“We know what to do. The question is, are we going to do it?”
That was the question posed by former Rhode Island Congressman Patrick Kennedy, son of former Massachusetts Sen. Ted Kennedy, as he spoke to a Milwaukee forum last Monday on the best ways to provide hope for those struggling with disorders of the brain: mental illness, addiction or intellectual disabilities.
Kennedy explained that illnesses of the brain should be treated like any other chronic physical illness, such as diabetes. Screen for it early, provide the best treatment possible and offer support as an individual lives with that chronic illness, which should be covered by health insurance. Every doctor’s visit should include a “checkup from the neck up,” Kennedy said, that includes a risk assessment for depression, anxiety, addiction and other forms of mental health issues, along with assessments for cardiac disease, diabetes and other chronic illnesses.
The early intervention advocated by Kennedy is contrary to how we currently treat these illnesses. Now, we wait until someone has entered “stage 4” of their illness, Kennedy said, then wonder why someone suffering with a mental illness or substance use disorder doesn’t respond to treatment or therapy and get back to health quickly. Instead of treating the individual early according to best practices, we blame the victim, deep into their disease, for lacking willpower, being spoiled or just needing some sense knocked into them.
Kennedy spoke at a critical time in Milwaukee’s opiate epidemic. According to data collected by Milwaukee Alderman Michael Murphy, Milwaukee County has seen a 495% increase in heroin-related deaths between 2005 and 2014. During that period there were 888 overdoses, primarily among white, middle-age men. More recently, Milwaukee County was home to 12 heroin overdose deaths over the Labor Day weekend.
Personal and Political
Kennedy has deep knowledge of the issues he discussed at the Medical Society of Milwaukee County forum. He battled addiction and his own mental health issues for years, and the Kennedy family includes members with substance abuse disorders, mental illness and intellectual disabilities.
He said the “real killer” is the family secrecy and shame that prevents individuals from seeking help and discussing their struggles with each other.
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During his 16 years in Congress, he championed mental health parity, which requires health insurance to cover diseases of the brain just as they do any other chronic physical illness. As recounted in his personal and political memoir, A Common Struggle: A Personal Journey Through the Past and Future of Mental Health and Addiction, the Mental Health Parity and Addiction Equity Act of 2008 was signed into law after years of advocating for policymakers to view substance abuse and mental illness as chronic illnesses that respond to medical treatment that should be covered by insurance policies.
At the same time Kennedy was fighting politically for greater awareness of brain diseases, he was battling his own mood disorders and substance abuse. Ultimately, he left office in 2011 after a headline-grabbing, prescription drug-influenced car crash on Capitol Hill. He got serious about his recovery, got married and had kids, and founded two organizations devoted to raising awareness of brain diseases. The Kennedy Forum advocates for behavioral health policies and is keeping a watchful eye on the implementation of the parity law. Kennedy encouraged Milwaukee doctors to become more involved in ensuring that insurers are covering brain diseases. In addition, Kennedy’s One Mind Institute brings together brain researchers so that they can form connections on brain illnesses, from traumatic brain injury to addiction.
“We need to decode it together,” Kennedy said.
Zeroing in on Addiction
Kennedy spoke at length on substance abuse disorders, explaining that they are not the result of personal weakness but that the brain is chronically addicted to a substance. He chalked up his own successful sobriety to a combination of medication-assisted treatment (MAT) along with cognitive behavioral therapy and the spiritual aspect of a 12-step recovery program.
He said he disagreed with the approach taken by his family’s home state, Massachusetts, where 14-day inpatient detox is now a mandatory insurance benefit for those with an addiction, saying it’s not enough to simply get an addict off of a substance and then send them back home, where they can easily relapse without proper supports.
“If their brain is on fire, they need that drug,” Kennedy said.
Instead, Kennedy advocated for medication-assisted treatment after detoxing, in which a doctor prescribes medication that addresses the physical addiction while the individual is in some sort of therapy to change their behaviors. He said other wraparound services, such as housing, mental health treatment and transportation, also need to be readily available.
Kennedy said the combination of medication—commonly methadone, buprenorphine or naltrexone—along with therapy works especially well for those addicted to opioids, including oxycodone or heroin. The federal government backs him up on that. Some individuals may need to be on the medication for the rest of their lives, just as diabetics need insulin, while others will need it for a shorter length of time, Kennedy said.
He encouraged more doctors to become prescribers of medications for addiction, saying there are thousands of addicts for every doctor who will write a prescription for them. This summer, the U.S. Department of Health and Human Services lifted the cap on the number of patients a doctor can treat with buprenorphine, from 30 to 275, with proper training and credentialing.
“There are not enough physicians out there writing against the epidemic out there,” Kennedy said.
Dr. Mike Miller, the medical director at Rogers Memorial Hospital’s Herrington Recovery Center in Oconomowoc, and a leading expert on medication-assisted treatment, told the Shepherd that doctors have been slow to prescribe medication for those with substance use disorders because medical schools don’t teach it and there’s a widespread misconception that the patient is swapping one addiction for another.
“The research on these treatments is very well-designed research,” Miller said. “Persons on medication have better outcomes than people not on medication.”
He said that when an individual’s tolerance is low—for example, after detoxing—the risk of death goes up if doctor-prescribed medication isn’t blocking the opioid receptors in the brain. If that person relapses and goes out on the street seeking drugs, they risk taking heroin that could be incredibly strong because it’s mixed with a type of fentanyl, a synthetic opioid that’s 50 to 100 times more potent than morphine.
“Because these extremely potent products are out on the street, people thinking they are buying something that will get them high in the way they used to get high end up overdosing accidentally because it’s way too strong and their tolerance is down,” Miller said. “That’s a really bad combination.”
Miller said there’s no one-size-fits-all treatment for those battling substance abuse, but he said medication-assisted treatment can be a component of successful recovery from addiction.
“From a public health standpoint, basically everyone who leaves a residential treatment environment should be on one of these medicines, at least for a period of time,” Miller said.
Although it may be difficult to find a doctor to prescribe one of these medications, Miller said a support group, such as Narcotics Anonymous, or professional therapy can help an individual break their addiction.
“There is definitely a better life out there,” Miller said.
