The medical director of the Sierra Tucson treatment facility in Arizona sees the addiction field moving toward an era of more precise diagnosis aided by technology. Of the technological options available, Robert R. Johnson, D.O., is clearly behind SPECT (single photon emission computed tomography) scans, which have received a somewhat lukewarm response from federal leaders but which Johnson says are part of a category of neuroimaging tools with substantial research support.
Johnson told ADAW in a wide-ranging interview that close to 1 in 4 people seen at Sierra Tucson are receiving a SPECT scan as part of the assessment process; the scans are offered as an option to individuals. While emphasizing that the scans contribute to accurate assessment but do not themselves produce a diagnosis, Johnson said he believes neuroimaging will be critical to moving away from diagnoses based on symptom clusters and toward a reliance on biological markers that will allow for more individualized treatment.
“I see us moving more to having diagnostic laboratories, providing SPECT, PET or fMRI scanning,” said Johnson. He added, however, “It is important not to overreach. We don’t use this to diagnose. It is one piece of the puzzle.”
While federal agencies such as the National Institute on Drug Abuse (NIDA) have been intrigued but cautious about the potential of neuroimaging in clinical services (saying that its clinical effectiveness remains unproven), a growing number of treatment centers are exploring scans’ ability to uncover what might be important information for treatment and recovery efforts. As of August, all newly admitted patients at Hanley Center in Florida began receiving baseline SPECT scans to demonstrate how substances have affected their brains (see ADAW, June 21).
Hanley officials hope eventually to arrive at a point where scan images will contribute to a better understanding of which clients might fare best under certain treatments.
Sierra Tucson procedures
Johnson considers the greatest benefit from SPECT scan use to be the motivational factor for the client, who is able to see vividly how substance use has affected brain physiology and blood flow to the brain.
“There is nothing more powerful than showing a normal surface brain scan and showing theirs, and then posing the question, ‘Which do you want?’” Johnson said.
The decision of whether to perform a scan on an individual is made in conjunction with the attending physician, who can determine whether information from a scan might have value for a particular patient. One group that Johnson considers good candidates for the SPECT scans are individuals who appear to have comorbid disorders (“tweeners,” as he referred to them, who don’t fit neatly into diagnostic categories). In these cases a scan might help reveal some information to give a clearer picture of the presenting problems.
“We want to get away from having 6 or 8 descriptive diagnoses for someone,” Johnson said.
While SPECT information is only one data point and cannot be used in isolation to diagnose, Johnson said the information it reveals allows staff to ask better questions of the patient and to have more impactful conversations.
“It’s amazing what you see when you look,” Johnson said. “There might be things that the assessment hadn’t hinted at. There may be a traumatic brain injury that the patient may have forgotten, or that he didn’t think counted.”
Sierra Tucson, which is a member of the CRC Health Group family of treatment centers across the country, has incorporated SPECT imaging as an option in its Assessment & Diagnostic Program (ADP), a service offered either as a fourand- a-half day inpatient service or a two-day outpatient service (depending on the complexity of the case). The imaging constitutes one element of a whole-person review under ADP that encompasses medical, psychological, family and other dynamics. A psychiatric evaluation always accompanies any use of SPECT technology.
Johnson said that most of the individuals who visit Sierra Tucson for ADP are found not to need inpatient treatment and are referred elsewhere; about 30 to 40 percent of those who require the most intensive services will end up staying at Sierra Tucson. The ADP service is often used by entities such as medical boards and employers to help evaluate an individual.
Johnson added that he is not aware of any other CRC facilities that have begun employing SPECT scans. A CRC spokesman told ADAW that the parent company is proud of Johnson’s leadership in advancing knowledge on science-based tools.
The scans at Sierra Tucson cost $1,500, up from $1,000 when Sierra Tucson started using them about 18 months ago, Johnson reported. He explained that the cost of the isotope that is injected into the patient’s bloodstream to produce the scan has soared, because of a worldwide shortage of the chemical element technetium.
The scans represent a direct-pay cost for patients who receive them. Johnson said Sierra Tucson provides itemized bills with diagnostic billing codes that might enhance the possibility that the patient’s insurance plan will cover the cost of the scan. But he added that “we don’t bill insurances directly, and certainly can’t guarantee they will be reimbursed for the scan costs.” He added that the cost Sierra Tucson imposes barely covers the facility’s expenses.
Johnson said that Medicare for years has recognized SPECT as a billable service for indications such as stroke and epilepsy. Perhaps there will be a time when its ability to offer additional clues for addiction diagnosis and treatment will make it a widely billable service in the substance use treatment community as well.
Advantages to technology
Johnson believes SPECT carries some advantages over other neuroimaging technologies. Once a patient is injected, he/she can be scanned for up to four to six hours without the image changing. This means that a patient who experiences some anxiety before taking the test could receive medication or otherwise be eased through the process over a period of time, with no effect on the image produced.
Johnson added that the scanning machine is not as large or expensive as a functional magnetic resonance imaging (fMRI) scanner would be for a treatment facility.
It is common for patients with a substance abuse history to see prefrontal cortex abnormalities on their SPECT scan, and this can help start a conversation with the provider about how their ability to manage impulses that conflict with their recovery goals has been compromised, according to Sierra Tucson. They will have a better understanding of why they struggle to make positive choices, and they may appreciate the need for extra assistance from professionals and the community to improve their recovery prospects, the center believes.
In other cases, a SPECT scan might reveal important auxiliary information. Johnson related the account of a patient who had endured extreme abuse in childhood; he had received a SPECT scan that showed increased blood flow in the temporal lobes, suggesting a propensity for irritability and related problems. He was prescribed the medication Lamictal and later showed improved mood and better quality of life. A subsequent scan showed a more stable temporal lobe region, Johnson said.
This subject might not have been explored without the finding that was achieved through neuroimaging technology, according to Johnson. He sees SPECT as being able to shift the conversation in assessment and treatment.
“We’re moving away from the DSM symptom cluster to a neurobiological approach,” he said. “We’re also going from guilt and shame to a neurobiological explanation for the patient.” •