The Florida drug crisis is due in large part to the state’s licensing of non-physicians to make diagnoses. Things won’t change until that does.
The state of Florida has become a destination for addiction treatment. There are presently 1545 addiction treatment programs licensed to provide treatment to those in need. These programs include various levels of care, including Residential Detoxification, Intensive Inpatient, Residential, Day/Night Treatment with Community Housing, Day/Night Treatment (without Community Housing), Intensive Outpatient Program, and Outpatient Program. They are licensed by a social service agency, the Department of Children and Families (DCF). The Department of Health, which is responsible for licensing all other health care facilities, has nothing to do with the treatment of addiction.
It starts with the brain and genetics
Addiction is a brain disease, as clearly described by research supported by the National Institute on Drug Abuse and the National Institute of Mental Health. It is a psychiatric illness, characterized by multiple changes in the brain. Various parts of the brain are responsible for everyday functions, and it is these parts that have been changed by the process of addiction. They include the prefrontal cortex, the orbitofrontal cortex, the anterior cingulate cortex, the nucleus accumbens, the amygdala, the hippocampus, the ventral striatum, and others. This results in impairment in judgment, executive function, impulse control, decision-making, mood regulation, anxiety-tolerance, motivation, learning and memory. All of the behaviors expressed in the individual suffering from addiction are a result of the effects of the substance upon the vulnerable brain, the changes of which have been determined by abnormal genes and/or early childhood trauma.
To truly diagnose the presence of addiction requires that these brain functions be examined and determined to be dysfunctional. For too long, it was thought that addiction was simply the excessive use of substances. Now, we understand what drives this use and how the brain has changed (in some ways, like a stroke) that results in impairment in these various brain functions. Evaluating the presence of this abnormal brain function requires a psychiatrist, or, more specifically, an addiction psychiatrist, who has been specially trained to identify these deficits. Would we ever accept that a physical therapist makes a diagnosis of a stroke? Or, do we expect it to be the neurologist?
The majority of individuals suffering addiction also suffer other psychiatric illnesses, including psychotic disorders (like schizophrenia), mood disorders (like bipolar disorder or major depressive disorder), anxiety disorders, post-traumatic stress disorder, attention-deficit hyperactivity disorder, and personality disorders. If these are not identified (diagnosed) and treated effectively, the likelihood of responding to treatment of addiction is markedly diminished.
The Florida Drug Crisis: WHO, not WHAT
In the state of Florida, individuals are admitted to Outpatient Programs, Intensive Outpatient Programs, and Partial Hospital Programs (Day/Night Treatment) every day. None of these programs is required to have a physician on staff. To admit an individual to any of these psychiatric programs requires a diagnosis and the clinical information that supports the need for that level of care. Who is making these diagnoses and treatment recommendations? Non-physicians. Not even nurse practitioners or physician assistants. In the state of Florida, a mental health counselor is legally allowed to make diagnoses! Is it any wonder that most diagnoses are missed and the patient is misguided and set up for relapse?
The treatment of addiction has been well-established and should include combinations of pharmacotherapy (medicines) and various psychotherapies which include cognitive-behavioral psychotherapy, motivation enhancement therapy, 12-step facilitation therapy, family systems therapy, contingency management therapy, and psychodynamic therapy. Knowing what the balance of these therapies should be and administering the proper interventions at the right time requires the expertise of the addiction psychiatrist. To determine this requires a medical degree. Allowing someone without a medical degree to determine diagnoses and the indicated interventions is sanctioning medical practice without a license, which is exactly what the state of Florida does.
This is akin to allowing clinics operated by masters level individuals, created to treat diabetes to promulgate simple diet and weight loss and never address whether insulin or surgery is medically indicated. It takes a physician to do the latter. Is it any wonder that people are dying? They are not properly being diagnosed and the indicated treatment (as supported by medical research) is not being recommended.
The Correct Diagnosis and Treatment
When it comes to Opioid Use Disorder, a terrible disservice is being provided. The medical research clearly shows that individuals presenting to “Detox” who are routinely treated with a week’s taper of buprenorphine have an 85-90% risk of relapse within 3 months, when further time on buprenorphine markedly decreases this risk of relapse. Yet, the former is the most common practice in South Florida. Imagine if a treatment for breast cancer was found to have an 85-90% relapse rate after three months. Yet, an alternative treatment was found to be more significantly effective! And, the vast majority of clinics continued to promote the markedly less effective treatment?! A travesty. Further, the American College of Obstetrics and Gynecology and the American Association of Addiction Psychiatry recommend maintenance treatment of buprenorphine for the individual with Opioid Use Disorder throughout pregnancy. In our program, a pregnant individual presented after having gone to a “Detox” program that tapered her off of buprenorphine over the course of a week which led her to relapse to heroin. She returned to that program which repeated the one week taper and she relapsed again. She finally made it to our program and remained on buprenorphine without relapsing.
The vast majority of programs in South Florida are operated by individuals who have, as their most important credentials, the fact that they, themselves, suffer from addiction, and therefore, know what the best treatment is for individuals suffering from addiction. The state of Florida accepts this as it does not require any credentials in the field of addiction treatment to own a treatment center. Even in those programs owned by someone with no credentials who employ addiction psychiatrists, the owner dictates the practice of addiction psychiatry. For example, an owner may tell the addiction psychiatrist that he is not allowed to maintain an individual on buprenorphine for Opioid Use Disorder, despite the fact that all research supports that practice. As a result, the individual is highly likely to relapse (a benefit for the owner who will “recycle” the patient through the program). All sanctioned by the state of Florida.
How do we expect to end this crisis when we have states enabling individuals to “treat” our most vulnerable population suffering from the disease of addiction, without requiring proper licensure?
Robert A Moran, M.D., F.A.P.A., F.A.S.A.M.
CEO and Medical Director, Family Center For Recovery
Certified in General Psychiatry, Addiction Psychiatry and Addiction Medicine
Diplomate, American Board of Psychiatry and Neurology and Addiction Medicine
Instructor in Psychiatry at: Weill Cornell Medical College, University of Miami Miller School of Medicine, Charles E. Schmidt College of Biomedical Science at Florida Atlantic University, Lake Erie College of Osteopathic Medicine, Nova Southeastern University, and MariettaCollege
