Vyvanse: An Inappropriate Medication in the Treatment of BED

In my previous blog, I wrote about Vyvanse, a type of amphetamine, that recently received swift approval from the FDA to treat binge eating disorder (BED).

No doubt, Vyvanse helps people who are accurately diagnosed with attention deficit hyperactivity disorder (ADHD). However, there are other treatments that help with ADHD as well, many of which you hear nothing about because they lack a pharmaceutical company-backed marketing campaign. (CBT is one example).

There are also non-stimulant medications for ADHD, which are utilized when there is a good clinical reason NOT to use a potentially addictive and appetite suppressing medication, such as if someone has a heart rhythm disorder, a substance use disorder or eating disorder. Last time I checked, BED IS an eating disorder.

Most clinically sound treatment approaches for BED, and any eating disorder, have at least some focus on helping the person accept their body’s natural size and shape (rather than struggle endlessly to achieve a societally sanctioned and sick thin ideal).

Another focus of clinically sound eating disorder treatment is helping patients learn to recognize and honor their natural appetites, hunger and satiety cues. Stimulants suppress this aspect of a person’s being. Therefore, such learning is limited for those who take medications like Vyvanse.

With an eating disorder, a person might binge, restrict, or practice other unhealthy food-related behaviors. We know this is not “the” problem, rather it is an overt symptom of the core emotional, spiritual, and physical pain the person is experiencing. Effective treatment necessitates getting to that core and discovering what is actually driving the disorder. Once the origin of the pain is unearthed, it can be addressed in a therapeutic environment.

We want the person to see that her method of hurting and controlling her body was born out of necessity and became an unhealthy strategy to cope with loss, anger, or trauma that once overwhelmed her ability to manage.

Since all eating disorders involve food, we also strive to help sufferers reconnect to their bodies and normalized eating patterns. We want them to understand the positive role food plays in health, enjoyment and functioning, as well as learn to honor satiety and hunger cues. Ultimately, we hope they will accept and value the natural, God-given size and shape of their own bodies.

For any clinician who values such approaches to eating disorder treatment, Vyvanse is an inappropriate medication choice for those who suffer from BED. A drug such as this serves to disconnect a woman from her body by shutting off hunger cues, which will result in weight loss.

Unfortunately, the trauma associated with a rape, the rejection she experienced from her mother, the spiritual chasm that developed because God seemingly let her down when she needed Him most—whatever emotional turmoil she has been living with is still there. It does not miraculously disappear with appetite suppression or weight loss.

Treating an obese person who struggles with BED with Vyvanse is not much different than considering weight restoration from tube feeding for a person with anorexia. A weight-related goal will be achieved. However, once the medication is curtailed, or the feeding tube is removed, the eating disorder will return. Or, she will substitute it with another equally harmful coping technique, such as chemical addiction or self-harm.

She will do this because she remains a wounded and hurting individual—a woman still in need of healing.

Those who promote market or prescribe Vyvanse to treat BED without highlighting the aforementioned risks are doing the public, and especially those with BED, an extreme disservice. For some, the return is at best temporary, and in the worst scenario, deadly.

The Perils of Consumer-Directed Medication Marketing

How often does it come to our attention that things are not exactly what they seem?

Let’s consider the recent launching of a nationwide media campaign to shed light on binge eating disorder (BED). Using well-known and probably well paid spokespeople, such as international tennis star Monica Seles, these public service advertisements are supposedly designed to increase awareness of BED, provide much needed education and help people get the treatment they require.

An informative website has even been established to assist in this effort. Keeping in mind that BED is the fastest growing eating disorder in the United States today, how could this campaign be anything but very positive?

Now, let’s consider the recent and very rapid approval of lisdexamfetamine dimesylate, which goes under the brand name of Vyvanse, to treat BED by the United States Food and Drug Administration (FDA). It is important to note that this drug, a product of Shire, is not new. Historically, it has been used to treat attention deficit hyperactivity disorder (ADHD). In this capacity, it has proved highly lucrative. In 2014 alone, sales of Vyvanse reached 1.5 billion dollars.

Another interesting occurrence is that within days of approval, Monica Seles began visiting medical centers and patient advocacy groups. Allegedly this was to increase awareness of the condition, but in all likelihood based on who is paying her, it was to strongly promote using Vyvanse in the treatment of BED.

Now, let’s look at the relationship between the media campaign and the drug approval. Not only is Shire paying Monica Seles, and other celebrities, but by and large, they are funding the campaign. They are even donating money to popular non-profit eating disorder organizations to get them to jump on the drug bandwagon. The mission of these organizations is to increase awareness and prevention of eating disorders, NOT to promote Shire’s pharmaceutical products.

This is a calculated strategy that the drug company has used in the past, namely with ADHD. First the drug manufacturer embarked on a campaign designed to “help” people who struggled with ADHD by creating awareness, de-stigmatizing the illness and assisting them to get the medication they needed.

Isn’t it intriguing that the medication they would seek and ultimately receive was either Vyvanse or Adderall, a pharmaceutical drug produced by Shire? And what a success this strategy has proven to be. Sales of Adderall remain in the billions.

Shire has been cited and fined by federal officials for inappropriately marketing their products; clearly this hasn’t slowed them down in the least, since this is the strategy currently being used to market Vyvanse. The steps are as follows: awareness of the disorder is created through a widespread media campaign, the drug achieves approval, a consumer direct marketing campaign is launched, and people flock to doctors for a prescription. Additional sales of Vyvanse are expected to reach between 200 and 300 million dollars.

But here is the problem: all obese people do not struggle with BED. In fact, of those who are seeking treatment for obesity, only 7 to 10% meet the clinical criteria for BED. But now, due to the “helpful” website, it is likely that more obese people will get the prescription. This is because they know what to say to receive an appetite-suppressing medication (phen-phen anyone?) Included on the site are the correct questions to ask, and symptoms to discuss, in order to garner the diagnosis of BED. In the time it takes to reach for a prescription pad, the deal is sealed and Vyvanse is on board.

The truth is, drug seeking is not confined to pain killers, benzodiazepines such as Xanax and Ativan, and opiates. Imagine the hardship of being an obese person today, with all the struggles and abuses that go along with living in our culture, which is sick with the thin ideal: health problems, employment discrimination, and societal intolerance. Many frustrated obese people have tried every possible weight loss focused therapies and diet plans without success.

But now, here is this drug, being touted as the first of its kind ever to treat BED. Of course, the reality is that similar to Adderall, phen-phen, and even cocaine, it is actually an appetite suppressant.

This legitimate pharmaceutical will undoubtedly be supported by physicians with little to no eating disorder or addiction training, and little to no success helping obese patients lose weight.

Vyvanse can help people achieve that desired, albeit short-sighted and often unhealthy, treatment outcome. What treatment-seeking obese person would “not” want it? The desire is completely understandable.

What they don’t know is that Vyvanse won’t help them with the emotional and spiritual underpinnings of their eating disorder. And what they probably will not be told by their physician is that it is a stimulant, which carries a significant abuse potential.

The story is not a new one. The drug is taken, it “works,” tolerance and dependence develop, more is taken, and eventually abuse and addiction can result.

Pharmaceuticals can often be a critical component of a treatment plan built to support sustainable recovery. However when drug companies promote products in this fashion, when the exclusive intent is to make huge profits, when the risks and dangers of addictive medications are not communicated, the outcome for patients using the drug can be very poor.

It is no wonder that many Americans hold corporations which operate in this manner in utter contempt. And also why many academic centers, non-profits and treatment centers alike steer clear of receiving monies from big pharmaceutical companies under the auspices of helping to promote disease awareness.

Reject Predictability

The holiday season has come and gone; it does so every year with great predictability. Thanksgiving leads to Christmas, which leads to New Years. It all goes according to plan, and by and large, it is good.

Equally predictable, and far less positive, is what happens the very minute America steps into a new year. With the turn of a single calendar page, we are catapulted back into the world of diet obsession and weight-loss fanaticism. This happens every single year without fail.

Today, stand in line at a grocery store. Magazine headlines announce the latest celebrity fitness or diet craze for 2015. Flip on the television or radio. Every other ad is touting a new weight-loss supplement or ab–toning device; chain fitness centers offer every imaginable deal to get you to purchase an annual membership. The implication is that you clearly lost all control during the holidays, ate everything in sight, and are now shockingly fat. In our culture that immediately translates into failure, weakness and the understanding that you are no longer worthy of love, happiness or success.

The truth is that holiday weight gain is minimal at best.

Research indicates that people gain an average of one or two pounds during this season. And yet, year after year, absurd numbers of people buy into this post-holiday hysteria and willingly throw more money at the diet and weight-loss industry. They buy the supplement or ab gizmo; they purchase the gym membership. In time, the supplement fails, the gizmo gathers dust and the membership only depletes the bank account month after month. It is time for this cycle of predictability to stop.

Instead of allowing the multi-billion dollar diet industry to continually lead us around by the collective nose, how about we react to their tactics in a whole new way? Instead of embarking on this New Year ensconced in guilt, shame and a negative body image, why not look forward to what 2015 might contain?

This new set of 12 months could offer a variety of new experiences and adventures, personal growth, and even new people to know and love. Be unpredictable. Be joyful. Be you!

By not responding to the diet industry in the expected fashion, maybe the advent of a new year will prove a little less predictable and a lot more positive.

A Message to My Readers

A little more than a year ago, I started writing my blog, Abundant Living. I love having the opportunity to weigh in on important news, comment on foolish fads that are here today and hopefully gone tomorrow, and to pass on some of my own recovery experiences.

In just a handful of days, my husband and I will be welcoming our new baby into the world. We plan to devote several weeks to ensuring the initial pages of his life are filled with lavish attention and shameless parental love! We are excited (and nervous) to begin this chapter of our lives.

All this to say that I will not be blogging for a while; I am certain all of you will understand.

Although I cannot state definitively when I will return to you, return I will. Because just as my life is soon to undergo an enormous change, the world is in a constant state of change, always offering up new things to write about and comment on.

Until then, I encourage all of you to keep on living the abundant life!

p.s. I will send you all a picture!

The Reality of True Recovery

What’s in a word? In the past few weeks, the ever-popular debate about “in recovery” vs. “recovered” has come up at a few talks I gave at conferences. It seems that those in the eating disorder world continue to debate these terms, which touches on a whole host of other questions: How do we define recovery? Do we ever tell patients they will always have to live with their ED, that they are “chronic”? Can people be fully recovered?

There are those professionals that define recovery according to the DSM-5, meaning that recovery is achieved when the individual no longer meets the criteria for Anorexia Nervosa or Bulimia Nervosa or Binge Eating Disorder. This means the person is no longer struggling with eating disorder behaviors, thoughts or body image, to the extent required by psychiatrists to meet full criteria for a formal diagnosis of an eating disorder.

Although I agree with the “no longer struggling” aspect of this viewpoint, I feel real recovery transcends this definition. I want every single woman and adolescent in our care to go on to live an abundant life, complete with ongoing personal, spiritual and emotional growth. At the point where a person’s life becomes not about fighting eating disorder urges, where her life is guided by her inner wisdom rather than eating disorder thoughts, rules, obsessions, she begins to live a life in full recovery. This is always beyond the point of engaging in eating disorder behaviors. Being recovered, a day at a time, means living with authenticity, according to your values (rather than the dictates of ED or our sick culture), and on a path of continual growth.

I believe the essence of a life in recovery is a person’s continual journey towards God’s objective for her life, which equals her full potential.

A healthy, rich life often includes regular connection with supportive and likeminded people (for example, through attendance at 12-step meetings, such as OA or EDA, through church groups, spiritual guides, mentors, etc.).

There are those who maintain that such interpersonal support should no longer be needed if the person is truly recovered. I disagree with that notion. I, like many recovered people, go to mutual support meetings, not to talk about struggles with food or eating disorder thoughts, but to have support in living my life along the spiritual principles found in the steps and traditions – personally, professionally, emotionally and spiritually. In doing so, I offer hope of full recovery and an abundant life to those who are still struggling, caught in the grips of the deadly illness, and unsure of the possibility of ever getting out. That’s where I was when I began my journey back to life—fairly certain I would die of my eating disorder. Although I lived in disbelief, I had some amount of intrigue about the people who were there at my first meetings who had recovered, and who kept telling me I could, too.

Do recovered alcoholics “have” to go to AA meetings? No, not at all. But many continue to attend because the message, interaction and environment remain an important component of their spiritual growth, a part of themselves they need to nourish in order to stay recovered. Do people have to go to church? No, but many people do because it feeds an important part of who they are—their spirit.

Those affiliated with the first edition of the Big Book of AA describe themselves as a group of 100 recovered alcoholics, despite the myth of many professionals and lay people alike that alcoholics or those with eating disorders (or trauma or depression), will always be sick. The words those in recovery or recovered use to describe themselves is not nearly as important to me as what it is that they mean by the words and what their living experience looks like. In the eating disorder field, it is not uncommon for professionals to take on certain aspects of the diseases we treat. The all or nothing, black or white, debate on recovered vs. recovery seems to me to fall nicely into that category. Sometimes we assume we know another person’s truth or experience based on our own. Sometimes we think we know the truth with a capital “T.” I know my truth. I am a recovered woman living my life a day at a time in recovery (aka that magical world called Recovery Land!).

 

Weight Stigma Awareness Week, September 22-26, 2014

Stigma is nothing new. Throughout the centuries people have been stigmatized for everything from the color of their skin and country of origin to their age and religion.

A hundred years ago, people were not stigmatized for weight; yet today, people are routinely and pervasively abused for being anything outside of our thin “ideal.” And, it starts early in life. Research reveals that even pre-school children, age three to four, view obese peers as mean, ugly and stupid. In elementary school, the likelihood of being bullied is 63% higher for an obese child. Obese youth are stereotyped as lazy, unfriendly, dishonest. Adolescents are teased more for being overweight than anything else.

Prejudice extends far into adulthood; even medical professionals (especially medical professionals, sadly) are guilty of weight bias, often perceiving  overweight or obese patients as less disciplined and non-compliant, or even viewing them as annoying or problem patients. Sadly, as body mass index (BMI) increases, so does a doctor’s intolerance of these individuals.

Medical education consistently promotes the falsehood that BMI is an end-all, be-all measure of health. Many healthy people such as professional athletes have BMI’s in a range that would be labeled overweight or obese. Very few of us would consider LeBron James unhealthy (physically, anyways!) despite a BMI that makes him obese.

The stigma and abuse of people of size is pervasive in the media and advertising as well. The popularity of TV shows such as the Biggest Loser indicates just how obsessed we are in America with thinness and extreme dieting or exercise. Sustainable health lives in the middle. People can be healthy at a whole wide range of sizes and shapes.

I wonder what it will take for us to start looking at and valuing more accurate measures of health such as blood pressure, exercise tolerance, and blood sugar instead of BMI? I wonder what it will take to shake us from our obsession with the health food and diet industry that exploits our fear of fat to the tune of billions of dollars a year? Does anybody know a person who has been able to sustain a healthy weight by going on a diet? Or taking a pill?

This is what Weight Stigma Awareness Week is all about. It is a chance for everyone to take a moment and consider how they view those who are overweight or obese, and if any negativity is attached, possibly reconsider this type of value judgment.

 

 

 

Lost Time

In our culture, we are taught that certain things happen at certain ages – you get your driver’s license at 16, retire at 65. This idea also extends to certain decades. The 20s are geared to finishing up college, starting a career, and securing a spouse. If the spouse doesn’t materialize in the 20s, surely marriage and children should occur early in the following decade. If not, you could end up single forever, growing old alone, unless of course, you count your pets. This is just the way life is “supposed” to unfold–the “normal” life trajectory.

This idea of what should happen by certain ages causes a tremendous amount of undue stress, turmoil and strife for many women who have struggled with an addiction, eating disorder or mental illness. They feel that they have “lost time” due to spending years in their illness that might have been spent otherwise. What’s more, these women believe they will never be able to make up the lost time; they have fallen off track with little hope of ever catching up or getting back into the stream of life. They tell themselves they will never get married or have a family because “the time” for that has passed.

I know how these women feel because I spent many years in early recovery living with those beliefs.

Even though I followed the career script by completing college, medical school and residency in my 20s, I departed from the social plan in the grips of a full-blown eating disorder and alcoholism that would take me years to recover from. The latter half of my third decade of life was dedicated to searching for and finally finding sustainable recovery.

By my mid-30s I became aware of something my diseases robbed from me: I had not found a mate nor started a family. I thought my only option was to accept it, grieve the loss, buy a dog and go on. Because, of course, there is only ONE decade when people can get married…and have babies, right? That was my distorted belief, and many women think likewise. I see them in recovery meetings, in professional circles, and in groups at TK. Their misery, though very real, is misguided. There is a real absurdity about our culture’s timetable. It does not take into account the unique plan that a loving God, or higher power, has for each and every one of our lives.

I remember when I was afraid to hope, to live life fully, to go after what I wanted, to trust it would be there for me, too. To actually dare to believe that God is kind and merciful, that even in my late 30s I had plenty of time to make up for lost time.

So I took a chance … followed my heart. I got married to someone I love on a soul level. Together, we are having a baby.

Just as I hope for women to discard the world’s adoration of unrealistic thinness and beauty, I hope for them to disregard artificial timetables. I have lived long enough to see women meet and marry the “love of their life” at every age, and have the family they always wanted, or elect not to. I have seen talented women launch successful careers, in their 20s, 30s, 40s and 50s. Life is dynamic and full of possibilities; it rarely runs according to a societal dictate.

In my life, things may still go terribly wrong at some point; that’s a risk we all take when we are in the game. Even if it does, I will be grateful for everything: the journey … the experience … for living.

 

 

 

Suicide: The Public Exploitation of a Private Tragedy

Earlier this year, I wrote about a personal experience that my family and I went through; it involved suicide. Losing someone you love is always horrible; but death by suicide usually adds a host of other complex emotions to the already considerable grief.

Even if a loved one has what is thought to be a terminal disease, there is still hope — advancements in medicine, a miracle of healing … something.

When a loved one completes suicide, hope evaporates entirely.

On Monday, the world lost Robin Williams, a beloved artist. But, what is so often overlooked by the media in particular is that right now one family is utterly devastated, suffering unimaginable pain. This family lost a husband, a father, a brother, a friend.

These family members may be reliving final interactions with him, repeatedly asking themselves what they might have done differently in order to prevent their current reality.

I know I did.

I endlessly asked myself how this could have happened; were there signs I had missed? If I had been closer to my nephew, spent more time with him, could this life have been saved?

I experienced many emotions after he died: guilt, sadness, pain and anger as well as profound gratitude for who he was. Only through the love I am shown by family and friends was I able to resolve this issue in my heart, soul and spirit. And only with the understanding that he is in the hands of God, now, do I find peace with how his life ended.

I can’t imagine going through that period of my life, my family’s life, with stories of my nephew’s death and life publicly displayed on every news channel, radio station, website or newspaper.

In this current situation, I pray for two things: first, for this family to be surrounded by a compassionate and supportive circle of true friends; and second, for another event to transpire in the world in order for the media to move on, thus ending the hoopla and exploitation of this tragedy.

Cocktails and Playdates: A Worrisome Combination

It used to be that a child’s playdate was just that: kids would get together and run around a park, swim in a pool, maybe just play in the backyard. Today, many playdates offer a new component; one that isn’t entirely centered on the children, but geared more toward the mothers. This added component is alcohol.

Mothers meet up, often at someone’s home, and as the children play, the mothers enjoy each other’s company, as they sip on a glass of wine, a cocktail, or sometimes several cocktails.

For those of us in the treatment field, children and alcohol in the same sentence and the same physical environment has certain implications. “Cocktail playdates” are growing in popularity throughout the country. Is it surprising?

Consuming alcohol is so socially accepted, integrating it into every event can seem reasonable. Even if one mom felt a minor hesitation, seeing everyone else engage in alcohol consumption in the context of a playdate could alleviate any apprehension. However, it’s important for us to remember – alcohol is a central nervous system depressant, which means it slows brain function, which can impair an individual on many levels. The children playing on the swing set or engaging in a game of tag in the back yard deserve responsible monitoring; this means, an adult will tell them when they are swinging too high, or will step in if one child is getting too rough. The more any mother drinks, the more her awareness of what is taking place around her is dampened.

Intrinsic, and even more worrisome, to the concept of a date is that there is a beginning and an end. Unless all involved live in the same neighborhood, driving home is required. Getting behind the wheel in any state of intoxication is dangerous, with higher stakes due to the presence of a child in the car.

Above and beyond the moment, what impact does a mother’s drinking have on a child? Although many mothers who consume alcohol – those who drink recreationally all the way down the continuum to those with severe substance use disorders – often don’t realize the effect on kids, especially if the kids are preverbal or too young for explicit memory.

Children know intuitively, on a body and soul level, when their mother starts dissolving away in alcohol. This is particularly true with extra sensitive kids, even when it is just a few drinks. They are hyperaware of the subtle changes that their mothers experience with even just one drink. This becomes problematic if they have no language for what they are perceiving; or if they do give voice to what they feel and the mother invalidates it.

We are as sick as our secrets, whether they are secrets we live alone with, secrets we are engaging in “socially,” or whether we are aware of them or not, the secrets we keep from ourselves. When we are mothers, this gets passed onto those dependent on us. The good news is so does our recovery, our wellness, and our abundant living.

Efforts to Combat Prescription Opioid Abuse

Prescription opioid abuse is now epidemic in our country. The statistics regarding addiction and death are staggering.

The rate of death due to overdose of prescription opioids more than quadrupled between 1999 and 2010. This far exceeds the combined death toll from cocaine and heroin overdoses. In 2010 alone, prescription opioids were involved in 16,651 overdose deaths, whereas heroin was implicated in 3036. A full 82% of the deaths due to prescription opioids and 92% of those due to heroin were classified as unintentional.

Rates of emergency department visits and substance abuse treatment admissions related to prescription opioids have also escalated dramatically. In 2007, prescription-opioid abuse cost insurers an estimated $72.5 billion – a substantial increase over previous years. Although these costs are similar to those associated with diseases such as asthma and HIV infection, a dramatically lower amount of health care dollars are spent to treat substance use disorders.

Responding to the prescription pill addiction epidemic, The Department of Health and Human Services (HHS) is implementing a widespread effort to address the key risks involved in prescription drug abuse, particularly opioid-related overdoses and deaths. This focuses on four main objectives: providing prescribers with the knowledge to improve their prescribing decisions and the ability to identify patients’ problems related to opioid abuse, reducing inappropriate access to opioids, increasing access to effective overdose treatment, and providing substance abuse treatment to persons addicted to opioids.

Basically, these objectives could be reduced to two words: knowledge and treatment. Physicians need increased education about opioids and heightened awareness about addiction. Prescriptions are written too flagrantly, far too often and with too little information about the patient’s substance use history. These dangerous and addictive drugs are simply too easy to obtain today.

For those with opioid addiction, we need a greater availability of treatment using evidence based therapies, including medication-assisted therapies (MATs) such as naltrexone and buprenorhine. When prescribed and monitored properly, MATs are safe, cost-effective, reduce risk of overdose and generally help patients recover. Yet, these drugs are underutilized due to barriers such as insurance coverage, too few qualified prescribers and negative attitudes and misunderstandings about medications among treatment professionals, recovering people, and lay people alike. Too many people continue to erroneously believe that MATs replace one addiction with another.

So, we return to the need for increased education. If physicians and the public alike had an improved understanding of substance use disorder, especially in the area of opiate addiction, patients would be helped rather than shamed. In place of lives continuing to be wrecked and lost by this disease (both addicts and their loved ones), we may see scores more added to the ranks of those who are saved, recovered and restored to health.