Motivating Addicts — and Their Doctors
As Corey Waller looked at his dead baby cousin, doll-like in an open casket, his aunt told him, “If you were a doctor, this wouldn’t have happened.”
At the time, Waller was five, growing up in Austin, Texas, and could barely understand why his family was crying.
“I understood, but not emotionally. I felt sad but didn’t know why,” he said.
Yet he gathered that being a doctor would be “a good thing,” and that belief propelled him to medical school. Yet when he became a doctor, he would focus not on the Sudden Infant Death Syndrome that killed his cousin, but rather the psychology and neurochemistry of pain and trauma that would make him more emotional about the wake years later than he was at the time.
“From a neuroscience perspective, what sticks in memory is the emotional component, the instinctual emotional reaction to a memory,” said Waller. “That memory was why I wanted to be a doctor.
That coupling also typifies post traumatic stress disorder and often underlay the behavior of drug addicts who showed up repeatedly in the Spectrum Health emergency department where Waller worked from 2006 to 2011, in Grand Rapids, Michigan. Of 130,000 patients passing through the emergency department each year, 20-30 percent had substance abuse disorders, said Waller.
Addicts often came in disheveled, he said. “They screamed and yelled. Emergency is a safe place to yell at people. You can do it without pushback. It’s safe to be outlandish. They would say they had chronic pain or anxiety. Some were inebriated and homeless.”
Many were dubbed “frequent flyers” because of their dozens of visits. But Waller had less than an hour of training in addiction.
“I thought it came from failure to control yourself,” Waller said. He recalled his grandfather, who had been a World War II bomber pilot, then later became an alcoholic, “orange and emaciated.” Because his mother, who worked as an office manager, and father, a marine turned banker, had not become alcoholics, he thought they had simply made a better choice that anyone could make. Waller had been a teetotaling track star in high school, concerned about his athletic performance.
“In the emergency department, we thought the addicts should have made a better choice,” said Waller. “The majority of caregivers have that visceral reaction.”
But patients’ complaints about pain indicated that “something wasn’t right,” he said. Their pain tolerance varied. A history of abuse magnified feelings of pain because of its associations.
“We understood, but they brought out anger, not empathy,” he said. “Doctors would start pain medication for three days and give them enough for three years, with the attitude, ‘What do I have to give you to leave me alone?’”
Protocol required patients to rate their satisfaction with treatment, and providing drugs was a convenient way to assure high ratings. That rating practice was dismantled only in December, Waller says.
“Despite cries about an addiction crisis, there was little movement to address it,” he said.
Doctors’ feelings of disgust and futility with those patients were exacerbated by “being overwhelmed by the emotional aspects of treatment, coupled with persistent secondary trauma,” he said, referring to daily encounters with distraught and furious patients, tragedy and death.
“‘Secondary trauma’ is well documented,” he said. “Think of emotions as energy. If you stand next to an exposed wire, it’s bound to arc from time to time. But if all you do is stand in a puddle in a lightning storm all day, even on a clear day, standing in a puddle will cause angst.”
Trauma that doctors experienced also affected how they treated patients, or failed to treat them, as a result of their own “learned helplessness and apathy” in the crisis-ridden, efficiency-driven department, Waller says. Doctors had largely given up on getting to know patients and having the kinds of conversations that would probe the roots of patients’ complaints, he said. This failure demoralized doctors, people accustomed to being high achievers. Their malaise would show up as anxiety, depression, irritability, and explosive anger that went from “zero to 100” in moments, with coworkers and patients, an epidemic in the medical profession, Waller says. Recent surveys show that doctors have at least a 50 percent rate of dissatisfaction with their work, he noted.
“Frequent fliers” frustrated doctors with their often shrill demands, for which doctors could provide no lasting remedy.
“They feel like they don’t have support from administrators, coworkers, patients, and sometimes even the patients’ families. All have emotional disregulation around the disease,” said Waller.
Most patients came to the emergency department complaining of pain.
“But it was apparent they wanted opioids or benzos — Valium, Ativan, Xanax, etc.,” said Waller. “It was those patients that drove me out of emergency medicine.”
Waller recalls Betty, a diabetic addicted to opioids and benzodiazapines, who came to emergency about 50 times.
“She was in her late 40s or 50s, but she looked 75,” he said.
Both her legs had been amputated. She would come in her wheel chair, screaming that no one was helping her.
“We were mean, dismissive, disrespectful, condescending,” he said. “After two years, I wanted to quit emergency medicine. I came home angry at these patients. I couldn’t do anything for them.”
Disdain for patients was an atypical turn for Waller, who had thrived in a variety of circumstances and come to emergency medicine because it gave him a chance to practice many kinds of medicine. After high school he had worked as an emergency medical technician. In college, he worked in the infirmary and in a cancer ward.
“It made me feel I was a part of where I wanted to be,” he said, as he envisioned becoming an oncologist and investigating cancer treatments. He attended to cancer patients at night, when they often had trouble sleeping.
“I sat with them when they were scared and lonely. I read to them and washed their hair and bathed them. In a situation where they could easily lose dignity, I was respectful and created a connection.”
He remembers a woman who asked him to read the Bible to her. She died as he read.
“I just kept reading,” he said.
But the poor quality of life chemotherapy gave cancer patients and the way oncologists distanced themselves from them changed his mind about oncology.
“They looked at the research for the tumor,” he said. “But sometimes they didn’t visit patients because they worried about reintroducing infections. They looked at the patient from the door, though they could have put on gear and come in.”
These days, a palliative care team assists oncology patients, he said.
Later, after he finished medical school, Waller would practice “tactical medicine,” Trained in a Homeland Security program in Washington, DC, he would dress in protective gear with guns to accompany police in potentially dangerous situations in Philadelphia. They would “do doors,” breaking down doors for no-knock search warrants. If anyone was hurt, Waller was there for them — and to reassure children who had to lie on the floor, arms up, with the adults.
That was exciting, “the right dose of dopamine and adrenaline,” he said. But research in that field failed to engage him.
In between, at what is now Texas State University, Waller had done a master’s program in biology, with a neuromolecular focus, which, he said, “helped me figure out that I needed to produce something, not just talk about it. It made me focus.”
He assisted chemist Debra Feakes in developing two cancer drugs, a task that required him to spend hours at night, “running columns,” separating chemicals from a solution with test tubes, ten drops at a time.
“In task-oriented boring focus work, you couldn’t do anything else. You had parallel thought streams, one for the immediate task, plus a creative one. But, according to neuroscience, you can focus on just one thing,” said Waller. “You can only increase the rate of switching between tasks. Emergency medicine requires more rapid switching because you have multiple patients. You have to shift emotional context as well as content.”
Developing the ability to concentrate on one person at a time gave Waller the ability to more fully recognize other perspectives, he said. But he found that medical school narrowed his vision, as doctors were trained “like car mechanics” and taught to depend on their intuition.
One week, Waller worked seven days in a row, which is not uncommon, he says.
“But I was wrecked at the end of the shift. All my patients were one of those,” he said, referring to “frequent flyers” who “fight tooth and nail, symptoms of disease that are hard to take.”
He took a month sabbatical in Ecuador with his wife to clear his head. Then, he said, “I decided to rotate my career to see only ‘those patients.’”
He invited 30 difficult “high utilizer” patients to come in on Wednesday mornings. He thought no one would show up, but they did. Waller had extensive conversations with them about how they were treated.
Betty was among them. Some probing revealed that her father had been an alcoholic, her mother a prostitute who locked her in a closet when clients visited. Betty had little education, so when she was diagnosed with Type I diabetes at 17, she failed to care for herself. She developed ulcers in her feet that became infected, and those infections reached her bones.
One snowy Wednesday morning, she called from a bus stop, using someone else’s cell phone. Unable to wheel fast enough in a foot of snow, she had missed her bus. She begged to be seen.
“These people needed help, and I decided to focus on them,” said Waller. “They had a slow-rolling equivalent of a gunshot wound and would die from the disease,” he said of their addiction.
The outpatient clinic became the basis of a pilot study, conducted in 2008 and 2009, that Waller and his colleagues published in the Annals of Emergency Medicine. They showed that emergency department use declined by 80 percent, decreasing costs by $1 million per year, as a result of the community medicine clinic, treating primarily addicts.
In 2011, after adoption of the Affordable Care Act, Waller and his colleagues convinced the Spectrum administration to open a community medicine clinic, staffed by a behavioral therapist, a case manager, and Waller, who became board certified in addiction medicine in 2010.
“Once I became trained in addiction medicine and asked the right questions, we found that more than 80 percent of patients with ten or more visits per year met criteria for addiction,” he said. “It was humbling to think I’d been in school so long, but knew so little about these patients.”
After 16 years of school beginning in college, in 1990, and concluding with medical school in 2006, he said, “I was only ready for the basics—strokes, broken bones, and gunshot wounds. My colleagues shared that lack of preparation.”
Most rewarding for Waller was working with pregnant addicts.
“It’s a way to stop the cycle,” he said. “The mother gets stabilized, and the baby doesn’t go to Child Protective Services.”
CPS would take 15 to 20 percent of babies, placing them in foster care or with a family member, temporarily or permanently, but much less than before the clinic was created.
“Almost always, the mother would get her baby back,” he said.
However, in small, rural areas, some judges required that the mother be off methadone to have custody of her child, which would make her highly vulnerable to overdosing, Waller said. Twice doctors resorted to threatening judges with practicing medicine without a license to convince them to back off that requirement.
Along with the change in plan for these women, the tone of care also changed in neonatal units, as staff was retrained. They became protective rather than angry with the women.
“If anyone was harsh or flippant with them, they got an earful,” said Waller. “Everyone advocated for the patient. It was fun to watch. It had been a massive trauma for women, having CPS threatening to take their baby, treating them in mean, punitive ways.”
In his explorations of addiction treatment, Waller noticed two paths to recovery, with proponents of each claiming a high success rate. One was 12-step programs, and the other was medication assisted treatment (MAT). According to a study published in the Harvard Review of Psychiatry in 2015, medication-assisted treatment of opioid addiction “at least doubles rates of opioid-abstinence outcomes in randomized, controlled trials,” compared with psychosocial treatment, placebo or no medication, with methadone as “gold standard.”
Other studies have shown an even greater advantage for medication assisted treatment, with 75 percent of addicts succeeding in recovery with MAT and only 8 percent without it, a finding that Waller encountered in The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry, by Lance Dodes and Zachary Dodes. However, he also noticed findings that 90 percent of addicts who relied on 12-step programs were sober after three years.
As he scrutinized those outcomes in data and many conversations, Waller said, he realized that providers of each approach had “picked the right patients.”
Those who needed MAT had become addicts early in adolescence and had killed their dopamine-producing brain cells.
“They need dopamine for a conversation to even make an impression,” he said. “They can’t produce enough dopamine for motivation. They were more likely to be the homeless Medicaid patients. They would always need supplementation.”
In contrast, those whose addiction began in their 20s or 30s could be “weaned off” drugs and their brains would stabilize within a couple of years.
However, Waller says, “It’s risky to start with abstinence.”
To identify and treat these patients and others with co-occurring disorders, doctors need training—and motivating, Waller says. Last year, he left the Spectrum Health Center for Integrative Medicine, where he was director, to become Senior Medical Director for Education and Policy at the National Center for Complex Health and Social Needs/Camden Coalition of Healthcare Providers in Camden, New Jersey, where training is a substantial part of his role. He speaks at town hall events, as keynote at national meetings, and at events for police, social workers, and patients.
“Anyone who will listen,” he says. “Addiction, behavioral health, and chronic pain patients are still maligned in criminal justice and health systems.”
He targets care of patients whose conditions are complicated by addiction, cognitive disorders, traumatic brain injury, and autism. “If those issues are recognized, they can be stabilized,” he said. “But often they’re treated like frequent flyers in emergency departments. An alcoholic with diabetes will not improve if you ignore their addiction.”
Waller also addresses the emotional aspects of care with doctors. For doctors, says Waller, “The topic is as difficult as telling someone a loved one has just died. We are taught how to have the death conversation, but not the angry patient one.”
When doctors confront an angry, yelling patient, Waller urges them to address the situation in an “evidence based” way.
“But everyone else says, ‘Give them what they want,’” Waller says.
For doctors who may have long ago become disillusioned about the possibility of caring for patients as they had initially envisioned, Waller uses a technique often used with patients. Motivational interviewing entails asking questions that elicit constructive solutions, giving doctors a way to move forward step by step.
He is also making a series of short training videos for the Robert Wood Johnson Foundation website. And as chair of the Legislative Advocacy Committee of the American Society of Addiction Medicine, he has testified before Congress several times about legislation to address addiction.
But despite widespread awareness of the addiction epidemic, says Waller, “Doctors’ attitudes are nicer, but there’s no change in treatment. They’re more knowledgeable about treatment, but fall short in implementation. When they see addicts, they give them clonidine to decrease withdrawal symptoms. Clonidine is a medication that helps, but doesn’t fix opioid withdrawal. While it is an evidence based treatment, by itself, it is incomplete and requires high doses and monitoring to actually stabilize the issue.”
Both published studies and discharge plans of patients from the ED showed this strategy to be “ubiquitous,” he said. “It’s easy to prescribe, cheap and not a controlled substance, but it doesn’t stabilize addiction.”
Then doctors send addicts home, Waller says, resulting in a mortality rate that is 90 percent of the rate for a missed heart attack.
Jessica Cohen is a freelance writer based in New York. Read her story about former heroin addict Louis Iacona in Clear-Eyed Return to the Scene.
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