromorphone for headaches and pain at home, but soon found himself needing more and more for pain control. The surgeon had not communicated the issue to his residents, and no one had asked pain management to help with his postoperative pain because of his high risk for addiction. Unfortunately, Michael’s use of opioids quickly got out of control. The care was consistent with usual practice, but Michael was not a usual patient; there was no integrative or coordinated system setup in the hospital for this sort of communication other than a medical chart that noted his procedure. Michael had told his family about the surgery, and fortunately his sister, also in recovery, figured out what was 1  “Michael” gave permission for his story to appear in this text; identifying details have been changed.

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happening and helped him get back into recovery. This was not the fault of any one individual, but rather of a system that does not look at the whole patient but instead focuses on a problem to be resolved. In Michael’s case, a professional silo would have served him well; he was treated by a highly skilled surgeon who was able to perform a procedure that many could not. However, this example shows a breakdown that may occur when teams are not communicating or providers do not operate as a team and where communication about other issues is not the normal procedure. In the current opioid-sensitive environment, this event probably would not have occurred, but this kind of problem occurs all the time, often with different doctors focusing on different aspects of the patient. Professional silos excel in straightforward cases and when things do not go wrong. However, mistakes or complications can challenge this system and inadvertently harm the patient if everyone is not coordinated. If early training, and the healthcare system, were to emphasize the importance of communication and integration, dangerous situations like Michael’s would not be so commonplace. Michael was a member of the majority of Americans who, prior to his brain tumor, had little contact with the healthcare system. He would have benefited from more coordination in this situation, but is able to navigate silos for the majority of concerns that may arise. However, as we describe in Chap. 2, more complex patients often suffer exponentially from fractured healthcare and siloed professionals. In settings that serve these complex patients, like community mental health centers, cancer or HIV treatment facilities, or other clinics that work with comorbid and chronic patients, it is a great advantage to have integrative teams. A great deal of knowledge is necessary across disciplines to treat these complex patients. Those professionals who wish to work with these populations especially benefit from training early on in an integrative fashion. As the advantages of professional silos are demonstrated regularly in the default healthcare models, this chapter will not devote much time to exploring this model of training. Students learn their own disciplines well, studying theory and practice that relates to their specific careers in a nuanced and thorough way. They learn the culture and style of thinking that best benefits their own work, for example, social workers are taught to look at systems that surround and impact the patient, while a physical therapist might focus more on the interconnection of muscles and bones in the body. The benefits of professional silos are a rich and thorough knowledge base about specific areas of healthcare practice. Specialists and experts in narrow areas are behooved to silo their education and practice so that they may get the most focused training in their niche. There is nothing in integrative healthcare that argues for the dissembling of these systems, merely the addition of some training in coordinating care, which still occurs so rarely in educational systems.

Why Trainees Benefit from Integrative Learning Integrative medicine is remarkable in its ability to expand the opportunities for learning beyond the traditional systems of training in professional silos. Traditionally, and unsurprisingly, advanced degree programs, medical 11  An Integrative Training Model

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school, nursing school, and other academic settings focus on their respective disciplines and rarely venture far from training related directly to that work. Medical physicians learn how to diagnose and treat medical problems, and psychologists learn how to diagnose and treat psychological problems. However, in an integrative medicine team, having knowledge beyond one’s own training is imperative for most efficient care. Thus, trainees benefit from early immersion within a multidisciplinary learning environment. Lest we scare away those who fear having to learn a new discipline in order to practice integrative medicine, training requires an awareness and appreciation of what other disciplines have to offer, not a mastery over other fields. At a minimum, understanding the system and knowing which providers can be helpful in providing which types of supports help to facilitate appropriate communication and coordination of care. A psychologist does not have to learn everything about medicine to be effective in working in an integrative team, but knowing that there are medical interventions available for certain conditions can allow them to consult with the physician to coordinate care. For example, a therapist working on smoking cessation can work on behavioral techniques and building up motivation to quit. However, their work can be enhanced by knowing that there are prescription medications available that decrease cravings to smoke. The physician can then be consulted and attend to writing a prescription and consider its interactions with the other medical care that they are providing. Furthermore, on this team, a patient navigator might be aware of smoking cessation coaches available through the patient’s insurance of which the doctor and/or therapist were unaware. By treating the patient as a team, each person’s discipline comes together to make all members of the team more aware of the options available to provide excellent care. Through early exposure to these systems, trainees are able to expand their learning beyond what they have received in school to become more well-rounded and competent in their abilities to serve patients’ needs.

Early Collaborative Training Programs While it is never too late to learn integration, there is a unique opportunity to build collaborative skills across disciplines by intervening at the university and early training levels. Some research in undergraduate institutions has found that students are most ready and open to interprofessional learning at the beginning of their healthcare programs, an openness to learning which declines significantly over time even in the few years of college [1]. Early interprofessional education (IPE), the term used for early learning opportunities that facilitate positive interdisciplinary attitudes and thus future collaborative healthcare, are proven effective early interventions to develop a more cohesive and effective healthcare system [2, 3]. Thus far, much of the research about integrative training relates to interprofessional education (IPE), which advocates for programs at early university levels to develop interactive and collaborative learning environments that facilitate the ideals and

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practical skills needed for integrative care of patients in healthcare. Topics that should be included in such programs are ethics, communication, and evidence-based practice [4]. Necessary for implementation are a common vision, values, and goals across the programs, opportunities for collaborative work both in learning and in practice, professional development of the faculty, individuals in leadership and practical positions who are champions of IPE, and attention paid to sustainability of IPE programs and learning [5]. Sustainability requires the participation and interaction of faculty, students of various disciplines, and field placements, administrative support, funding, and a curriculum that fosters teamwork, shared decision-making, and patient-centered care [2]. Thus, obvious barriers to IPE include financial constraints, a lack of buy-in or support from faculty and administration, already-full curricula with little room for additions, and conflicts between professions and faculty or between academia and professionals [4, 5]. However, with enough effort committed to doing so, barriers can be overcome and lead to successful programs that develop competent integrative clinicians early on [3].

Developing Expertise The benefit of training in a multidisciplinary setting is that it starts clinicians off with extended practice in developing the skill of integrative medicine. A common rule of thumb in the development of expertise is that it takes 10,000 h, or 10 years, of practice to fully develop a skill at a master level. However, a quantity of experience alone is insufficient for improving performance to the expert level. The individual must engage in deliberate practice, which is defined as “practice activities involving specific goals and strategies” [6]. Thus, training must be intentional and targeted in integrative medicine practice, molding practitioners in thoughtful ways to learn the skills necessary for this mode of operation. Ericsson, Roring, and Nandagopal (2007) expand this idea to argue that extended deliberate practice results in physiological adaptations and complex cognitive mechanisms that have a causal relationship with expertise [7]. In other words, while the quantity of practice is important in developing a skill, the individual must be intentional and strategic in the type of practice in which they are engaging. Part of the success of deliberate practice in developing expert skill is the role of mental representations in practice [6, 7]. In numerous domains, such as music, chess, or sports, experts are able to increase their performance by engaging in cognitive activities such as studying others’ performances or strategizing about various outcomes. Creating these mental representations plays a role in the expert performance beyond what replication or rote practice is able to accomplish; in fact, rote repetition may be harmful in the development of mastery because it does not encourage complex thinking and the formation of mental representations around the skill [6, 7]. Comprehension and complex understanding of the situations increase the individual’s performance within it at a high level. The individual should be

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pushed to continually improve and strive beyond current skill levels, even if failures occur along the way [7]. Considering long-term goals and motivations and making efforts to understand the skills increase the success in developing expertise [6]. In learning to develop a skill like practicing medicine or providing therapy, it is not enough to just provide the service, but this practice needs to be planned and strategic to optimize the benefits of practice and the contribution it makes toward expertise. Clinicians must have targeted goals for learning, overt integration of skills and learned techniques into practice with patients, and monitor their own progress to adjust accordingly in developing this complex skill. Integrative medicine contributes significantly to the development of trainees within this field. Conceptualization and complex thinking are promoted in the integrative medicine settings for all clinicians, let alone trainees. Students are not memorizing diagnostic criteria or manualized treatment protocols, but seeing real and complex patients and being forced to think about them in nuanced ways with the support of the team. Extrapolating from studies related to sports or music, the importance of supervision and feedback, as well as interactions with others, is noted in the development of expert skill [6, 8, 9]; being able to learn in a multidisciplinary and collaborative setting only increases the effectiveness of training and learning in developing expertise.

L ifelong Learning for Integrative Clinicians and Staff Beyond the training that occurs in formal training settings, such as internships or postdoctoral placements, integrative medicine sites provide a level of ongoing training and supervision that is unique for licensed professionals as well. For those who go into private practice, or even those within supposed team settings, decisions are often made unilaterally and without discussion regarding patient care. Once licensure is accomplished, there is little incentive to seek out costly or time-consuming supervision outside of one’s normal practice. While peer consultation is an option, it is rarely a regular occurrence; seeking out a colleague’s advice or support is usually reserved for particularly difficult or confusing patients. However, within the team format of integrative medicine, discussions about patients occur regularly and regardless of the “success” or “ease” of the patient’s case. As all disciplines are working together to treat the patient, discussion about planning, treatment options, and the contributions of each discipline are inevitable. Questions are answered, and peer supervision of one another occurs organically in the collaboration to determine the optimal treatment for patients. Sites that are able to integrate didactic opportunities as well are able to provide ongoing training and learning environments, serving the role that supervision sometimes takes as well in furthering the knowledge that each clinician has about their field and to use with their patients. In this way, training is a continuous exercise, both formally and informally, allowing clinicians to consistently seek and provide support and information for

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one another that allows them not only to treat patients to the best of their ability but to better themselves as clinicians throughout their careers.

Undoing Hierarchies and Territoriality A topic that cannot go unmentioned is the undeniable hierarchies within healthcare that currently exist. Readily apparent in settings like hospitals or community health centers, medical doctors are reigned as the highest position in healthcare, while trainees fall to the bottom, with psychologists, social workers, case managers, and other professionals falling somewhere in the middle. The chief vulnerability of this hierarchy is that it can feed the divides between the different disciplines impeding collaborative work that best serves the patient. Decisions can be made unilaterally; doctors decide about medications, therapists about psychological treatment, and social workers about systems-based interventions. Professionals untrained in collaboration may feel like they are speaking a different language than colleagues from other professions. At its worst, resentment or territoriality may divide caregivers and cause strife in attempts at medical care. Siloed training can inadvertently teach trainees to fight for their own perspective instead of learning the value of other disciplines and how to integrate care for the benefit of the patient. In order to overcome these professional rifts, there need to be settings that set up collaborative teams from their outset, taking an integrative approach to medicine and behavioral health. These sorts of settings would allow students to not only witness members of different disciplines working together cohesively, but to see the powerful and positive impact it has on a patient when the treatment team is integrated. Most importantly, perhaps, these sorts of settings undo some of the damage that has been done by hierarchical training sites. They teach trainees to work together and not to vilify those from other professions. Above all, an interdisciplinary approach to postgraduate training allows the student to truly learn what other clinicians do, how their work benefits the patient, and how each trainee may incorporate other perspectives into their own care of the people they work with. For example, a psychology trainee working in integrative medicine can learn more about potential side effects from psychotropic medications, the impacts of chronic illness on mental health, the necessity of understanding the worlds of insurance and public benefits, and even how medicine establishes differential diagnoses; these opportunities for learning occur in addition to their ongoing training in providing therapy and behavioral health interventions. When clinicians work together in integrative medicine, the atmosphere of collaboration and truly valuing integrative work allows the trainee, a person who would otherwise fall at the bottom of the totem pole, to learn and contribute equally to providing thorough and effective patient care. By being treated as a clinician with value early in one’s career, the trainee is taught that the battle between clinicians is meaningless and, at times, irresponsible. 11  An Integrative Training Model

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Instead, the trainee moves forward in their career appreciating and understanding colleagues in the helping professions, seeking out working relationships in order to collaboratively treat patients and striving to end the war between disciplines.

Conclusion While there is a place and need for siloed training within healthcare, an early and comprehensive intention to foster interdisciplinary and coordinated interventions develops nuanced and thoughtful clinicians who are able to intervene with patients in a unique way. Not only is training a richer experience, but the face of healthcare can shift to more collaborative and less combative and hierarchical systems of communication among professionals. Providers and patients both suffer when conscious efforts are not made to overcome these barriers to care and to interdisciplinary work. Only with communication and professional respect among team members can patients get better.

References 1. Coster S, Norman I, Murrells T, Kitchen S, Meerabeau E, Sooboodoo E, d’Avray L. Interprofessional attitudes amongst undergraduate students in the health professions: a longitudinal questionnaire survey. Int J Nurs Stud. 2008;45(11):1667–81. 2. Lam AY, Plein JB, Hudgins G, Stratton MA. Silos to systems: three models for developing geriatric interprofessional education. Consult Pharm. 2013;28(2):122–33. 3. Margalit R, Thompson S, Visovsky C, Geske J, Collier D, Birk T, Paulman P. From professional silos to interprofessional education: campus-wide focus on quality of care. Qual Manag Health Care. 2009;18(3):165–73. 4. Rafter ME, Pesun IJ, Herren M, Linfante JC, Mina M, Wu CD, Casada JP. A preliminary survey of interprofessional education. J Dent Educ. 2006;70(4):417–27. 5. Ho K, Jarvis-Selinger S, Borduas F, Frank B, Hall P, Handfield-Jones R, et  al. Making interprofessional education work: the strategic roles of the academy. Acad Med. 2008;83(10):934–40. 6. Lehmann AC, Ericsson KA. Research on expert performance and deliberate practice: implications for education of amateur musicians and music students. Psychomusicology; J Res Music Cogn. 1997;16(1–2):40–58. 7. Ericsson KA, Roring RW, Nandagopal K. Giftedness and evidence for reproducibly superior performance: an account based on the expert performance framework. High Abil Stud. 2007;18(1):3–56. 8. Ericsson KA, Krampe RT, Tesch-Römer C. The role of deliberate practice in the acquisition of expert performance. Psychol Rev. 1993;100(3):363–406. 9. Gobet F, Campitelli G.  The role of domain-specific practice, handedness, and starting age in chess. Dev Psychol. 2007;43(1):159–72.

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Applying Coordinated Treatment Skills to a Case Example Julia Hodgson, Kevin Moore, Trisha Acri, and Glenn Jordan Treisman

Integrative medicine is an intensive service that facilitates patients dramatically improving their quality of life. It is directed at rehabilitation of the person and at function, quality of life, and longevity due to improved health. Once a diagnostic formulation of the patient is completed by the team, we deliver coordinated care using the model we have described. This chapter illustrates how integration works in our clinic, which we provide as a case example. We recognize that the mechanics of an integrative clinic are likely to vary with the patient population, setting of clinic, and staff as we often need to change our model as needs shift. So, the illustration we provide is a snapshot of our model.

Intake Process For patients who come primarily for substance use issues, initial assessment involves a thorough biopsychosocial evaluation conducted via clinical interview by a trained psychotherapist. This provides the case history as well as an initial picture of the patient’s concerns and symptoms at the beginning of treatment. Additionally, a survey is administered at the beginning of treatment and every subsequent 6 months to assess progress in care. This quick self-report measure looks at limitations based on physical and emotional factors, as well as the subject’s report of their social and overall functioning. All patients are evaluated by the medical members of the team as soon as it is feasible, and they are included in discussions of the patient. © Springer Nature Switzerland AG 2020 J. Hodgson et al., Integrative Medicine for Vulnerable Populations, https://doi.org/10.1007/978-3-030-21611-5_12

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At intake, patients meet with a therapist to provide a comprehensive history of their problem. We discuss their background, their medical, psychiatric and substance use history, their reasons for coming into treatment, and their goals for being in treatment. We look at a number of factors at this initial screen, but notably focus on the following items of information that our providers need to determine medication and fit for our program.

Personal History We collect a history that reviews the person’s life story, beginning with where they were born and raised; their family history including medical, psychiatric, and substance use issues; development issues such as delays in walking and talking; and other factors. We collect an educational history including milestones in school, how far they went educationally, and areas where they functioned best as well as an occupational and work history and a sexual and relationship history including important relationships and children. During these we look for patterns of disruption, key events that had a significant impact, and trauma. We then take a psychiatric history and a substance use history (see below) as well as a legal history. Finally we take a medical history including current medications. Because we are focusing on the elements usually lacking in medical care, we will focus here on the substance use issues, understanding that the medical issues and psychiatric issues are of equal importance.

Substance Use History We start by assessing the patient’s addiction history, focusing on their current and most recent use of opioids (amount, means of use, frequency of use). The responses help us determine correct medication recommendation based on patterns of use. We also look for comorbid addictions or use, starting with substances that are similarly depressants and thus have the potential to be dangerous in combination with buprenorphine. We also look for dependence on substances that require a higher level of monitoring to cease, such as alcohol and benzodiazepines because of their risk of seizure if stopped suddenly. This may necessitate a referral to a detox or inpatient program to assist in stopping these substances before starting MAT in our program. We want to know about history of overdoses and assess for current risk of overdose and withdrawal so that we may provide Narcan (see Chap. 8 “Adjunctive Pharmacotherapy for Opioid Addictions”) or refer to an inpatient rehab if the situation is risky.

Recovery History In addition to a patient’s use history, we want to know about their history in recovery. Often, patients have made more than one attempt to stop using before entering our program, and it is helpful to discuss what was effective,

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what led to relapses, and how they think about their recovery. Does the patient take responsibility for their use? Are they able to identify disingenuous attempts in their past? Do they expect others to recover for them instead of putting in the work? This all provides useful information in how much the patient will be willing to do to work on their recovery.

Level of Motivation Patients often arrive claiming a strong desire to recover from their addiction, so we look at other motivating factors to get a sense of where the patient is. If a patient is required to come to treatment by a probation/parole officer or children and youth services, for example, we know that we will have to build up internal motivators, which are significantly more motivating in the long term. A person externally motivated is not inherently a bad candidate for treatment, but they require close attention to shift the locus of control in their life.

Social Context It is vital to look at both positive and negative environments that the patient is attempting recovery within. We ask about positive peer supports such as involvement in a 12-step fellowship, religious groups, or friends who are also in recovery. We also ask about contact with peers or family who are still using in order to assess risks for relapse that they deal with on a regular basis. When a person has a partner, for example, who is actively using, we may encourage them to bring their partner in and/or to consider if they will be able to sustain recovery with a partner who uses. We have found that unless both individuals in a relationship are committed to their recovery, neither has any chance sustaining their sobriety and recovery in the long term.

Agreement to Program Finally, while this may seem intuitive, we have a conversation with our potential patient about the expectations of them while in our program and make sure that they agree to all of our requirements. This is the point when, perhaps surprisingly, we find people decline our services because of the rigor with which we expect patients to work for their recovery. After determining fit and agreement to our program, we sign consents, administer an observed urine drug screen, and set up a next appointment, and the patient then undergoes a medical evaluation.

Coordinating Care After Intake After the evaluation, the integrative medicine team discusses the (potential) patient, each discussing the patient’s medical and psychological issues. Substance use, HIV, medical issues, dental issues, educational issues, 12  Applying Coordinated Treatment Skills to a Case Example

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living situation, and all other psychosocial aspects of the patient are included. The elements of our program and the patients’ needs are discussed in terms of adequate “fit” (can we provide what is needed and is the patient able to benefit from our program). Examples of patients who might not fit are those who need a sanctuary to severe mental illness beyond our capacity to provide or patients with a terminal medical illness that may be better served in a hospice setting. For patients with addictions, medication-assisted treatment and our recovery program are included in our offering. While the prescribing physician makes the final decision when to initiate medication-assisted treatment (MAT is discussed further in Chap. 8), the psychotherapist and the entire team provide valuable input. Questions about the person’s motivation, supports, and what changes they might need to make are discussed. We try to expedite the induction of any medication treatments that are going to be part of treatment. The “induction appointment” with a specialized physician uses the biopsychosocial assessment to inform the medical history (including mental health) and a physical examination prior to administration of medications. For opioid therapy, we use mostly mixed agonist-antagonist treatment (buprenorphine in varied forms) and antagonist treatment (naltrexone in various forms), and therefore we score patients on a standardized opioid withdrawal scale and identify any urgent primary care needs, especially pain management strategies. Acute conditions, e.g., skin lesions, dental infections, or a need for birth control, are typically addressed. Chronic conditions, e.g., HIV, hepatitis C, diabetes, and asthma, may be addressed but are often tabled until after stabilization on MAT. Either the physician or the psychotherapist sees the patient every day until an appropriate MAT dose is achieved, i.e., between two and three consecutive days. Twice a week or once a week, psychotherapy is initiated and focuses on recovery education, the nature of addiction, recovery planning, how to utilize recovery supports such as sponsors or loved ones, depression and anxiety monitoring, and beginning to address the cyclical maladaptive patterns [1] that make the individual vulnerable to relapse. Plans are made for a follow-up physician appointment to address ongoing and chronic physical health conditions. Patients can move seamlessly back and forth between treatment team members based on needs and recovery. Patients on stable psychological treatment may be seen primarily by their medical provider, and patients with stable medical problems may be seen primarily by the mental health providers, but all patients are discussed in an ongoing team meeting weekly (Box 12.1).

Box 12.1: Intake Form to Guide Evaluation of Need Interview First Appointment Intake/Level of Care Assessment Patient Name:______________ Date of Birth:________________ Date of Intake:______________ Insurance:__________________ Referred from: ______________

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Use history

Opioid use history (include current/most recent and highest use) Current benzodiazepine use? (amount, frequency, illicit/prescribed?) Other use (esp. barbiturate, alcohol, muscle relaxer)? Any overdoses or had Narcan used on them? Current overdose/withdrawal risk?

Recovery history

Past attempts? (rehab, IOP, MAT, etc.) Currently doing what for recovery? Attitude toward recovery/MAT?

Motivation

Is anyone requiring treatment (PO, CYS, etc.)? What is motivating recovery now?

Social context

Positive supports (12-step, religious, peers) Living situation (incl. with whom) Negative supports/contact with people who use?

Medical/ psych issues

Interfering medical/psychological concerns? Suicide history or current risk? Violent or aggressive behavior? Psychopathy risk?

Recommendations: As a result of this level of care assessment, the care plan is: Staff Involved in Intake and Recommendation: Intake conducted by [name/signature]:___________________________ Additional Staff Consulted:

Planning for Treatment The treatment of complicated patients requires a coherent plan that prioritizes some elements of treatment over others, and expert collaboration is required to create that plan. Treatment must include ways to simultaneously improve conditions that will otherwise interfere with the response to other treatments. As an example, a patient with a sexually transmitted disease acquired through high-risk sex driven by depression may be non-compliant with their antibiotics unless the depression is addressed and may even get reinfected if the depression is untreated. This scenario requires urgent treatment of the STD to avoid damage and transmission that might otherwise occur with continued infection. Because of the limited capacity of some patients to engage with more than one treatment effort at a time, judgment is required to develop a treatment plan that addresses the limitations of the patient while considering the risks. A patient who is unwilling to seek care for their depression might need an antidepressant prescribed by their infectious

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disease doctor, but the infectious disease doctor will need mental health resources to comfortably provide an antidepressant. After correct diagnoses are established and initial stabilization is achieved, the integrative medicine team shifts emphasis from assisting early recovery to treating the antecedents of opioid addiction, such as untreated chronic pain, depression, bipolar disorder, schizophrenia, personality disorder, mental subnormality, or lack of developmentally appropriate relational skills. Each is actively addressed in a dynamic, coordinated effort with assistors often playing crucial roles, e.g., physical therapy referral for chronic pain and care coordination with the physical therapist. Following CDC guidelines [2], infectious diseases such as HIV and HCV are routinely screened and aggressively treated. Treating long-standing medical conditions frequently assists the primary treatment goal of recovery and adds momentum toward other behavioral changes such as living an active lifestyle and making one’s health a priority.

Care Plans In determining how to proceed in treatment, care plans are widely touted in integrative medicine research as organizing the team to best serve the patient. While this would be the appropriate stage to implement a complete care plan, our team does not routinely use written care plans as our frequent care coordination meetings maximize care. The team meets at least multiple times a week depending on services provided and needs. Care plans are often used by credentialing and certifying oversight bodies to see if integrative medicine is occurring. While this may be a necessity in many settings, one of our successes lies in minimizing extraneous documentation. A lean and agile integrative medicine team documents relevant clinical information and devotes time to patient care and skill acquisition. This is an example of how a small, independent team has advantages over a practice operated by a large healthcare system.

Patient Guide As the patient is a core player in their own recovery and in the treatment team, we take care to lay out the expectations and requirements of patients for them explicitly. At the end of this chapter is a sample of our patient guide to treatment. We place high value in being transparent about our process and involving the patient in their own treatment. Additionally, this gives us a starting point when a patient is attempting to detour from the agreements of treatment or claim that they were unaware of their responsibilities. As with any form of consent, we do not just hand this booklet to patients and expect them to read it, but we review it with them and ensure that they understand what they are agreeing to throughout their treatment in our program.

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Engagement Through Coordination As an increase in prescribed pain medications is partially driving the opioid epidemic, opioid addiction patients are best engaged by offering interconnected primary care and behavioral treatment. Someone calling about our buprenorphine program (see Chap. 8 for description of buprenorphine and other MAT options) first receives clear information about our program: “we provide comprehensive care; we will be your primary care provider as well as provide the buprenorphine; we require at least weekly individual psychotherapy sessions in order for continued dosing of buprenorphine; we require weekly observed urine drug screens for the duration of treatment.” Those who divert buprenorphine as a source of employment hang up. Some callers are excited by the emphasis on individual therapy. Others are surprised they will have a primary care provider, and as one patient commented, “you guys aren’t like other places.” One feature that distinguishes our model is that we plan to care for our patients for the long term with an emphasis on gradual improvement of health and function without an endpoint. Another feature that distinguishes our model program from other intensive drug rehabilitation services is the structure, frequency, and effectiveness of our care coordination. Our care coordination meetings consist of daily huddles focused on practical considerations of patients to be seen on that day, multiple weekly case conferences to review all active patients and collectively create a case formulation on each patient, and weekly didactic meetings to increase the skill base of the entire team across a wide variety of relevant clinical topics. We invite collaborating professionals to our meetings. When a patient requests treatment team meetings, we add those as well. We use meetings to share updates on patients, new laboratory results, records that we have received, and our best case formulations. We support our fellow team members in the emotionally difficult work of integrative medicine. Lastly, we share information about public benefits relevant to our patients including SNAP/food stamps, social security, unemployment insurance, transitional subsidized jobs, Section 8 housing, home energy assistance, and negotiating public transportation. A standard drug treatment center generally offers both counseling and case management, but these services are provided separately, and it is infrequent that a counselor may ever talk to a case manager about a mutual patient. Complicated patients often slip through the cracks in traditional healthcare settings. Lack of access to medical information, lack of time to discuss the case, and most of all, lack of buy-in from the patient to the treatment plan all occur because of a lack of cohesion in a team caring for the patient. Furthermore, efforts by clinicians may contradict one another or neglect to consider the effect of one treatment on another. Patients can play clinicians against one another, circumventing those who give recommendations they do not like or avoiding accountability. These sorts of problems are simply avoided when the team as a unit treats the patient and when they have one place to go for all their care. This, however, requires a common treatment plan and effort.

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Flexibility The way our care is delivered differs from both standard primary care and standard behavioral health services and looks like a cross between the two. Traditionally, primary care is scheduled mostly in an as-needed fashion with infrequent “checkups.” Treatment is usually problem focused, has short appointment times, is fast paced, and emphasizes a medical focus. Traditional behavioral health is structured in more regularly scheduled, slower paced, and time dependent (e.g., “the 50 minute hour”), displays firm boundaries, time dependent fashion and usually emphasizes professional emotional distance. Integrative medicine inculcates patients to come to a regular weekly appointment but also flexes on a case-by-case basis to accommodate the still chaotic lives of recovering people. Integrative medicine meets the demands of patients in the office on that day, which might mean a shorter session to see more people in the waiting room, but it also strives to create the reflective, insight-enhancing, exploratory dialogues that promote long-­term personal development. We look to find the right balance between “love and boundaries” to provide individually tailored continuous and team-­based healing relationships.

Avoiding a Focus on Consequences An important feature that distinguishes our care from traditional drug treatment is our therapeutic use of understanding the individual pattern of behavioral drivers for a given person. Traditional care often attempts to describe consequences of using drugs, losses the patient experienced related to the use of drugs, and may include strict rules and increasing penalties for subsequent infractions. It is a standard idea that people stop using when the price for using drugs becomes too high. We conceptualize patients as displaying a variety of complex behaviors that have been reinforced by their environment over their entire life [3]. We find it therapeutically useful to work with the patient’s feedback from their environment rather than only the relatively limited setting of our offices. We often say “let’s try to think of what you might want your life to be like and discuss how to get there.” As we discussed in Chap. 5, we understand the majority of our patients are extraverted, now-centered, and reward-sensitive. Negative consequences are notoriously ineffective for creating behavior change in this population due to the type of people that most of them are. Thus, we emphasize the current rewards that come from the patient’s life as they achieve their recovery goals over a focusing on consequences. Counterintuitive to most clinicians, talking about the poor health outcomes, familial ruptures, difficulties with employment, and other possible negative consequences of drug use and avoiding care are insufficient to change the behavior of extraverted patients. Instead, focusing on concrete benefits and rewards, like saving money that isn’t being spent on cigarettes or drugs, finding a partner, or other desires the patient has can increase motivation. If a patient is not doing well, a provider might be tempted to say, “if you keep missing meetings, we will have to discharge you.” However, because

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they are consequent insensitive, this will not change behavior. Instead, saying something like “if you come to more sessions, we will be able to help you get housing” can motivate a patient to change their behavior and come in more often. Interventions have to be shaped and explained in a way that will motivate the patient. Understanding and exploring the benefits, rewards, and positive outcomes of the behavior we want from our patients helps to reword the consequences we implement. At times, it is more about how the system is explained than the consequences themselves. For example, a clinic may have a policy that missing weekly appointments results in being required to come in twice or three times weekly. This can be worded for introverts: if you miss an appointment, we will punish you by increasing your session requirements. Or, it can be worded for extraverts: if you come to your appointments, we will give you more time between sessions as a reward. It’s the exact same policy, but worded in a way that correctly considers personality to increase motivation.

Conclusion Enacting integrative care is difficult, but provides the best care for complex patients. The complicated efforts of diagnosis and treatment are greatly enhanced by coordination of care, and many patients fail treatment without it. Each member of the team has a specialty, physicians focusing more on medical care and psychologists on therapy, but everybody on the team talks. Care for the patient is rich and integrated, meshing the best from multiple expertises. Flexibility is key and care is individualized. Every patient needs a program with boundaries and rules, but every patient also needs a treatment plan that’s integrated and individualized. Models that are all programmatic and models that individualize everything tend to fail with many of our patients. Clinicians may have trouble adapting this idea to typical outpatient care, wanting to hold on to the 55 min hour for therapy or a problem-focused 15 min visit for primary care. Yet, if one patient needed a 20 min surgery and another needed a 9 h surgery, would we question adapting how long we spend with the patient? Neither should we question how long we spend with patients or how often we see them in behavioral health or medical care. Some patients need more time than others. At the root of decisions is determining what is best for the patients.

References 1. Strupp HH, Binder JL. Psychotherapy in a new key. New York: Basic Books; 1984. 2. Centers for Disease Control and Prevention. Integrated prevention services for HIV infection, viral hepatitis sexually transmitted diseases, and tuberculosis for persons who use drugs illicitly: summary guidance from CDC and the U.S. Department of Health and Human Services. 2012. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6105a1.htm. 3. Treisman GT, Angelino AF. The psychiatry of AIDS: a guide to diagnosis and treatment. Baltimore: Johns Hopkins University Press; 2004.

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A Sample Guide to Treatment for Patients Julia Hodgson, Kevin Moore, Trisha Acri, and Glenn Jordan Treisman

Abbreviations CYS IOP MAT PO UDS

Children and youth services Intensive outpatient program Medication-assisted treatment; tools in recovery (like Suboxone™/ Subutex™ or Vivitrol™) Parole/probation officer Observed urine drug screen

Introduction The entirety of the chapter—with the exception of this introduction—is an example of a patient guide for a patient in a medication-assisted treatment (MAT) program within an integrative medicine setting. We believe that part of our responsibility to our patients is to ensure that they fully understand what they are committing to when they join our program; we consider this informed consent to treatment. Because we consider them such a vital piece of the integrative medicine team, we are as transparent as possible about our expectations and our responsibilities to our patients as their treatment provider. By detailing our program and providing it to the patient upon entry to the program, we are giving them a resource that they may use ongoingly as an active participant in their own recovery.

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Your Guide to Treatment  art One: Introduction to Expectations, Rights, P and Responsibilities of Patients Expectations of Patients 1. Work on your recovery: • It is your job to commit to your recovery. The team is here to help you. Your job is to work to make changes in every part of your life. 2. Do not take substances—drugs or prescriptions—that you are not currently prescribed: • Opioids (heroin, Percocet™, Tramadol™, etc.), benzodiazepines (Xanax™, Valium™, etc.), alcohol, and muscle relaxers (Flexeril™, etc.) are dangerous for a person on medication-assisted treatment (MAT). • Old prescriptions or prescriptions from another doctor must be reported. 3. Observed urine drug screen: • Every time you come to the clinic, you must give a urine sample while you are watched. • You cannot change the sample. • You may be asked to provide and give a sample. • You will not be given MAT until you give a sample. –– Missing a sample is a reason MAT may be stopped. • It is your job to provide a sample and be honest about what you put into your body. The drug screen will show everything you take, including vitamins and over-the-counter medications. 4. Individual treatment plan: • Every patient has a unique recovery plan. There are guidelines that all must follow that are in this manual. Your plan is created by you and your team. It is your job to follow your own recovery plan. 5. Inductions: • When you are started on medication-assisted treatment (Vivitrol™ or Suboxone™), we will tell you the schedule for your 1st week. We will probably ask you to come in multiple days in a row, first thing in the morning, and expect you to stay for multiple hours up to the whole day. • You will need to plan for this and schedule yourself for this induction period in order to be started. After it is over, your schedule is much more flexible, and you can decide it with your therapist.

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6. Hope and personal responsibility: • The two things you need for recovery are hope and personal responsibility. You need hope that recovery and change is possible. You need to take personal responsibility of your behaviors and choices for your recovery.

Your Rights and Responsibilities Rights You have the right: 1. To not be treated like “an addict” 2. To work with flexible and patient staff who listen to you 3. To be given feedback when you are not meeting the expectations of the program/treatment team 4. To help create your own individualized recovery plan 5. To receive treatment that is based on the most current science and research

Responsibilities You have the responsibility: 1. To take feedback and work to change 2. To show respect at all times to other patients and staff (a) Showing respect includes not threatening, yelling, name-calling, or using slurs. (i) A slur is a negative comment based on race, sex, gender, sexual orientation, gender identity, health status, body type, religion, disability, age, country of origin, or background. 3. To work with the treatment team to improve your recovery, personal health, and community 4. To not bring substances of abuse to the clinic campus, offer or accept medication not prescribed to you, or do other addiction-related behaviors 5. To apologize and make appropriate amends if you are disrespectful toward other patients and staff 6. To not be physically or verbally aggressive to other patients or staff and to not bring weapons of any type to the clinic, or you will be discharged from the clinic 7. To arrange your schedule to fit your recovery plan, including finding childcare, so you can attend appointments

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Part Two: How to Work with Your Treatment Team Your treatment team is made up of your primary care provider, your therapist, the medical staff, and other members of the therapy team. This section answers questions you may have about your medical care.

What Is Primary Care? At the clinic, we are your primary care provider. This means that we do regular medical visits or checkups. We are available if you are sick or have medical concerns. We prescribe medications for psychiatric and other health conditions. To make an appointment with your provider, call the front desk. Please say if there is a more urgent concern, and we will call you back quickly.

What Kind of Medical Services Can I Get? • Bloodwork to check for cholesterol, blood sugar levels, and other important measurements • Blood pressure checks • Hepatitis C screening and treatment • Testing and treatment for sexually transmitted infections (HIV, gonorrhea, syphilis, and chlamydia) • PrEP (preexposure prophylaxis)—a medication that protects you from HIV • Birth control • Gynecological exams and Pap smears • Psychiatric medication management • Medications and tools to stop smoking • Nutrition counseling • Referrals to specialists if needed, including physical therapy • Coordination with specialists and assistance with pain management if you are having surgery

How Do I Learn More About My Health and Diagnoses? We are happy to explain what is going on to you in language that makes sense and to give you the clearest answers we can. We are invested in figuring out what is going on with your health and working with you to come up with the best diagnosis and treatment possible. We need you to be open and honest about what you are experiencing. We need you to trust that we are listening to you and providing you with the best care that is available. We take this job very seriously and have high levels of training and experience taking care of very complicated medical situations. Because medicine is so complicated, we ask that you get your information about what is going on with your health from us—from the doctor, medical team, or your therapist—and not from friends, the Internet, or TV. There is a lot of bad information out there, and we do not want you to be guided to do something that may make you sicker. Unless we recommend a specific website or article, rely on us to answer your questions.

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How Do I Take My Medications Correctly? We will take over prescribing all medications that we think are helpful for you or coordinate with a specialist to make sure you are being taken care of correctly. It is your job to take medications as we instruct. Do not make any changes to your dose or medications by yourself, even if you are having side effects because they may be normal. We cannot do our jobs well if you do not do yours. We work hard to figure out what is the appropriate medication for you. We even use a test that uses a swab of DNA from the inside of your cheek to give us information about which medications your body will respond to best. Every person responds to medication differently, so we use our best judgment to figure out how to treat your specific situation. What works for one person may not work for another, so talk to us to get the best advice and information about your health.

What Do You Mean by a Mind-Body Connection? The mental (mind) and physical (body) parts of you are connected and impact one another. This is why we offer therapy in addition to primary care and take care of the entire person. It also means that there are certain things that we suggest for every person: • Exercise—Even going for a 20 min walk every day can make you healthier and decreases depression, bipolar disorder, and symptoms of many physical and mental health problems. Talk with your treatment team if you need help figuring out types of exercise that you can handle. • Forty hours of activity every week—Whether you are working, volunteering, going to church, or doing other activities, having a full and meaningful routine is very important for your health.

What If I Need Help After Hours or on Weekends? If you are experiencing an emergency, call 911. If an issue that is not an emergency (but you do not think can wait) comes up during a time we are not open, like at night or on the weekend, you can always call our main phone number and leave a message. One of our providers—a medical doctor or nurse practitioner—will be on-call to listen to your message and call you back.

How Do I Work with Staff at the Medical Office? • The waiting room is only for patients who are currently waiting for a service in that building, like a medical visit, giving a sample, or picking up medication. Our waiting room is tiny, so all other patients should wait in the common space where lunch is served. • There is a sign-in sheet to do your UDS and get your medications. You must sign in and then wait for your turn to go—the staff knows that you 13  A Sample Guide to Treatment for Patients

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are there if you sign in. If you leave the building, you will be skipped. Patience is very important. • Please follow any directions given to you by staff. We have a lot going on and give directions to help things go smoothly and safely.

Part Three: Treatment at the Clinic for Addictions Addiction and Recovery Are Long Term Addiction is a chronic disease. It is a lifelong condition. It is not your fault that you are dealing with addiction. It is your responsibility to commit to your recovery. Recovery takes many years and requires you to make changes in every piece of your life. Expect to work on your recovery for your entire life. To help you, we offer long-term treatment. We do not have limits on how long you can be in treatment and do not think that ending treatment after a set time is helpful. As long as you are fighting for your recovery, we are happy to work with you and welcome you back to treatment.

Individual Therapy Everyone is required to see their therapists a minimum of once per week. While medications can be a helpful tool, it is through therapy that you learn how to build the skills and heal from the events in your past that have led to your recovery and are causing you pain. Because the therapy is so important, you will work with one person who will get to know you on a deep level. This means that the two of you will form a relationship of respect and trust, so you can do the difficult work of changing your life. We will do our best to honor specific requests when you first begin, for example, connecting you with someone who works in the evenings if you work during the day. If problems come up, try to work with your therapist to solve them. Working through issues with your therapist is helpful. We take requests to switch therapists very seriously and will work with you to resolve the problem before taking such a serious step. Your therapist’s supervisor may meet with you to help you to move forward and help to solve the problem.

Medication-Assisted Treatment (MAT) At the clinic, we have a few different medications that we can use to help people in recovery. Each works a little differently but requires the same commitment to our program and your recovery. Below, we will talk about each of the options.

Naloxone (Narcan™) Narcan™ is a medication that can reverse an overdose from opioids. We will order you a Narcan™ kit and teach you how to use it, so you may keep it with you in case you or someone else overdoses. It is important to teach your

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loved ones and/or the people around you how to use it and where it is kept. It is legal to use it on another person, and the Good Samaritan law protects people who administer Narcan™ from being arrested.

Naltrexone (Vivitrol™ Shot, Naltrexone Tablets) Naltrexone is a blocker that prevents you from using. It does not help with withdrawal or urges/cravings. The Vivitrol™ shot lasts a month, or the tablets last a day. Program requirements: • • • •

Individual therapy once per week (minimum) Observed urine drug screen (UDS) The clinic designated as primary care provider and prescriber Openness in therapy and commitment to recovery

Buprenorphine (Suboxone™, Subutex™) The main medication we prescribe for addiction is Suboxone™. Suboxone™ is a tablet that is taken multiple times per day and dissolves under the tongue. A version of it, called Subutex™, is used in pregnancy. Suboxone™ helps in three important ways: 1. Prevents urges and cravings to use 2. Blocks the brain from getting high if you do use 3. Prevents withdrawal Suboxone™ is a tool in helping someone who is working on their recovery; it is not a cure. Suboxone™ takes care of the physical effects of addiction, so you can start the hard work of changing your life to get into solid recovery. We use tablets, not strips, in our practice. We typically recommend dosing of two tablets (16 mg) or three tablets (24 mg) per day, depending on what you need to control withdrawal and cravings. Above this dose, there is no added benefit. How much you may need depends on your prior use, how well withdrawal is controlled, and how your body processes the medication. We will figure this out in your first few days with us (during your induction). To take Suboxone™, you must put the tablet under your tongue and wait for it to completely dissolve. This can take 5–10 min. Do not drink or eat anything while it is dissolving. Do not swallow the tablet (you will not get the medication in your system). If you are struggling to take this medication correctly, we are happy to have you meet with a member of the medical team to coach you through taking your dose. Space out your doses throughout your day. If you are on two per day, take them 12 h apart. If you are on three per day, take them 8 h apart. Some people find it helpful to set a timer on their phone to help them to remember to take it regularly. This will allow the medication to stay in your system consistently. Do not skip doses, even if you feel okay. 13  A Sample Guide to Treatment for Patients

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When we start someone on Suboxone™, it is called induction, and we ask people to stay for most of the 1st day and then return a 2nd day. We will ask you to come in mild withdrawal (if you have been using drugs), so we know that the opioids are out of your system enough that you will not get sick from taking Suboxone™. If you have not been using, do not start. If you are already taking Suboxone™, don’t take your morning dose until you are in the office, so we may observe. Then, we check in with you throughout the day and make sure you feel better. This process allows us to: 1. Make sure you are on the correct dose. 2. Take care of you if anything goes wrong (like an allergic reaction or not reacting well because of other use we did not know about). 3. Be sure that we have time to have you meet the prescriber and do a medical visit. Program requirements: • • • •

Individual therapy once per week (minimum) Observed urine drug screen (UDS) The clinic designated as primary care provider and prescriber Openness in therapy and commitment to recovery

The way we dose is unique in our program. We will give you enough Suboxone™ to last until your next scheduled appointment at our clinic. You will receive a maximum of 1 week’s supply of tablets and often less if you are coming in multiple times per week. To receive your Suboxone™, you must provide an observed UDS and go to the individual or group session that you are scheduled to attend that day. When you first start our program, part of the paperwork you are given outlines how we store and handle your medications. We have our own pharmacy, and we require that you make us the people responsible for holding and administering your medication to you. If you decide to leave our program or are otherwise stopped on your Suboxone™, it is our responsibility to dispose of your medication. We will not provide you with whatever is leftover of your script because it is no longer the correct medication for you. We properly destroy and dispose of leftover medications. There are different reasons a person may stop Suboxone™. The best reason is that, after a long period in treatment, you decide with the treatment team that this is no longer a tool that is needed because you are so steady in your recovery. This will likely happen after over a year of abstinence from use and serious commitment to recovery. We ask that you commit to a minimum of a year of Suboxone™. We typically recommend people stay on Suboxone™ up to 5 years and for some to stay on for life. If you miss a therapy session (including if you arrive too late to meet with your therapist at the scheduled time), do not give a UDS, or do not come in on a scheduled day, you will not be given your Suboxone™. You are not guaranteed to get your medication when you return. You need to meet with your therapist and plan how to move forward in your recovery. We take this very seriously and will not restart Suboxone™ until you can prove your commitment to your recovery and our program.

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If you are not working on your recovery goals, we will slowly taper (ween) you off Suboxone™. This will never be a surprise. You will have conversations with your therapist about if you are doing what you need to do in your recovery before a decision is made to taper you. We may consider tapering a person off of Suboxone™ for different reasons. 1. If you have ongoing use of opioids, benzodiazepines, alcohol, or other sedating substances, this may result in a quicker taper/stop of Suboxone™ because it increases risk of overdose and other negative health effects. 2. If we discover that you are not taking your Suboxone™ as prescribed, or are diverting/selling it, you will be stopped. 3. If you are not honest about what you are using—if your UDSs do not match what you are telling us—then we will taper you. 4. If we see that behaviors are not significantly changing over time or there is ongoing use of other substances, we will talk about if our program is effective for you. Your commitment and engagement in recovery are the strongest indicators of success, more than the presence (or lack of) relapses. We do not have a “three-strikes” rule or kick people out for a relapse. However, we demand that you are committed and fighting for your recovery. We want your behaviors to match your words and for you to be consistently making efforts to change your life. We will talk with you if this is not occurring, so you can make decisions about how to move forward. If you are no longer prescribed Suboxone™, you may continue seeing us for primary care. In some cases, therapy may be continued as well. We welcome you back when you are ready to work on your recovery and can discuss restarting Suboxone once changes are made.

Additional Treatment and Benefits Group therapy is available in addition to your individual therapy. Some groups are more open, supportive groups for people in recovery, and some have specific topics, like art therapy or yoga for recovery. Groups are only for current patients of the clinic. Family or partner sessions are offered if an important person in your life wants to come in and learn more about how to be a support in your recovery. We do not do ongoing couples or family counseling but are happy to offer limited sessions to help with challenges that come up in recovery. Community lunch is available for free, Monday–Friday at the community building at noon for patients who are attending the program that day. You will be asked to sign in and to take only enough food for yourself, so there is enough for everyone. Seconds are offered once everyone has had a chance to eat. These extra options depend on the recovery plan you decide with your therapist and team. It also depends on your ability to respect other patients. If you are acting in ways that jeopardize the health or safety of other patients, you will not be allowed to attend groups or other benefits of this program.

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Other Drugs At the clinic, the main thing we treat is opioid addiction. However, we treat the whole person, and this includes other substances that may be abused or adding to addiction. We are strictest about sedating drugs when a person is on Suboxone™—like benzodiazepines, alcohol, barbiturates, muscle relaxers, and opioids—because of the danger of combining them with Suboxone™. We also want to talk about your use of other drugs, like stimulants (Adderall™, cocaine, methamphetamines), marijuana, other prescriptions that we are not providing, and even nicotine. We require that you are honest about all use, even over-the-counter medications. We will work with you to talk about how these substances are impacting you and your life and plan for how to address them within your recovery. While we may not require that you immediately stop every drug, we want to keep the conversation open about how different use is impacting your life. For example, we have medications and other tools to help people to quit smoking if this becomes of a goal in their recovery. Some drugs, like PCP, meth, or cocaine, are more disruptive to your recovery and may be bigger topics of conversation if there is regular use of them. We require that you do not get prescriptions from other providers, however, and we do not believe in the use of stimulants or benzodiazepines for people dealing with addiction, even if you have been prescribed them in the past. These medications act as temporary fixes that block you from building the skills you need to deal with the underlying problems—they make you sicker. We may be able to help you taper off benzodiazepines (depending on how high a dose you are taking) because it is dangerous and even deadly to stop suddenly—if we cannot help you taper down, we will refer you to detox to keep you safe. We will also refer you to detox for alcohol dependence because of the danger of suddenly stopping alcohol.

Complaints/Grievances Dr. Example handles all complaints. If you are unsatisfied with the treatment team’s decision regarding your medication or a taper, this is not a reason to call him; he is aware of decisions made among treatment teams and will support the provider and therapists in these decisions. However, if you are concerned about your safety, privacy, or have other serious concerns, these are reasons to reach out to Dr. Example.1

 art Four: Privacy and How Your Information Is Used P and Protected Confidentiality As we explain in our privacy policy and when you start at our clinic, we take your confidentiality and privacy very seriously. You have the right to have a copy of the privacy policy at any time, which outlines your rights as a patient 1

 Name and contact information redacted; patient manual includes phone numbers.

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in our program. We work hard to protect you and your privacy in most circumstances. There are some exceptions, like when you give us permission to share information or when there is a danger to yourself, someone else, or a child or elder that we are legally required to report to keep you and/or them safe. If you give us permission to disclose (share) any information about you, we will write it in a log that is kept in your patient file. You have the right to request a copy of this log at any time to see who has been given information about your care. Even with your permission, the law limits how much we can share.

Team and Case Conferences An important thing to understand about the clinic is that we work as a team. The team includes medical staff, front desk, therapists, and medical providers. We do not share information outside our agency, but we do not keep secrets from one another on the team. We meet multiple times per week to talk about you and your care, making decisions and figuring out how to best help you with your goals. If you ever want to meet with the treatment team, we are happy to schedule a meeting with you, your therapist, medical provider, and other relevant staff.

Partner and Outside Agencies With your permission, we will talk to other agencies that we work with who may be providing care to you. We like to collect records from other doctors you have seen, so we have a better picture of your medical history. We belong to the local health information exchange, which sends us notifications if you are in the hospital, so we can communicate and make sure you are taken care of. All hospitals in this region participate in the local health information exchange. We will also reach out after any hospitalization and try to get records. It is very helpful if you bring in any discharge papers or documentation you are given to speed up the process. If you attend IOP or treatment elsewhere, we will talk to them and coordinate care. One example of a partner agency is Example IOP, who we work with so we can help one another to support you in your recovery. It is important that you are an active member in all programs that you are involved with. Trying to manipulate or play different providers against one another only hurts you and your recovery. We have special releases for legal entities (probation/parole) and children and youth services (CYS). We are limited in what we can tell these agencies, and we may only talk to them with your permission. If you are involved in either system, you are not required to give us consent to talk to them but should discuss this with your therapist. We will not lie or mislead CYS or POs but are happy to confirm your attendance and advocate for you when you are doing well. You have the right to refuse to give us consent to speak to other agencies. Please have a conversation with your therapist about this choice, so we can answer any questions or calm any of your worries. 13  A Sample Guide to Treatment for Patients

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Records We keep records of all medical visits, labs, and therapy appointments in our clinic. You have a right to the medical chart, which includes notes from the medical provider. You may request these records, and we will provide them in a reasonable amount of time. We do not give out copies of urine drug screens or therapy notes. We can write a summary of your progress in therapy if requested.

Conclusion You have taken an important step in your recovery by seeking out help and support. We are honored to be a part of your journey and know we can help you to achieve your recovery goals and change your life!

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Conclusion Julia Hodgson, Kevin Moore, Trisha Acri, and Glenn Jordan Treisman

Treating patients with chronic medical and psychological comorbidity depends on the accuracy of the diagnostic formulation, as every element of intervention is based on treating the disordered elements of a patient. It also depends on the clarity of the treatment plan so that different members of the team can effectively deliver the correct care. Team communication allows for refinement of both the diagnostic formulation and treatment plan and is perhaps the most essential part of integrated care. This work requires a strong commitment, creative problem-solving, clear and continuous communication, and vision that adapts while applying stringent standards of efficiency and efficacy. Most of all, it requires a particular mind-set in the clinicians and staff who are bold enough to accept the call of working with the most challenging circumstances and patients. This book was started as a way to document the work that we and others have done and to inspire others to adopt this model to help the most vulnerable patients in our society. The work goes beyond the logistics that have been described in setting up and operating within an integrative setting. This work requires a sense of advocacy, a belief in the concept that helping others improves the health of all and that the people we treat have come to us as a result of misfortune, illness, and frustration, rather than through malfeasance, laziness, or evil intent. When we see evil behavior, we need to evaluate whether it is a product of illness or a genuine ill intent. The patients in need of integrative medicine are marginalized, stigmatized, and have no real voice with which to speak up for their needs and advocate fully for themselves. The people who work with them, then, must be that voice. Advocacy, education, research, and looking carefully at the assets of the person as well as the vulnerabilities make a huge difference. For those without access to an integrative clinic, the values and mind-sets of integration and coordination may still be practiced. Breaking down hierarchies, increasing communication, and training clinicians to think holistically always improves care and outcomes.

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The authors of this book have spent our careers in the practice and refinement of integrative models of care. We have not “burned-out” in working with our patients, but instead have had the rare privilege to see the miracle of a person reborn and successful after years of illness and dysfunction. Not every patient gets completely well, but we remain hopeful for all as we have not been able to predict who will get well. Even some of the most stubborn and refractory patients have had dramatic recoveries, while others have languished despite our best efforts. We are inspired by those who succeed, and while we are saddened by those who do not, we understand that if you treat seriously ill patients, some will not do well. Our efforts to refine our skills, to know more, and to be more effective are driven by both our surprising successes and our disappointing failures. This practice is not for the faint of heart, but for those who can master this practice, it is renewing and exciting. In the Talmud is the famous quote, “...And whoever saves a life, it is considered as if he saved an entire world” [1].

Reference 1. Mishnah S 4:5; Yerushalmi Talmud 4:9, Babylonian Talmud Sanhedrin 37a.

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Index

A Addiction ADHD, 37 adjunctive pharmacotherapy (see Adjunctive pharmacotherapy) ambivalence (see Motivational interviewing (MI)) amplification loop, 41 animal behavioral models, 41, 42 behavior and brain physiology, 41 benzodiazepines, 37, 41 cocaine, 37, 40, 42, 43 complication, 43–46 definition, 40 diagnosis, 49, 50 drug overdose deaths, 37, 38 lifetime opioid dependence diagnosis, 89 long-term treatment, 91, 93 opioid epidemic, 46–49 patient guide benzodiazepines, 188 community lunch, 187 complaints/grievances, 188 family/partner sessions, 187 group therapy, 187 individual therapy, 184 marijuana, 188 MAT (see Medication assisted treatment (MAT)) recovery, 184 policy makers, 90 post-script, 147, 148 psychological interventions, 89 psychostimulants, 37, 39 psychotherapy, 89 relapse and crave, 42 relapse prevention skills

animal models, 95 identifying triggers, 96 re-exposure, 96, 97 strategies, 97–99 stress-induced relapses, 97 stigma and stereotypes, 50, 51 substance use disorder, 39, 40 traditional psychotherapy vs. recovery-o ­ riented therapy, 93–95 trauma (see Post-traumatic stress disorder (PTSD)) treatment contracts, 50, 90–92 Adjunctive pharmacotherapy buprenorphine, 109, 112–116 chronic pain anticonvulsants, 127 anti-depressant medications, 126 disulfuram, 128 drug-seeking, 125 evaluation, 125 graded activation, 127 initiating care, 126 low back pain, 127 medication, 125 naltrexone, 127 non-medication interventions, 127 non-opioid treatment options, 125 non-opioid medication treatments, 126 non-pharmacologic, 125 opioids block, 125, 126 opioid treatment, 125, 128 patient satisfaction ratings, 126 2012 National Health Interview Survey, 126 types, 125 vital sign, 126 methadone, 110

© Springer Nature Switzerland AG 2020 J. Hodgson et al., Integrative Medicine for Vulnerable Populations, https://doi.org/10.1007/978-3-030-21611-5

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Adjunctive pharmacotherapy (cont.) multidisciplinary team, 109 naloxone, 110, 112, 116, 117 naltrexone, 113 opioid addiction, 113, 114 opioid maintenance, 110 types, 110 UDSs (see Urine drug screens (UDSs)) Advocacy, 191 Alcoholics Anonymous, 93 Amphetamines, 135 Angelino, A.F., 23 Arousal-related symptoms, 103 Assistors, 154 B Bacterial pneumonia, 79 Benzodiazepines, 30–32 Bregman, P., 157, 158 Broken-heart syndrome, 12 Buprenorphine, 112–116, 175 MAT, 185–187 C Charles Bonnet syndrome, 11, 12 Children and youth services (CYS), 189 Chronic illness, 167, 192 Cocaine, 132, 135, 139 Co-location, 16, 19 Community acquired pneumonia, 80 Coordinated care, 171, 172 Coordinated treatment skills consequences, 176, 177 coordinated care, 171, 172 intake process agreement, 171 medication, 170 motivation, 171 patient’s concerns and symptoms, 169 personal history, 170 recovery history, 170, 171 social context, 171 substance use history, 170 planning benefits, 175

194

Index

buprenorphine, 175 care plan, 174 complication, 175 flexibility, 176 intensive drug rehabilitation, 175 opioid addiction, 174 patient guide, 174 STD, 173 D Deductive logic, 79, 80 Dennis, M.L., 118 Depression, 134, 135, 144–146 Diagnosis algorithm, 79 bacterial pneumonia, 79 community acquired pneumonia, 80 co-morbidity, 85 deductive logic, 79–82 diagnostic formulation, 80, 81 headache and fatigue, 80 IgA deficiency, 80 inductive logic, 80, 82, 83 major depression, 83 obesity, 83 Ockham’s principle of parsimony, 81 patient care, 85 patient evaluation, 80 psychiatric illness, 85 reliability, 81–84 uncertainty, 80 validity, 81–84 Diaphragmatic breathing, 103, 143 Doctor-patient relationship, 23 DSM 5 criteria, 134 E Early interprofessional education (IPE), 164, 165 Ericsson, K.A., 165 Evaluation and management code, 21 Extraversion, 60–63, 65, 66 Eysenck, H., 60 Eysenck, S., 60

F Fatigue, 135 Freud, 56 G Gonorrhea, 133 Grimm, J.W., 42, 95 Guided imagery, 104 H Hackman, J.R., 155, 157 Heath, B., 16 Hepatitis B, 131, 133 Hepatitis C, 24, 131, 133, 144–146 Heroin, 132 HIV, 131, 133, 138, 142 Hope, B.T., 42 Human Resources (HR), 157 I ICD, 77 IgA deficiency, 80 Induction appointment, 172 Inductive logic, 80 Insurance and public benefits, 167 Integrated diagnosis, 133, 134 Integrated treatment depression, 144–146 hepatitis C, 144–146 HIV, 142 maintenance, 147 suicidality and acute symptom management addiction, 144 antidepressant and antipsychotic, 142 flexibility, 143 medications, 143 overconfidence, 142 panic attacks, 143 placebo effect, 143 trauma work, 146 Integrative medicine appendicitis, 5 assisters, 154 benzodiazepines, 30–32 communication and collaboration, 24, 25 complexity and longevity, 131

definition, 4 depression and anxiety, 6 doctor-patient relationship, 23 education and expertise, 23 effective teams characteristics, 155, 156 definition, 155 larger agency, 156, 157 organizational psychology, 155 size, 156 gathering and sharing, 25, 26 goals and vision, 151 healthcare model, 3 leadership liability, 158, 159 qualities, 158 setting, 157 longevity, 4, 5 medical providers, 153, 154 mental health specialist, 153 mind-body dualities Charles Bonnet syndrome, 11 fight/flight instinct, 11 intersectionality, 12 medical disorders, 12 stress, 11 sympathetic arousal, 11 Takotsubo cardiomyopathy, 12 obesity, 6 patient advocacy, 26, 27 patient-centered care, 27, 154, 155 patient satisfaction, 27–29 patient’s co-morbidities, 6 patient’s quality of life and function, 4, 5 process of, 132 randomized clinical trials, 3 specialty referral care, 6 super-utilizers and fractured healthcare chronic conditions, 8 health care spending, 7, 8 health insurance plan, 7 medicaid, 7 mood disorders and addiction, 8–10 patient responsibility and adherence, 7 target population, 6 waste of resources, 4 wheel metaphor, 152

Index

195

Integrative training model for clinicians and staff, 166, 167 expertise development, 165, 166 IPE, 164, 165 professional silos advantages, 163 communication, 163 in healthcare, 161 highly-skilled surgeon, 163 integration, 163 medical decision making, 162 neurosurgeon’s strengths, 162 patient history, 162, 163 specialized procedural roles, 162 specialized training, 162 training institutions, 161 resentment/territoriality, 167 trainees benefits, 163, 164 undeniable hierarchies, 167, 168 Introversion, 60–63, 65, 66 J Jaspers, K., 55 K Katzenbach, J.R., 155 Kolodny, A., 109 L Leadership, 157–159 Local health information exchange, 189 Low back pain, 26 M Major depressive disorder, 134, 135 McGregor, D., 155 McHugh, P.R., 55 Medical providers, 153, 154 Medication assisted treatment (MAT), 172, 179 buprenorphine, 185–187 naloxone, 184 naltrexone, 185 Medico-legal responsibility, 159 Methadone, 110 Meyer, A., 56 Michael, 162, 163 Miller, W.R., 62, 63 Models of integrative practice

196

Index

billing and finances, 20–22 case formulation, 15 co-location, 16, 19 integrative behavioral medicine, 19, 20 medicine, psychology, and nursing, 15 primary care, 15 reverse co-location, 19 SAMHSA-HRSA levels, 17–18 Mood disorders, 8 Motivational interviewing (MI), 99 affirmations, 100, 101 change talk, 99 engaging, 99, 100 evoking, 99, 100 focusing, 99, 100 information/advice, 100, 101 open-ended questions, 100, 101 planning, 99, 100 reflective listening and statements, 100, 101 righting reflex, 100 sustain talk, 99 therapeutic work, 99 treatment outcomes, 99 N Naloxone, 110, 112, 116, 117, 184 Naltrexone, 113, 185 Nandagopal, K., 165 Narcan™, 184 Narcotics Anonymous, 93 National Institute for Health Care Management, 7 O OB-GYN services, 153 Obsessive compulsive disorder (OCD), 76 Opioid use disorder, 48 P Panic attacks, 103, 104 Patient advocacy, 26, 27 Patient-centered care, 27 Patient conceptualization biopsychosocial model, 55 deficit from disease, 76, 77 disrupted life story

adult-child sexual contact, 57 assumptions, 57 behavior, feelings, and thoughts, 56 cycle of experience, 56, 57 history of introspection, 56 isolation/negative experiences, 58 narcotics, 58 positive aspect of, 58 psychology, 56 self-analysis and description, 56 sexual career variables, 57 toxic environment and struggle, 57 introversion and extraversion, 60–63, 65, 66 maladaptively conditioned behavior addictions and paraphilias, 73 addictive drugs, 73, 74 appetitive behaviors, 75 associational conditioning, 71–73 human behavior and dysfunction, 70 methadone/buprenorphine, 75, 76 sexual activity, 73 shape behavior, 70, 71 social, genetic, and environmental circumstances, 74, 75 Thorndike’s law of effect, 70 medical setting, 64 pathological entity, 55 problematic personality, 69 psychiatric disorders, 55 role induction conversation, 69 stable extraverts, 66, 67 stable introverts, 68 stable spectrum, 63–66 temperament confounds clinicians, 69 therapeutic behaviors, 69 unstable extraverts, 65, 66 unstable introverts, 68 unstable spectrum, 63–66 vulnerabilities of endowment, 59, 60 Patient guide addictions benzodiazepines, 188 community lunch, 187

complaints/grievances, 188 family/partner sessions, 187 group therapy, 187 individual therapy, 184 marijuana, 188 MAT (see Medication assisted treatment (MAT)) and recovery, 184 confidentiality, 188, 189 partner and outside agencies, 189 patient expectations, 180, 181 patient responsibility, 181 patient rights, 181 records, 190 team and case conferences, 189 treatment team emergency, 183 health and diagnoses, 182 medical office, 183 medical services, 182 medications, 183 mind-body connection, 183 primary care, 182 Patient satisfaction, 27–29 “Pay for performance” models, 21 Personality disorder, 59, 138, 139 Post-traumatic stress disorder (PTSD), 136, 137, 158 avoidance, 104 diagnostic features, 101 hyperarousal, 103 impulsivity, aggressive behaviors, hostility, 101 integrative medicine sites, 101 life-threatening events, 100 major depression, 103 mood and cognitions, 104, 105 overview, 102 re-experiencing/intrusion, 105 safety, 105 treatment issues, 106, 107 Probuphine, 113 Progressive muscle relaxation (PMR), 103, 104, 143 R Reverse co-location, 19 Reynolds, K., 16 Robert Cloninger’s seven factor model, 60 Rollnick, S., 62, 63 Roring, R.W., 165 Index

197

S Schema-based inductive reasoning, 82 Schizophrenia, 93 Scott, C.K., 118 Sexual abuse, 133 Sexually transmitted disease (STD), 173 Shaham, Y., 42 Skillful therapists learn techniques, 94 Slavney, P.R., 55 Smith, D.K., 155 Stigma, 50, 51 Stress, 11 Suboxone™, 185–187 Substance use disorder (SUD), 26 behavioral reinforcement drugs, 139, 140 religiosity and seeking treatment, 141 sex work, 140, 141 heroin, 137 medical concerns, 137, 138 personality, 138, 139 smoking, 137 Subutex™, 185–187 Suicidal planning, 133 Syphilis, 133 Szsaz, T., 77

U Urine drug screens (UDSs) accountability, 117, 118 buprenorphine levels inconsistent use and relapses, 122, 123 laboratory data, 124 norbuprenorphine, 119 stable, consistent metabolism, 119, 120 stable, variable metabolism, 119–121 Suboxone™, 119 tapering off, 120, 122 team approach, 124

T Takotsubo cardiomyopathy, 12 Team communication, 191 Team dynamics, 158 Traumatic reactions, 135–137 Treisman, G.T., 23

X Xanax, 30

198

Index

V Vivitrol™, 185 W Whelan, J., 117 White, W.L., 118 Wise, R.A., 42 Wise-Romero, P., 16

Z Zimbardo, P., 60