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Thursday, January 31, 2019

Choosing the right mental health provider

The crushing toll of the opioid crisis is daily news, including stories about ways to “fix” it. A wide array of initiatives has been brought forward in an attempt to curb this epidemic and the damage it causes. Prescription monitoring programs (PMPs) are one of them. The goal of PMPs is a good one — to identify patients who are being prescribed multiple medications by multiple clinicians. It is a means to introduce some stewardship for preventing overuse and misuse of prescription drugs.
How prescription monitoring programs work

Prescription monitoring programs are state-based electronic databases that provide a way to track prescriptions, specifically controlled substances including opioids, benzodiazepines, and amphetamines. They are intended to support access to legitimate medical use of these drugs, and to help identify and deter drug misuse and diversion (when medications are not used by the person for whom they were prescribed). Currently 49 states, the District of Columbia, and Guam have PMPs, and in many states providers must access the PMP before prescribing a controlled substance.

PMPs have had some success, with several states demonstrating an overall decrease in prescription opioid overdose after implementation. At the same time, there are several challenges hindering effective use of prescription monitoring programs, including issues of lag time, state to state variability, and important privacy concerns. These issues need to be addressed as this tool is used more and more frequently.
Prescription monitoring programs in medical practice

I work in emergency medicine, and the emergency department (ED) is on the front line of this epidemic in many ways. Not only do we treat people who overdose, but many patients who come through our doors are in pain and need our help. But there are some patients who come to the ED with the sole intention of getting a prescription for an opioid pain medicine, either for illicit use or with the intention of selling it. These same individuals may go to multiple EDs, obtaining several prescriptions in a single day. The ED isn’t the only place this sort of thing happens; some patients are prescribed the same opioid medication by two or sometimes even three different doctors.

The PMP should help “weed out” patients with this risky behavior, and allow the prescriber to identify such individuals and ideally get them help. Good intentions aside, there are some unintended and negative consequences of PMPs. The PMP can incorrectly target some patients. And for those people the system may actually do more harm than good, including taking away much needed medications. The results include poorly managed pain, inadequate palliative therapy, and in some cases driving patients to turn to illicitly obtained prescriptions or street drugs like heroin and fentanyl.
Unintended harms of prescription monitoring programs

I like to use a case as an example. I had a young woman who came to my ED one day with thoughts of self-harm. She said that she felt hopeless and lost. She had suffered from a chronic, painful condition for many years. A small daily dose of oxycodone managed her pain and allowed her to live a normal life. Other treatments hadn’t worked for her and she had never misused this drug. When she changed primary care doctors, her new doctor, who had accessed the PMP, stopped the prescription. While the concerns were legitimate, that left the patient in pain and this eventually led her to buying oxycodone from friends, then on the street, and eventually she started using heroin. She was now homeless, addicted, and contemplating suicide. This example is extreme, but illustrative. As we navigate the opioid epidemic, we must attend to appropriate use as well as misuse. Opioids have a place, such as when treating people with cancer pain or those receiving palliative or end-of-life care. The deep concerns among prescribers about misuse and diversion are completely justified, yet we must make sure that the pendulum doesn’t swing too far and cause harm to those patients who need these medications.
Beyond prescription monitoring programs: Prescribing stewardship

The PMP is a valuable tool, and it has helped to identify patients who may need help with substance misuse. However, as with any tool it needs to be used with caution. Not every patient who gets an opioid is misusing it, and there are many for whom opioids mean the difference between suffering and being able to manage pain. There is certainly a lot of room for prescribers to do a better job addressing pain, discussing both drug and nondrug options as well as early referral to pain clinics. Prescribers, policy makers, and the public need to ensure that these medications are available to the people who truly need them, for the short or long term. The opioid epidemic is a crisis, and we need to develop strategies to reduce harm and the loss of life. At the same time, we need to be vigilant that our approach doesn’t cause unintended harm. “Treat the patient, not the number.” This is a very old and sound medical school teaching. However, when it comes to blood sugar control in diabetes, we have tended to treat the number, thinking that a lower number would equal better health.

Uncontrolled type 2 diabetes (also known as adult-onset diabetes) is associated with all sorts of very bad things: infections, angry nerve endings causing chronic pain, damaged kidneys, vision loss and blindness, blocked arteries causing heart attacks, strokes, and amputations… So of course, it made good sense that the lower the blood sugar, the lower the chances of bad things happening to our patients.
Tracking blood sugar control over time

One easy, accurate way for us to measure a person’s blood sugar over time is the hemoglobin A1c (HbA1c) level, which is basically the amount of sugar stuck to the hemoglobin molecules inside of our blood cells. These cells last for about three months, so, the A1c is thought of as a measure of blood sugars over the prior three months.

Generally, clinical guidelines have recommended an A1c goal of less than 7% for most people (not necessarily including the elderly or very ill), with a lower goal — closer to normal, or under 6.5% — for younger people.

We as doctors were supposed to first encourage diet and exercise, all that good lifestyle change stuff, which is very well studied and shown to decrease blood sugars significantly. But if patients didn’t meet those target A1c levels with diet and exercise alone, then per standard guidelines, the next step was to add medications, starting with pills. If the levels still weren’t at goal, then it was time to start insulin injections.

While all this sounds very orderly and clinically rational, in practice it hasn’t worked very well. I have seen firsthand how enthusiastic attention to the A1c can be helpful as well as harmful for patients.

And so have experts from the Clinical Guidelines Committee of the American College of Physicians, a well-established academic medical organization. They examined findings from four large diabetes studies that included almost 30,000 people, and made four very important (and welcome!) new guidelines around blood sugar control. Here’s the big picture.
Doctors and patients should discuss goals of treatment together and come up with an individual plan

Blood sugar goals should take into account a patient’s life expectancy and general health, as well as personal preferences, and include a frank discussion of the risks, benefits, and costs of medications. This is a big deal because it reflects a change in how we think about blood sugar control. It’s not a simply number to aim for; it’s a discussion. Diabetes medications have many potential side effects, including dangerously low blood sugar (hypoglycemia) and weight gain (insulin can cause substantial weight gain). Yes, uncontrolled blood sugars can lead to very bad things, but patients should get all the information they need to balance the risks and benefits of any blood sugar control plan.
An A1c goal of between 7% and 8% is reasonable and beneficial for most patients with type 2 diabetes…

…though if lifestyle changes can get that number lower, then go for it. For patients who want to live a long and healthy life and try to avoid the complications of diabetes, they will need to keep their blood sugars as normal as possible — that means an A1c under 6.5%. However, studies show that using medications to achieve that goal significantly increases the risk of harmful side effects like hypoglycemia and weight gain. To live longer and healthier and avoid both the complications of diabetes as well as the risks of medications, there’s this amazing thing called lifestyle change. This involves exercise, healthy diet, weight loss, and not smoking. It is very effective. Lifestyle change also can help achieve healthy blood pressure and cholesterol levels, which in turn reduce the risk for heart disease. And heart disease is a serious and common complication of diabetes.

Lifestyle change should be the cornerstone of treatment for type 2 diabetes. The recommendations go on to say that for patients who achieve an A1c below 6.5% with medications, we should decrease or even discontinue those drugs. Doing so requires careful monitoring to ensure that the person stays at the goal set with his or her doctor, which should be no lower than 7%, for the reasons stated above.
We don’t even need to follow the A1c for some patients

Elderly patients, and those with serious medical conditions, will benefit from simply controlling the symptoms they have from high blood sugars, like frequent urination and incontinence, rather than aiming for any particular A1c level. Who would be included in this group? People with a life expectancy of less than 10 years, or those who have advanced forms of dementia, emphysema, or cancer; or end-stage kidney, liver, or heart failure. There is little to no evidence for any meaningful benefit of intervening to achieve a target A1c in these populations; there is plenty of evidence for harm. In particular, diabetes medications can cause low blood sugars, leading to weakness, dizziness, and falls. There is the added consideration that elderly and sick patients often end up on a long list of medications that can (and do) interact, causing even more side effects.
The bottom line

There is no question that type 2 diabetes needs to be taken seriously and treated. But common sense should rule the day. Lifestyle changes are very effective, and the side effects of eating more healthfully and staying more active are positive ones. Every person with type 2 diabetes is an individual. No single goal is right for everyone, and each patient should have a say in how to manage their blood sugars and manage risk. That means an informed discussion, and thoughtful consideration to the number. When faced with mental health conditions such as depression, anxiety, or other symptoms of the mind and brain, it can be difficult to know where to find the best care. In part, the challenge of finding the right professional for you stems from the highly variable manner in which mental health concerns can emerge. One person’s depression, for example, may be very different than someone else’s, and the same can be said for anxiety, post-traumatic stress, obsessionality, attentional issues, substance use disorders, and even psychosis.

There are also lots of different kinds of mental health providers out there doing all kinds of distinct clinical work. It can be intimidating to even know where to start searching for help, but often telling your primary care doctor about your symptoms, and if necessary asking for a referral to a specialist, is a good place to begin.

If your doctor determines that specialized care is needed, you may be referred to a psychiatrist who can do a global assessment of your clinical needs. It may be the case that you will benefit most from an integrated treatment approach that features both psychotherapy and medications, or you may be referred primarily to one treatment or another. Here’s some additional information about the different kinds of mental health providers and the treatments they offer to help diagnose and treat psychiatric issues.
Psychiatrists

Psychiatrists are medical doctors who have graduated from medical school and completed at least four years of additional specialized training, through residency and often fellowship, in the medical treatment of mental disorders. Because of their advanced medical training, psychiatrists are able to prescribe medicine and also have at least basic training in most evidence-based psychotherapeutic approaches. Some choose to see patients for medication management only, while others focus on therapy and still others integrate both approaches into the same clinical sessions. Also, psychiatrists are generally the only mental health providers who can perform electroconvulsive therapy, transcranial magnetic stimulation, or other neuromodulatory treatments that use devices to noninvasively stimulate the brain in severe or medication-resistant cases.

Though some psychiatrists still practice traditional psychoanalysis involving multiple sessions “on the couch” each week, this kind of approach has become less available and less common in recent years, in part because insurances generally do not cover it, and in order to practice it providers must complete additional psychoanalytic training for several years after residency. Often, psychiatric nurse practitioners or other appropriately trained “physician extenders” can take on the traditional role of a psychiatrist, though it is important that they have access to adequate supervision, particularly for complex cases.
Therapists and counselors

Many types of professionals can provide the variety of psychotherapeutic approaches used in the treatment of mental health disorders. Therapists who have obtained PhD or PsyD degrees with a focus in clinical psychology, for example, have perhaps the most extensive training in providing talk therapy, including psychodynamic or “insight-oriented” therapy, cognitive behavioral therapy, interpersonal therapy, and others. Clinical social workers and mental health counselors may also have excellent training in particular therapeutic areas that can be very helpful to patients. Therapists and counselors may even offer some therapies, such as eye movement desensitization and reprocessing (EMDR), that psychiatrists generally have less experience with.

In each of these areas, it is important to remember that there is a spectrum of quality, and so it is essential for people with mental health concerns to find well-trained and credentialed providers that seem to be a good fit with them individually.

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