For many years, physicians received their educational training primarily during medical school, internship and residency. Thereafter, clinical practice and regular review of the medical literature was seen to drive ongoing understanding and wisdom, but there were no requirements to practice clinically or to read the journals. Naturally, there were a few bad apples: a doctor here or there who failed to keep up, or who returned to clinical practice after a decade of administrative work.

Rules were modified to prevent the potential for a negative outcome. Continuing Medical Education (CME) requirements were instituted by state medical boards and specialty societies. Many state boards instituted a requirement for recertification if a physician had not practiced for an extended period of time and wanted to return. Specialty boards instituted requirements for recertification every 10 years – family practice always has worked this way. But ultimately, even these requirements were perceived as being too open-ended. Thus begat—to make a very long story short—the maintenance of certification (MOC) process.

The definition of "quality" should not be mistaken for that of a value judgment. Quality is simply a characteristic, perhaps inherent or essential, but neither necessarily positive nor negative. A “quality measure,” therefore, should not be presumed to measure the degree of the target’s goodness.

A small business runs a machine shop where employees are responsible for operating equipment that punches holes through metal plates. The tolerance for error is small. Each punch must be within a few millimeters of the specified center point. The equipment itself is high powered and it takes several employees to position the metal plate, and then another to push the appropriate button to engage the machine. If the button is pushed at the wrong time, the metal plate is potentially wasted, and human injury may occur. After many years of employment, Ms. Jones makes a mistake, pushing the button before the plate is properly engaged in the harness. A fellow employee loses a portion of one finger as a result.
In the ensuing investigation, Ms. Jones is found to have been under significant stress. She is in the midst of a divorce, recently lost her mother, and is having serious economic difficulty. She took on a second job six months before the accident, and according to fellow employees, frequently complains of fatigue while at work. Per company policy, Ms. Jones is drug tested following the accident. She tests positive for oxycodone, and admits that she has been taking this medication, as prescribed, for five years to treat her fibromyalgia. Her dose has not changed in four years, and she said it effectively treats her chronic pain.
At another company across town, Mr. Smith finds himself in a similar position. Following his involvement in an accident that resulted in personal injury to another employee, Mr. Smith tests positive for oxycodone. Mr. Smith is not taking it under a physician’s prescription; rather, he has been buying the drug on the street for several years. Mr. Smith reports that his dosage varies, and that he had actually been using less oxycodone at the time of the accident.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was a landmark Act through its eliminating much of the protection that previously existed with respect to patient information held by a treating clinician. The Privacy Rule, a component of HIPAA, allows the treating clinician to disclose otherwise protected health information without any authorization or permission by the patient, in 12 specific instances: to employers who request information concerning a work-related illness or injury; under a wide variety of local statutes, regulations and court orders; to governmental authorities where victims of abuse, neglect or domestic violence are involved; in response to a law enforcement official’s request for information about a victim or suspected victim of a crime; or when a clinician believes that protected health information is evidence of a crime that occurred on its premises.

That is but a small sampling of the wide range of disclosures that are permitted under HIPAA, again with absolutely no permission required from the patient. Can you imagine? Under HIPAA, if a clinician feels that a patient might have given a controlled substance to another patient while on the premises, thereby committing a crime, the clinician could comfortably turn both patients in to law enforcement officials. Similarly, an eager new law enforcement agent suspecting such behavior among your methadone program patients could request your records and under HIPAA fully expect that you would deliver these records at once.

Thankfully, we have federal confidentiality regulations at 42 CFR Part 2, commonly called simply Part 2, which take precedence and protect our patients. Part 2 applies to all medical information about any person who has applied for or been given a diagnosis or treatment for substance use disorders at a federally assisted program. Within Part 2 is protection for all such information, forbidding disclosure to any third party, independent of those allowed for within HIPAA, without specific approval by the patient. This past June, the Substance Abuse and Mental Health Services Administration (SAMHSA) released additional information as to how to apply these confidentiality regulations.

In the past, Part 2 was generally interpreted to apply only to federally assisted programs such as a licensed drug/alcohol treatment center. The newly released interpretation indicates that a private physician, who is registered with the U.S. Drug Enforcement Agency (DEA) to dispense a controlled substance used in the treatment of alcohol or drug abuse, such as buprenorphine, would also be included in Part 2 protections. Clinicians who use benzodiazepines for alcohol detoxification “require a federal DEA registration and become subject to Part 2 through the DEA license,” notes the new guidelines. I find it difficult to imagine a scenario in which a clinician or program treats substance use disorders but would not fall under Part 2.

The information protected by Part 2 is any information identifying an individual as having a current or past drug problem, or as being a participant in a Part 2 program.  That latter sentence is fascinating: those of us with a DEA registration now represent a Part 2 program, and if we cannot release information indicating that individuals are patients, we cannot release any information about the patient. Note that this holds true even for purposes of payment,  except under certain specific conditions. Also to be taken into consideration, are the specific elements required for patient consent to release of information. There are nine such elements, all of which must be in writing and which are fully described at 42 CFR § 2.31. The entirety of the SAMHSA guidance is available at http://www.samhsa.gov/newsroom/advisories/1006165837.aspx

The new guidance has given rise to much debate within the field of addiction medicine. On one side are individuals who feel that HIPAA has left patient privacy tattered and torn, who are proud that our patients have very reasonable privacy provisions in place, and who believe that Part 2’s protections should be expanded to cover all patients in any medical setting. On the other side are individuals who have a deep concern that separating addiction patients in this way will cause further disdain for the diagnosis of a substance use disorder in patients for whom it may be applicable, resulting in a deterioration of availability of addiction treatment despite the obvious great need. These latter individuals have a further concern that as electronic medical records become more prevalent, the privacy requirement applying to addiction patients could result in information about their treatment not reaching other treating clinicians. Imagine if a patient on metha­done is admitted for surgery; the surgeon checks the available medical information and finds everything except that the patient is an opioid addict who is now maintained on 170mg of methadone per day. That could turn out to be a critical point of information.

However, under HIPAA alone, our methadone patient could find his employer knowing all about his past opioid addiction and current methadone maintenance simply as a result of an inquiry about a recent workplace accident that had nothing to do with the addiction history or treatment. Is there a middle ground that would better serve our patients? It was simple in the good old days where treating clinicians shared all the information about any given patient with one another but with no one outside the healthcare treatment boundaries. Is it possible to return to those days, yet still have the benefits possible in terms of public health and public safety that we could gain through further sharing of information?

What are your thoughts? Should Part 2 be kept as strong as it is, or is the wide-open lack of confidentiality inherent in HIPAA the way of the future? Please send me your solutions at This e-mail address is being protected from spambots. You need JavaScript enabled to view it . The most insightful alternatives will be part of a future column.

Stuart Gitlow, MD, MPH, MBA, a psychiatrist, is a member of the American Medical Association’s Council on Science & Public Health, and an officer of the American Society of Addiction Medicine. This column represents his personal opinion and does not imply any position or
policy taken by either the AMA or ASAM.

I recently found myself walking along the streets of Edgartown, Mass. The town, an old whaling port on the island of Martha’s Vineyard, was my home for the summers of the mid- to late-1960s. I had been back only a few times since, but was amazed as I walked within the shiny aura of the village. Each house on the streets surrounding Main stands on property now worth in excess of $1 million. The houses looked the part, each with what seemed to be a fresh coat of paint, and many surrounded by flocks of gardening teams spreading mulch and ensuring that flowers and bushes were all properly tended. The result is a town that looks as if it would be right at home as a movie set—so perfect as to appear fake.
I walked along the street toward my old home. One house stood out; it had always been especially run down, but now it looked perfect.  Some of the Victorian design features that I vaguely recalled appeared to be missing. Something wasn’t right, and I later asked a cabbie about the home. “You’re right,” he said, “The original house was torn down a few years ago. This is actually a brand new house on the same footprint. It’s not as nice, but they sure keep it up now, don’t they?”

I finally got to my old house. The grass was poorly maintained. A clothes line reamained in the backyard, giving away the lack of a clothes dryer in the house. The driveway, rather than being brick or well-manicured pebbles as in surrounding houses, remained two ruts in the lawn. I imagined I could see an outline of where my old vegetable garden was. I walked up the porch and knocked on the door. A pleasant woman in her mid-80s stepped out and I introduced myself. She asked after my parents, as it was the daughter of the woman from whom we had rented the house decades before. I gazed inside: the wallpaper and furniture was all as I remembered it. She told me how all her neighbors, old friends all, had moved away. She could barely afford the property taxes on what used to be an easily affordable home. Even if she could afford it, she found paying $50/hour to gardeners absurd when the grass, bushes and trees all look so nice in their natural state. Indeed, that home looks now the way the entire town did back when I called it home.

And Main Street itself, she pointed out, is now home to shops catering to tourists, rather than to newsstands, grocers and other stores that earned their income from the workers who lived nearby. Only a single store, a hardware store from the 1940s, remains on Main Street. The rest were built in the 1970s or much later. The town is picture post card perfect, but no longer appears to be quite right. It’s not a working town anymore but is a representation of what such a town might be, given amazing sums of cash.

I left Edgartown feeling sad, with something of a “you-can’t-go-home-again” sense, and with concern for our family friend who finds herself growing older in the home she was born in, but in a town that is no longer her town.

My personal physician has a small office in which he works as a solo practitioner. We sit in his office and talk before he examines me. He reviews the EKG and the urinalysis and then we sit and talk some more, discussing various health-related issues. He often jots some notes on a blank sheet of plain paper. On my way out the door, I write a check to pay for the visit. My doctor has known me since 1970 or so. I don’t have to remind him of my personal or medical history. He barely has to check his notes, but if he does, there are only a few pages that he would need to review. As a result, I spend my time there in actual conversation, not watching him as he interacts with a computer screen or pages through sheet after sheet of useless treatment plans or other policy-driven paperwork that an “efficiency expert” in government feels is an important part of the medical record.

I worry that my medical care is turning into the world of the past—that the comfortable ruts in the driveway will be replaced soon by expensive bricks. On the few occasions when I’ve needed to go to another doctor, I often find myself in decorator-designed waiting rooms. Halogen lights shine down on movie-set like versions of what doctors’ offices might look like if there were a few extra tens of thousands of dollars hanging around. Computers glow in each room, and I never know which clinician is going to see me. I do know one thing—whomever walks in won’t know me. They’ll spend more time with the chart than they will talking, more time with the insurance-related paperwork and medical codes than with the actual work of formulating and diagnosing, and I’ll end up feeling like I did in New Edgartown—sad about the loss of what was, and how so often we find ourselves as a society moving in a direction that seems inevitable even as it departs from the sane, the comfortable and the inexpensive.
In the coming decades, we will see a rapid move toward guideline-oriented medicine, where people will be treated as if on a production line, each one treated according to evidence that is based on population norms, all as ensured by enforcement of quality measures and electronic reviews. The days of individualized healthcare are drawing to a close. The bushes will all be neatly trimmed, the grass uniform, but the feeling will be impersonal and cold. Is this really the road we wish to take?

Stuart Gitlow, MD, MPH, MBA, a psychiatrist, is a member of the American Medical Association’s Council on Science & Public Health, and an officer of the American Society of Addiction Medicine. This column represents his personal opinion and does not imply any position or policy taken by either the AMA or ASAM.

Every so often, the field of psychiatry undergoes significant change. What was once a disease is no longer. A former mere constellation of symptoms now represents a diagnosable illness. I speak, of course, of the release of a new edition of the Diagnostic and Statistical Manual of Mental Disorders. DSM-V has been under construction for several years now, and though it still has many months of remaining gestation, the first few images were recently revealed. Contained within the fifth edition, which is actually the seventh if we count DSM-IIIR and DSM-IV-TR, is a section for addictive disease; and lest we forget, the new iteration is actually DSM-5, not DSM-V, to allow for incremental decimal updates as slight alterations are introduced.

Most specialties of medicine do not have equivalent diagnostic manuals. There is no such manual, for instance, for specialists in ophthalmology or obstetrics. The one for psychiatry, starting its life as a mere consensus statement to assist in the development of consistent research approaches, has taken on a life of its own wherein the text now rules the field rather than the reverse. Expert witnesses take the stand on psychiatric issues and are intensively questioned if they are so bold as to not accept DSM as being the defining description of the disease states they describe. Journalists immediately comment if a new edition of the manual alters some previously accepted content, as they have recently with expected changes related to autism and Asperger’s.

Addiction specialists do not have a diagnostic manual. Most addiction specialist physicians are not psychiatrists, but psychiatrists have, for some years now, been incorporating a diagnostic section for the field of addiction within the psychiatric DSM. Should they be? I suppose one argument in favor of this is that many individuals with psychiatric illness also have addictive illness; but many of those with mental health difficulties also have myopia. Should that be in the diagnostic manual? Another well-taken point is that addiction is a disease of the brain, but then so is epilepsy, and I don’t see a section in DSM for neurologic diseases as a separate category. That would be for the neurologists to develop.

Why haven’t the addiction docs gathered to write their own diagnostic manual? Psychiatry botched the definition of alcoholism years ago, dividing up a well-defined entity into one that currently spans several illnesses. Sedative dependence, in which one uses any sedative except alcohol, is a separate disease state from alcohol dependence—in DSM, though not in real life. And since DSM drives research, the past decade of alcoholism research has been led astray by the lack of recognition that sedative use counts just the same as alcohol use in one who suffers from alcoholism. More importantly, a generation of prescribing clinicians has no recognition that they are not to prescribe any sedative to patients with alcoholism. They don’t know, in part, because their diagnostic manual authors didn’t get it right.

In the new manual, we are thankfully and finally losing the Abuse and Dependence terminology that never took hold outside of psychiatry, all to be subsumed under the new term, “Use Disorders.” But here we are, on the brink of DSM-5, and once again benzodiazepines and barbiturates are in their own category, separate from alcohol, despite the basic pharmacology and years of alcoholism definitions instructing the contrary. And once again, the psychiatrists are composing, within their diagnostic manual, a diagnostic section for another specialty containing a continued enormous error with respect to that specialty’s second most prevalent illness (nicotine dependence still having the lead). How many more patients must we all see that have histories like this?

Ms. Smith, after 15 years of heavy drinking, attains sobriety following her fourth detox and rehab. She attends AA regularly and has a solid recovery in place. Following the birth of her second child, she complains to her physician about difficulties staying asleep. She is prescribed Ambien. Shortly and predictably thereafter, she begins to develop daytime anxiety. A small dose of Klonopin is prescribed  . . .

We all know what happens next. The alcohol use, which is guaranteed to take place in this case, happens every time because somewhere in the world of psychiatry, the definition of alcoholism was forgotten. They translated “alcoholism” and thought it was about alcohol rather than about a class of pharmacologic entities all of which are cross-tolerant with alcohol. So as a result, there are clinicians who say, “My patient has alcohol dependence, not sedative dependence, so prescribing Soma, Klonopin and Ambien is perfectly acceptable.” Isn’t it time that we wrote our own addiction ­diagnostic manual? One that uses the terminology of the field of addiction—alcoholism instead of sedative use disorder, perhaps—and one that gets the actual definitions aligned with the actual disease states as we’ve recognized them for decades?

Yes, it will be nice one day when we have a full understanding of the basic pathophysiology of addiction. The actual subtext of addiction will, one hopes, boil down to a common genetic pathway, or perhaps there will be a metabolic error identified, or some abnormality of brain structure. Of course, it also might not; the fact that an environmental precursor is necessary to the development of addictive disease makes it quite likely that such an easy ultimate description of addiction will not be achieved. Either way, until that red letter day arrives, we need a single document of our own in the field of addiction that describes the various disease states that we attend to each day. I therefore propose that we start work on ADM-I, the Addictive Disease Manual, first edition. Alternative names? Roman or Arabic numeral? Or should we try at all? Let me know what you think with email to This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Stuart Gitlow, MD, MPH, MBA, a psychiatrist, is a member of the American Medical Association’s Council on Science & Public Health, and an officer of the American Society of Addiction Medicine. This column represents his personal opinion and does not imply any position or policy taken by either the AMA or ASAM.