Interviewed by Mark Gold, MD
FEATURED ADDICTION EXPERT:
John Thompson, MD
Professor, Chair, and Director, Division of Forensic Neuropsychiatry
Founding Director, Fellowship in Forensic Psychiatry
Tulane University School of Medicine
Nora Volkow has described addiction as a disease of free will. Our group has shown for impaired professionals that coerced or involuntary treatment has the same outcome as voluntary treatment. What are your thoughts about involuntary hospitalization for addicts? Don’t you think many of the addicts who have died during this opioid epidemic might be alive if their local MD or family could have initiated commitment?
Free will vs. disease is an argument that has little meaning to me and likely to Dr. Volkow as well. Chicken or egg arguments undermine the complexity of the addiction problem and often thwart treatment. When a drug enters the human body it cares little about why or how it got there, its just looking for a receptor to occupy. Thorough evaluation, accurate diagnosis, and effective long-term treatment pave the road to good outcomes.
It is my opinion that involuntary treatment must have a prominent place in the treatment of addictive disorders. Generations in the future will look back on our response to the addiction epidemic and say, “What were they thinking”? Allowing addicted individuals to “die with their rights on” is the true iatrogenic disease of our time. Lawyers and advocates lobby for individual rights while individuals are dying by the thousands. We as a society are allowing patients with “diseases of their brains” to make poor decisions with the very same brains that are diseased in order to protect their free will. We know forced treatment and contingent treatment works especially while the individual is recovering from short- and long-term drug effects.
PCP, cocaine, methamphetamine and other drugs are associated with violence and violent behaviors, even directed at EM or healthcare personnel. When a psychiatrist evaluates them for commitment or violence, what should he or she ask or do?
Whenever I evaluate a potentially aggressive patient I want to know his or her behavior in the past two weeks, previous long-term behavior patterns exhibited, and significant psychiatric and antisocial tendencies so that I can develop a rational treatment plan to deal with these issues. Most aggressive patients are playing out a script of violence that has happened over and over in their lives. If you know the script, you are way ahead of the game when planning treatment options. The dance of aggression is specific to each patient and the drug is merely a catalyst that speeds up or disinhibits the process. Most drugs of abuse increase aggressive behavior, including THC intoxication and withdrawal, which is commonly present in the patients we evaluate who have been charged with serious crimes of violence.
Psychiatrists are often asked to evaluate patients who need a liver transplant, some who have had hepatitis and others cirrhosis related to SUDs. How do you decide who is an appropriate candidate for a transplant?
It’s not rocket science if you perform a thorough evaluation of the surgery candidate. The poor candidates for surgery will have obvious addictive disorders. The important take-home point is to advocate for holding off on surgery if possible and getting the patient into meaningful treatment. While psychiatric and psychological evaluations are often mandated, they are also frequently downplayed or ignored. It is rare that a surgery will actually be postponed or cancelled due to an addiction or psychiatric issue in my experience. Advocate for your opinions when a patient is clearly a poor candidate and you will be doing a great service to other patients waiting in line for transplant, who are committed to sobriety.
Are some drug related crimes ever considered in an insanity defense or not? Why? Some examples of drug-related paranoid psychotic homicides include the Manson family. What makes one murderer, who committed their crime under-the-influence, not guilty by reason of insanity and another guilty with mitigating factors?
Most state statutes and federal law look down on insanity pleas that are associated with chronic substance use. Exceptions can include “involuntary intoxication” that is out of the defendants control. The horrific story of the Manson family and routine heavy LSD and alcohol use is one example. The Manson Girls and Tex could not sell an insanity defense because of their chronic voluntary use. If the murders had occurred after a single or first use of LSD, they might have had a chance at insanity as a defense. Historically, voluntary intoxication has been frowned upon by most cultures since recorded history.
Lord Chief Justice Matthew Hale in 1736 wrote, “ A person who commits an offense while he or she is afflicted with dementia affectata (intoxication), shall have no privilege by the voluntary contracted madness, but shall have the same judgment as if he were in his right senses.” This dictum has become know as the voluntary intoxication exclusion.
Some states allow for lowering of the charge to a lesser charge if the person was clearly intoxicated and it affected his or her ability to form the mental state need to meet the charge.
Can you explain DUI laws as they relate to blood alcohol content (BAC)? Are these laws and blood level response relationships similar for riding a bike? The DSM assumes that the MD ruled out being under the influence of alcohol or drugs when making a psychiatric diagnosis. So, why don’t psychiatrists do a BAC or breath test on every new evaluation in the ED or office?
Briefly most laws have a minimal alcohol content that equates to an offense of DUI, .08mg% is a common level used in many states. Some states also use .055mg% plus failure of a field sobriety test before charges of DUI are prosecuted. Other drugs of abuse are much more complicated. Marijuana is obviously causing concern as testing modalities lag behind use patterns and THC intoxication is hard to measure. Several new tests are in development.
Wide spread use of breathalizer is likely curbed by accuracy and chain of custody issues. Other testing is limited by financial and laboratory availability in each system.
Limited use in psychiatry is likely secondary to the misguided belief that most patients are being honest with their doctors, which we know is unrealistic in addiction evaluation and treatment. In my experience, general psychiatrists and general practitioners rarely use substance use disorders to exclude psychiatric diagnoses. This is a major difficulty in accurate diagnosis. This is an educational issue that academic institutions must take on and champion. Nora Volkow commonly gives examples in her talks on addiction regarding her experience on consult service where addictive disorders and diagnoses were routinely ignored.
Tulane has one of the best double board programs with Fellows training in Internal Medicine and Psychiatry. After training, which specialty do they practice? If you had to list the last 25 graduates, what kind of academic or job setting did they take?
Our MED-PSYCH residents practice in a variety of settings. Some focus on internal medicine and use the psychiatry training to deal with the many psychiatric issues in primary care. Others practice psychiatry and use their medical training to feel more comfortable in acute settings. I am proud that many have used their unique skill set to improve Medically-Assisted Treatment.
Can you describe some classic forensic cases you have seen and evaluated and provide some outcomes?
The typical cases that we deal with in our forensic system are chronic mentally ill and substance using individuals who commit serious crimes while psychotic and are sent to the state hospital for treatment and gradual return to the community. Since we have the ability to mandate treatment post hospitalization with a conditional release model, we can often move individuals safely into the community and help them maintain sobriety, resulting in a great track record of safe outcomes. Comparing groups of forced treatment with conditional release orders vs. those civil committed and released with no order, we see clear winners in the forced treatment category. Families often relay to us that their family members are much less symptomatic in the forensic system because they stay on their medication and are forced to remain clean and sober.
You have thought about the tobacco litigation and tobacco companies, have you thought about the opioid epidemic and litigation related to the pharmaceutical companies who over-manufactured opioids, trained MDs and promoted use in non-malignant pain, and who over-stated safety and minimized addiction liability?
This is a complex problem that likely has no simple solutions. I believe that physician awareness of the addiction potential of all pain relieving medications that attach to opiate receptors is the key. It’s easy to blame companies for complex human behavior but blaming does little to address the addiction epidemic. The root cause of the problem emerges from an overemphasis by all parties (doctors, patients, and drug companies) to find the easy to administer “magic bullet” that will “cure” addiction without cognitive treatment. This dogged pursuit, in my opinion, has lead to devaluing the complexity of the problem as well as the importance of the physician-patient relationship.
In my 30 plus years of psychiatric care and treatment I have found very few “magic bullets”. Pain treatment is complex and a few simple rules can keep most doctors and patients out of trouble:
- Use pain meds to treat acute pain in the shortest amount of time necessary.
- Don’t use pain meds to treat psychiatric or emotional conditions that enhance pain but are not the root cause of the pain.
- Use adjunctive treatments and therapies for emotional or chronic pain issues.
Mindfulness therapies such as yoga, stretching, and meditation have clinical efficacy and yet are rarely used or studied. Hypnosis is awesome for acute and chronic pain but is woefully underutilized. There is, unfortunately, little funding from NIDA or SAMSHA studying the use of hypnosis and mindfulness therapies in pain management.
Post addiction anhedonia and depression are common. Suicide evaluation is part of every good psychiatric evaluation. But for many addicts they are simply detoxed or treated with Narcan or referred elsewhere. Are these psychiatrists responsible for a comprehensive suicide evaluation and what should any suicide evaluation or this SUD related one include?
Narcan is no substitute for a good psychiatric assessment to include a suicide risk assessment. Narcan wakes the patient up to the same reality they were experiencing before they overdosed. A psychiatric assessment and suicide risk assessment gives the treatment team the tools they need to design a program of resilience and recovery. The common risk factors that I typically emphasize with residents include active suicidal ideation with a plan, lethality of the plan, comorbid psychiatric disorder, and comorbid substance use disorder. Previous suicide attempts and family suicides are also worthy of consideration and are emerging as important risk factors. If the clinical team develops a plan to address the “dynamic” risk factors and documents the plan, they are way ahead of the game in addressing the risk reduction strategies necessary for good outcomes. Suicide prevention is everyone’s job; 30,000 plus Americans lose their lives to suicide each year. Many opiate overdoses are likely suicides or suicide attempts in my opinion and thus should be taken just as seriously.
- Take the time to perform a thorough evaluation and document your rationale. A five-page history with a one line assessment and plan does little to explain your rationale.
- Document Informed Consent with the patient on new medications and drug interactions. A simple line in your note: “ I discussed the risks and benefits of medications prescribed and drug interactions to include common and serious side effects tailored to this patient.”
- Document that you warned about the use of alcohol or drugs by the patient. “The patient was warned that the use of alcohol or drugs may decrease the effectiveness of medications prescribed and/or increase sedation.”
- Ask for medical records even if you know you will not get them in time to assist you in medical decision making.
- Perform and document practical risk assessments with a plan to address common dynamic risk factors. “The patient’s major two dynamic risk factors for suicide are Major Depression (which I am treating with antidepressant medication and cognitive behavioral therapy) and Alcohol Dependence (which I am treating with naltrexone and referring him for substance abuse counseling/motivational enhancement therapy). Other factors in his life are protective, stable marriage, good social support, and stable employment. With the above plan he/she is a low risk for completed suicide in my opinion.”
Finally, the best overall advice is to practice sound medicine, document your rationale, and have good malpractice insurance. If you are sued, take the time to meet with and listen to your attorney. Avoid arrogance in depositions and on the witness stand. Humility and methodical descriptions of your best practices usually wins the day. Also seek the advice of a forensic psychiatrist with experience in malpractice actions to help calm your concerns and assist your attorney in mapping out a practical defense.