How Not to Die a Tragic Death from a Drug Overdose

Whitney Houston, Michael Jackson, Heath Ledger, Amy Winehouse, Anna Nicole Smith -- I imagine you know what these celebrities all have in common: they've died from accidental overdoses.

In the first 20 years of my career, I can't recall hearing a single story of an accidental overdose resulting in the death of a young person that I knew, a friend knew, or a patient told me about.  Maybe I've forgotten them, but if so, it's because they were spaced well apart and there weren't memorable trends. One close friend had a young relative, a substance abuser, overdose and end up in an ICU, but he lived.  Somehow, in the past year, I've been hearing more and more stories of tragic deaths of young people, full of life and promise, who partied just a little too hard and stopped their lives in it's tracks.  Not suicides, just a little too much of whatever the substances might be.  

So young people party.  They drink, they smoke weed, and sometimes they pop pills or shoot drugs (though please do note that IV drug use is not considered to be "recreational.")  Given that this is the reality of some people's youths, and these stories are heart breaking, let me offer some words of wisdom.  It's not just the hardcore addicts who are dying, it's not just the shooters, and often the deaths are caused by medications with legal uses.   And the horror of the deaths is not just their tragedy, but the guilt that gets left behind, by the person who left the victim alone, who noticed they seemed off but not enough to call an ambulance, by the person who didn't think much of an unanswered call or text and gets to wonder if they had done something differently, if their friend might have lived.  It's all horrible.

Here are my words of wisdom:

Only take one substance.

Don't drink and take drugs.  Don't do it even if you've done it 2,413 times and it was fine all those times,  Many people who die accidentally have lots of experience with it and have never died before.

Don't mix drugs.  Benzodiazepines may be relatively safe, but once you take your Xanax, add a little oxycontin, and have a beer, you may be in for a very long sleep.  Xanax/Valium/Ativan/Klonopin (benzos) and Oxycontin/Oxycodone/heroin/methadone/morphine/MS contin/percocet/percodan/darvocet/demoral (opiates)  --- these medications have effects that are more than additive and they cause respiratory depression and have unpredictable effects.  This combination of xanax/alcohol/pain killers seems to be especially popular and especially lethal.  Cocaine and stimulants are also a really bad idea.

If you've had a drug problem, quit using, and have been clean for more then a few days, your body starts to heal, and if you relapse, it will take much less drug to get the same effect,  Taking your old dose of medication can be lethal.  This is a major reason why death rates are so high soon after prisoners are released from jail -- they hit the streets and take their former dose of drugs -- it's much more than their body can handle after being clean.

Don't drink on an empty stomach.  Food slows absorption.  The body is made to resist dying from alcohol poisoning -- it's why people throw up, it keeps them from absorbing too much alcohol.  You can overwhelm this safety mechanism if you drink too fast.  

---Don't do shots.  See the above logic.  It's hard to kill yourself drinking beer alone, but I've heard of people doing 21 shots on their 21st birthday or drinking an entire bottle of straight vodka as part of a frat initiation.  This can kill you.  If you must do shots, don't do them on an empty stomach, let a fair amount of time pass between shots, and drink a non-alcoholic drink in between to slow the process down. 

----If you must drink heavily, do it with friends and stay with each other, don't lose your drunk friends.  Don't leave someone who has passed out alone, roll them on their side so that if they vomit they don't aspirate it (aspirate = breathing your puke into your lungs, a common reason people die after heavy drinking or overdosing).  If someone can not be aroused after drinking, call an ambulance! It's better to be embarrassed than to be dead.  Remember, you don't have to be an alcoholic to die of alcohol poisoning.

-----Don't drink and drive.  There is a cab driver out there who needs your business. 
-----Don't drink and go on the roof.
-----Don't drink and walk on railroad tracks.

If you take prescription drugs for medical reasons, don't increase the dose without checking with your doctor first.  If you're not sure if it's safe to combine prescription drugs, ask your doctor or call a pharmacist (any pharmacist, look for a 24 hour pharmacy and call and ask to talk with the pharmacist.)

And probably the best advice: don't abuse drugs or alcohol.  

If you take prescription pain killers, sedatives, or stimulants,  know where they are, and know that someone else can't access them.  These medications aren't meant to be shared.

New CPT Codes Are a Coming

 

In 2013, the CPT codes that healthys use will be changing.  The new ones are said to better reflect what we do.  What does that mean?  Hmmm, I don't know, I thought I'd ask you.  The code for pharmacologic management, the so-called "med check" with no time requirements, is going away, and psychotherapy codes will be for 30, 45, and 60 minutes.  I'm not sure what happens to the 50 minute hour.  I'm going to try to figure this stuff out over the next month and write about it here or on Clinical Psychiatry News.  But first, let me ask you a few questions (these are for mental health professionals only, but everyone else,  hang on, I'll have other questions.  

Do you use CPT codes now?
Are you worried about the changes that are coming?
Do you think this will increase reimbursement to you?
Do you think it will increase reimbursement to your patients?
How do you plan to learn the new codes?
Oh, I'm going to set up a poll, but do feel free to write in on the comment section!

You voted for WHO??

Please don't forget to vote, no matter who you support.

The Trauma Recovery Movement: Where Did It Come From?

For anybody who's interested, you can follow along with me as I learn about this stuff. I put the tape measure pic up because I'm learning about trauma treatment and outcome measures.

I was curious about SAMSHA's National Center for Trauma-Informed Care so I did a little background reading based on material I found on their web site. (And if there's anybody reading involved in this who would like to jump in and provide more information, please do. Shrink Rap also allows guest posts!)

It appears that this arose out of a SAMSHA initiative to encourage study of innovative program delivery systems. It was recognized that certain groups of people had severe and overlapping treatment issues. In other words, there were women with high levels of childhood abuse, adult violence, mental health issues and substance abuse. They wanted to figure out how to best provide treatment to these folks and they theorized that the key link or ingredient, a "cause" if you will, was the trauma history.

A two-phase, multisite study was designed to look at this problem. (1) In the second phase, nine cities were selected to participate. They enrolled thousands of women in a variety of treatment settings. The women all had one or more of the three issues: trauma history, substance abuse and mental health problems. One key fault is that there was a non-random assignment of the patients: they were allowed to self-select the "intervention" versus "usual care" condition. Both the trauma and usual care groups provided mental health and substance abuse counselling. The trauma group was additionally provided a women-only therapy group that employed one of four trauma treatment recovery models. The usual care group provided some additional not clearly specified intervention (I didn't have time to read in detail, it sounded like a generic social skills group).

The results were difficult to interpret because it turned out that two of the nine sites had significantly different study subjects. They had to break out certain sites from the rest to analyze the data. However, when pooled two interesting findings came out: the first was that a program that integrated all services (mental health, substance abuse and trauma/generic) was better than a program that offered disjunctive services. The second finding was that the more core services the patient used, there was a slight but significantly worse outcome. (2)

Outcomes were measured at six and twelve months. Overall mental health scores were measured using the Global Severity Index (GSI) and the Brief Symptom Inventory (BSI). Mental health status was improved more when services where combined, even when there was no change in addiction severity. Traumatic symptoms also improved.

What I take away from this is: integrated treatment is better.

That doesn't surprise me. Maryland is reorganizing it's public health services to reflect this, and the Affordable Care Act also recognizes this. There's also been at least one study (I've got it pinned on my pInterest board) which showed that integrated care post-release can decrease felony recidivism.

But improvement with integrated care does not prove that the treatment effect comes from treating the trauma. I think that's the mistake. This model can be useful for anyone with complicated co-occurring conditions, male or female, traumatized or not.

OK, I'll shut up now. What's new with you, Dinah?



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1. McHugo, et al. Women, Co-occurring disorders, and Violence Study: Evaluation design and study population. Journal of Substance Abuse Treatment 28: 91-107, 2005

2. Morrissey et. al. Twelve-month outcomes of trauma-informed interventions for women with co-occurring disorders. Psychiatric Services 56: 1213-1222, 2005

Yes, You're Better

One of the fun things about Shrink Rap is that periodically ClinkShrink and I like to wrap our hands around each others' necks and squeeze really hard while screaming.  

So let me refer you to ClinkShrink's post below,  Am I Recovered Yet.  Read that first and come back.  It's a rich post with many different agendas. Don't worry,  we are on opposites sides of town and we are both getting sufficient airflow. 

1.  Clink talks about Tonier Cain who was horribly abused as a child, both physically and sexually.  Ms. Cain's abuse led her to a dysfunctional life of drug abuse, prostitution, and repeated incarcerations.  By dealing (whatever that means) with her trauma, she has overcome these problems, she now lectures on the importance of dealing with trauma, and she is a productive member of society.  I know nothing about Ms. Cain, this is what I gleaned from ClinkShrink's post.

2. Because of Ms. Cain's efforts, laws have been passed requiring that anyone working in a state facility must be trained in trauma-informed care, which ClinkShrink tells us has not been proven to be effective in studies. Remember, Ms. Cain is an individual who benefited, and studies look at populations, not individuals.

----Dinah's commentary:  I am going to stay out of the evidence-based medicine question because, well, evidence-based studies are limiting, they don't look at the full range of what we do clinically, studies are often conflicting, and sadly, we've seen that pharmaceutical companies have skewed some studies.  
      Moving on, I am against the concept of legislating medical care and medical standards.  I agree with Clink (take a breath now) that there should not be laws requiring training in trauma-informed care.  There should be industry standards and mandates; lawmakers shouldn't be requiring CPR training.  The law doesn't require me to have a flu shot.  My hospital, however, has said that if I'd like to continue treating patients there, I need a flu shot (I had a flu shot).  There was a really nice article on the intrusion of legislation into the practice of medicine a few weeks ago in The New England Journal of Medicine, see  "Legislative Interference With the Physician-Patient Relationship."

3.  Clink goes on to question whether Ms. Cain is really better if she continues to be fixated on issues related to her trauma.  Wow.  Let's see, she was a  homeless, drug abusing, criminal who sucked resources from society (I'm assuming that the tax payer funded her forays into prison) who now living in free society, working to help others, on a mission (I love people who have missions), and doing well for herself.  Yup, she's better.  Is she cured?  I don't know.  I don't even care. I'm with the commenter who suggested that the patient is the one who determines better.  She's feeling good about herself, presumably making a living (there's an award winning movie), lobbying for something she believes in, looks like she's raising her kids, getting a message across.  She's not homeless, not smoking crack, not in jail.  Does she need to be an accountant to be 'better?"  Plenty of people get better by focusing on their past problems.  Is the incarcerated drug addict who later becomes an employed addictions counselor who helps others not 'better' because he still lives his days thinking about addiction-related issues?  Yes, they are better.  Is it any different from the person who goes on to be an oncologist because his mother died or cancer, or the person who becomes a healthy because he had personal or family experience with psychiatric problems?  What about my short friend who became a pediatric endocrinologist?

4.  Is she Cured?  Clink defines this as being symptom-free, able to move on to a life not involving a focus on their problems,who no longer requires resources and frees up these scarce resources so that others can use them.  What a funny way to define "cure" in a field where 'serious mental illnesses' are often chronic or recurrent.  I'll go with Freud here: "Well" is about the ability to work and to love.  It's not about the ability to live life free of symptoms. Is she Cured?  What does is matter?  Why does that need to be judged?

5.  Clink tells us that her goal is to get someone to zero symptoms (--I would never qualify, I didn't sleep well last night as I was worried about the election) and free them of being her patient.  "Government money for mental health services is limited, and should be directed toward people with serious mental illnesses and evidence based practices."

I'm not sure what ClinkShrink is getting at here.  I agree that government money should not be used for mandating training in trauma-informed care.  We don't mandate training in schizophrenia (it comes as part of psychiatry residency training and it's mandated by those who oversee residency training programs, not legislators).  I'm not sure what she means by 'government money' or by 'serious mental illnesses.'  So a patient with Medicare should not be allowed to access mental health services for a mild mental illness?  What's mild? Anxiety?  Election-angst?  Irritability with co-workers?  What if a person finds that a medication or a regular psychotherapy appointment helps their personal comfort level, and that by maximizing their comfort, they are better able to function as a parent and thus help a future generation?  What if having somewhere to process their issues makes it easier for them to function as a surgeon, or as a teacher. Okay, you say, not government funds.  But then what if our surgeon who feels better with care, or our legislator who influences the lives of thousands, or our public health researcher who benefits from care, what if they turn 65 and are now having services paid for by Medicare, do we bounce them off?   We don't tell people they can't have repeated doctor's appointments for belly pain, why should we limit care to those with "serious mental illness" whatever that is.  

Okay, I'm ranting. Clink, let go of my neck now. 

Am I Recovered Yet?

Today on our local public radio station I heard an interview with Tonier Cain, a team leader for the National Center for Trauma Informed Care. Ms. Cain is a renown speaker who has appeared at multiple national venues to talk about her horrific childhood history of sexual and physical abuse, multiple adult arrests, history of prostitution and drug abuse, and incarceration in our own Maryland prison system. Her story is remarkable for her 180 degree transformation to become an accomplished organizer and advocate. She has repeated her narrative many times online, on the radio, and even in local theater. She frequently speaks to women prisoners to talk about the importance of trauma recovery therapy.

I was familiar with her story because the state of Maryland passed a law last year which mandated that anyone working in a state facility must be given training in trauma-informed care. I went through this training myself where I saw a shortened version of the documentary "Healing Neen," about Ms. Cain. Following the presentation the instructor asked what we thought about the film. Everyone in the room thought that it was wonderful, that Ms. Cain's story was amazing, that the trauma recovery treatment she had had was miraculous.

"Isn't it amazing how she has overcome her trauma?" the instructor asked.

I should have kept my mouth shut. I really should have.

But I couldn't help myself.

"But she hasn't recovered!" I blurted out. "She just reshaped it. She has recreated her personal and professional identity around her trauma narrative." And that's true---she is now a professional trauma victim/survivor. How is this overcoming her past? How is this recovery?

The room fell silent. People looked at me, a bit aghast and shocked. Some people tried to explain: "Well, you don't ever really COMPLETELY overcome the past, you just learn to live with it."

Well OK, that sounded reasonable. But wasn't the point of the trauma recovery movement that you actually are supposed to recover? That at some point, you stop being a patient? I mean, when I treat someone my goal is complete recovery----zero symptoms----that's what I call recovery. My goal is to free someone from being my patient, as much as possible.  Isn't that the goal of the trauma-recovery movement?

Maybe I just was uninformed. Maybe I needed to read more about it.

I did a PubMed search using the terms "outcome" and "trauma-informed care." This search produced all of four articles. One focussed solely on trauma-informed interventions to reduce seclusion and restraints in the hospital. Another paper discussed the dirth of outcome-based evidence for trauma informed care for people with schizophrenia. There were no controlled trials, nothing in the way of any standard study of anything related to trauma informed care.

Yet education about this recovery movement and treatment approach is being mandated by our state government. There's something seriously wrong here. An intervention with no evidence base is being required and weighed on the same level as a requirement for CPR certification.

The trauma recovery and prevention movement also has moved into the domain of disaster psychiatry. This is the idea that prompt mental health intervention can prevent longterm psychiatric complications for people who experience traumatic events. I've written about this before on the blog in my posts "I Don't Need to Talk" and "I Still Don't Need to Talk", including a review of studies to suggest that for some people these interventions may actually be harmful. In his Mental Illness Policy blog, DJ Jaffe expressed similar concerns in his post "NYS Office of Mental Health: Wrong Response to Hurricane Sandy," where he discussed the diversion of mental health workers to crisis counseling and away from services for the seriously mentally ill.

Government money for mental health services is limited, and should be directed toward people with serious mental illnesses and evidence based practices.

Sandy

So, I've been taking a little break while ClinkShrink posts about the AAPL conference.  I always enjoy hearing about what she's learned there.  We both had the pleasure of being in the sky last weekend as we awaited the arrival of Hurricane Sandy, though my flight, the only one heading to the East coast from Milwaukee that was not cancelled,  did not include unscheduled stops in the wrong part of the country.  Clink and I were both pleased to get home, and even more pleased that our region was spared the brunt of the storm.  In 1999, a large tree fell on my house during Tropical Storm Floyd, and I've never liked storms since then.  If there's a post-traumatic tree disorder, I have it. 

So Seaside Height, New Jersey is a place I remember from my childhood.  The day I got my drivers' license, I drove two miles to a friend's house.  She and another friend jumped into the car and said, "Let's go to the beach."  Now I had been a licensed driver for six hours, and we didn't live near the beach.  "No," I said, "too far."  "Oh, come on."  Why not.  We drove to Seaside Heights, played games on the Boardwalk, and drove home.  No cell phones back then.  I dropped my friends off and returned home around 1:30 in the morning (no laws requiring midnight curfews back then, either).  I walked in and my mother greeted me with, "I was so worried, I thought you'd been caught in a flash flood."  Flash flood?  What flood? "It rained," I said.  She stopped and said, "Where were you?"  Ah, obviously someplace where it hadn't rained.  I like that memory and I don't like seeing photos of the rides in the water.  

To all those who are still feeling the effects of the storm, our hearts go out to you.

Thinking About Bellevue

Little did I know as I was writing that last post on Sunday that just a few days later some of the same docs I was listening to and learning from would end up evacuating their hospital. When I read about the desperate conditions at Bellevue Hospital in New York as the storm struck and the remarkable efforts to evacuate every one of those hundreds of patients---without any loss of life, to my knowledge---I was impressed and humbled.

Every hospital and institution theoretically is supposed to have emergency policies and procedures, and is supposed to run occasional disaster drills to make sure everyone is aware of them, but who ever really believes they'll be needed or used? Those kind of large scale, potential mass casualty events seem to horrible to think about or really imagine could happen. Until they do.

There's not much I can do from a distance, but from my brief contacts with the Bellevue docs I know that those seriously mentally ill patients and prisoners received the best care possible under the worst possible conditions.

Let's hope that when the storm clouds clear and the rubble is swept away, the hospital that re-emerges is a newer, better and brighter one. The patients and staff deserve it.
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Addendum from Dinah: there is an article on the Bellevue evacuation here. 

Bariatric Weight Loss Surgery and Low Calorie Diet for Diabetes 2

Can Bariatric Weight Loss Surgery Control Type 2 Diabetes Mellitus? Cleveland Clinic Declares Bariatric Surgery as a Top Medical Innovation

Many diabetes experts now believe that weight-loss surgery should be offered much earlier as a reasonable treatment option for patients with poorly controlled diabetes. Also in a related development scientists in England have reported treating type 2 diabetes with extreme diet.

What is the difference between diabetes Type 1 and Type 2?

---

Type 2 Diabetes, which tends to be the kind people get when they are in middle age or older usually is a problem more with so called insulin resistance where the cells aren't responding efficiently to the insulin (rather than as in Type 1 where there is a deficit of insulin) although it's not quite that clear cut and people do get insulin injections sometimes even for Type 2 Diabetes.

Have gastric bypass surgery. Lose your diabetes? Could it be that simple? There is evidence that gastric bypass surgery can help people with type 2 diabetes to the degree that the Cleveland Clinic put bariatric weight loss surgery on their list of the top 10 medical innovations of 2013. The benefit of gastric bypass surgery for some people with diabetes may derive from more than just the simple weight loss.

What is the evidence that weight loss surgery can help diabetes type 2?

---

According to a past article in the LA Times, "As many as 86% of obese people with Type 2 diabetes find their diabetes is gone or much easier to control within days of having weight-loss surgery, according to a meta-analysis of 19 studies published earlier this year in the American Journal of Medicine (78% of patients with a remission of diabetes and 86.6% with remission or improvement). But experts still aren't sure why obesity surgery helps resolve Type 2 diabetes or how long the effect might last. And they disagree on how big a role surgery should take in treating the illness."

Have Bariatric Weight Loss Surgery Lose Type 2 Diabetes Could It be That Simple?

healty medical Blog had written previously about another study called Adjustable Gastric Banding and Conventional Therapy for Type 2 Diabetes. Researchers divided obese people with Type 2 diabetes into two groups. One group of obese diabetics got weight loss surgery, laparoscopic adjustable gastric banding and the other group of diabetics got conventional diabetes therapy with a focus on weight loss by lifestyle change. The researchers found that "participants randomized to surgical therapy were more likely to achieve remission of type 2 diabetes through greater weight loss. These results need to be confirmed in a larger, more diverse population and have long-term efficacy assessed".







Video Says Gastric Bypass Might Improve Diabetes









"The study, of 60 patients, showed that 73 percent of those who had the gastric banding surgery had complete remissions of diabetes, meaning all signs of the disease went away. By contrast, the remission rate was only 13 percent in those given conventional treatment, which included intensive counseling on diet and exercise for weight loss, and, when needed, diabetes medicines like insulin, metformin and other drugs". Type 2 diabetes is the more common form of diabetes. Doctors have known for some time that weight loss tends to improve Type 2 diabetes. It tends to appear in older people and can be due to a lack of sensitivity of the insulin receptors in the body. Type 2 diabetes is more likely to be treated with pills than insulin shots.

Click healty medical Study Suggest Less Cancer With Gastric Bypass

Click Here for Risks Rewards Gastric Bypass Weight Surgery



The Times article writes "There is strong evidence that surgery -- especially gastric bypass surgery, which makes the stomach smaller and allows food to bypass part of the small intestine -- causes chemical changes in the intestine, says Dr. Jonathan Q. Purnell, director of the Bionutrition Unit at Oregon Health & Science University. The small intestine has been thought of simply as the place where digestion occurs".



"But researchers now suspect it has other functions related to metabolism. (Gastric Bypass) surgery somehow alters the secretion of hormones in the gut that play a role in appetite and help process sugar normally".

BRITISH RESEARCHER AT DIABETES MEETING SAYS RADICAL DIET MIGHT GET RID OF DIABETES MELLITUS TYPE 2 AND VIDEO ABOUT DIABETES

Cleveland Clinic: Top 10 Innovations announced

Adjustable Gastric Banding and Conventional Therapy for Type 2 Diabetes

Gastric bypass: Is it a diabetes fix?

Diabetes Study Favors Surgery to Treat Obese