Veterans Care Today: Joseph Volpicelli Of Volpicelli Addiction Treatment Center On How The US Has Improved Its Care For Veterans Over The Past Five Years
An Interview With Eric Pines
Learn finances. I learned and practiced medicine in privileged environments, an academic (nonprofit) setting, and at the VA where I was salaried. In these environments, I did not have to be concerned with financial aspects of medicine. When I left Penn and the VA to set up my own program, I discovered the many challenges to set up and run a clinical practice and the importance of understanding finances to make a program viable.
The daily headlines remind us of how countries around the world care or do not care for their military service members. How does the United States hold up with regard to how it cares for its veterans? We know in the past questions have been raised about the VA system, but it seems that a corner has been turned and veterans’ care has improved. How exactly has the VA system been improved? How does the US care for veterans compared to other comparable countries? What exciting new technological or methodological innovations are being used to improve veterans’ health outcomes? To address these questions, we are talking to successful physicians, healthcare workers, veterans, or other VA employees and officials who can share stories and insights from their experience about the state of veterans’ care today and how the US has improved its care for veterans over the last five years.
As a part of this series, I had the pleasure to interview Joseph Volpicelli, M.D., Ph.D.
Joseph Volpicelli, M.D., Ph.D., has 40 years of clinical addiction treatment research and clinical experience. Prior to founding the Institute of Addiction Medicine, Dr. Volpicelli was a tenured faculty member of the University of Pennsylvania where he conducted clinical trials on pharmacological treatments for alcohol, opioid, and cocaine addiction. Prior to his academic appointment, he completed his medical and graduate education at the University of Pennsylvania which was followed by a Fellowship in Neuropsychopharmacology.
A world-renowned scientist-clinician, Dr. Volpicelli’s research has led to many important discoveries in addiction treatment, including research that led to the discovery of naltrexone to treat alcohol addiction, an FDA-approved medicine used worldwide to reduce alcohol craving and relapse (often referred to as MAT for addiction treatment).
Thank you so much for joining us in this interview series! Before we dive into our interview, our readers would like to get to know you a bit. Can you tell us a bit about your backstory and a bit about what brought you to this specific career path?
I’ve had a long-standing interest in biology and psychology. After graduating from college with a double major in psychology and biology, I entered the MD, Ph.D. program at the University of Pennsylvania (Penn).
My interest in addictions began as a medical student during a rotation at the Philadelphia VA hospital. A patient of mine suffered from severe alcohol withdrawal symptoms and took a swing at me while I presented his case to the attending doctor and fellow medical students. When he recovered from alcohol withdrawal, he apologized for hitting me. Still, he gave me a wake-up call to the suffering people feel from addiction. He described his time in Viet Nam about a decade earlier, where he and many troops used heroin to cope with the stress of war. When he returned to the States, he stopped using opioids but began drinking heavily to cope with nightmares and other PTSD symptoms. Over time, the alcohol addiction consumed him, and he lost his job, wife, and overall physical health.
After meeting this patient, I decided to turn my research into understanding how uncontrollable stress, opioids, and alcohol drinking were interrelated. From this, I developed an animal model of alcohol drinking. I found that a drug that blocks the effects of opioids (naltrexone) would also block stress-induced increases in alcohol drinking.
Can you share the most interesting story that happened to you since you began your career?
After graduating from medical school and completing my residency in Psychiatry at Penn, I was hired by the Philadelphia VA to become chief of the Alcohol Treatment Unit (ATU). The VA allowed me to conduct a clinical study with veterans to test my theory that naltrexone could effectively treat people with alcohol addiction. During the two years of conducting the study, I did not know which subjects received the medicine (naltrexone) or the placebo. I remember the ‘Eureka’ moment when I finally looked at the study’s results. Not being much of an athlete, I can only imagine what it feels like to break a world record or win a championship. But it must feel like something I experienced when I saw the results. Naltrexone worked to reduce alcohol relapse to heavy drinking in the VA population. This opened a new territory for us to explore in helping veterans and, by extension, all who suffer from alcohol addiction. The study would not have been possible without the support of the VA and my mentor Charles O’Brien. I am grateful for the long tradition of VA support to find evidence-based treatments in medicine, particularly addiction medicine. With pride, I recently saw the study cited on the official VA website. The Office of Research and Development considers this study one of the major accomplishments of VA research on substance use disorders.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
Most people who know me will say I’m interested more in the facts than people’s conclusions. Once you reach a conclusion or judgment, you stop looking for new facts and do not grow. I’m a big fan of the show Ted Lasso, and in it, he has a phrase, “be curious, not judgmental.” By being curious and accepting new observations and data, one can learn to see the world and others in a new light. This offers the possibility of growth and understanding. This attitude has been very helpful as a physician, scientist, husband, and father. I try to avoid judging myself and others harshly when things don’t go the way I hope. For example, sometimes my patients will skip appointments, stop taking their medicines, and relapse. It would be easy to judge them as being poorly motivated and deserving of their bad outcome. But, when one begins to learn more about the patient, we may find that they could not afford the medicine and treatment or perhaps they were having unpleasant side effects. By staying curious and not judging the patient, we can work together to overcome barriers to treatment and work toward a common goal
Are you working on any exciting new projects now? How do you think that will help people?
Yes, during the pandemic, there was an increased need to use remote and digital means to communicate and offer treatment to patients. I was surprised to see how telemedicine effectively and easily could be adapted to fill the needs imposed by the pandemic restrictions. This has led me to work on other digital technologies to improve patient care. For example, the use of digital therapeutics to support patients in their medical treatment.
Digital therapeutics are web-based computer programs that deliver behavioral support to improve clinical outcomes for various disorders. The programs typically teach Cognitive Behavioral techniques and are available to patients anytime, and anywhere there is an internet connection. Unlike typical downloadable cell phone apps, these programs undergo rigorous clinical testing to ensure their effectiveness. Increasingly digital therapeutics are being used for behavioral health. The VA has been actively involved in adapting digital therapeutics for various disorders. For example, a digital therapeutic is available to veterans to help with insomnia. Recently the VA conducted a study to use a digital therapeutic to help veterans with anxiety and PTSD and found the program very helpful.
I am currently involved in a research study in a non-veteran population, using a digital therapeutic with buprenorphine to help people with opioid use disorder. I am hopeful these programs can help patients remain engaged in treatment and reduce the risk of opioid overdose. The VA has been very progressive in facilitating the adaptation of these new devices into clinical practice and providing support for these devices to be tested.
How would you define an “excellent healthcare provider”?
Two qualities make an excellent healthcare provider. First the provider must be aware of and know how to use the best available evidence-based treatments. This involves keeping up with new research and being willing to incorporate this research into their clinical practice. Secondly, the provider needs to place their patient’s needs as the top priority. Clinicians are under constant pressure to meet the needs of the clinical practice or insurance companies that place limits on the time one can spend with their patients or types of clinical services one can offer. Of course it is important to keep the costs of healthcare down, but I fear that the loss of the personal relationship between the provider and their patient adds to healthcare costs in the long run. It makes little sense to correctly diagnose a problem and offer effective treatment if the patient is uncomfortable with their provider and does not use that treatment. An excellent healthcare provider understands the science as well as their patient.
Ok, thank you for that. Let’s now jump to the main focus of our interview. Based on your experience can you please share three recent improvements to veterans care that you are really pleased about?
There are three areas that have been a focus of the VA and have shown substantial progress. First, in order to improve treatment access, particularly for rural areas where distances from the local VA may make it difficult to physically attend a health care visit, the use of telemedicine is widespread. This enthusiasm for digital technologies was especially helpful during the pandemic and continues to be an example to non-VA health systems.
Second, there is increasing awareness of the profound effects of behavioral health on the welfare of the veteran. The VA has done a very good job at addressing these needs. From programs designed to identify veterans at risk for suicide to programs designed to provide easy access for the treatment of brain injuries and PTSD, the VA has shown a commitment to addressing behavioral health needs that are often neglected in traditional health settings.
Finally, I consistently hear how the VA as an institution has been committed to understanding the needs of the veterans, from reducing delays in seeing clinicians, to reducing barriers to getting access to medical care. As I discussed above, the VA makes a concerted effort to identify what veterans need and puts resources in place to meet those needs.
In contrast, can you highlight three areas of veterans care that still need improvement? What would you suggest needs to be done to address those challenges?
As they say in the real estate business, the three most important factors in the value of a home is “Location, location, location”. The three most important areas of veteran’s care that need improvement are “Access, access, and access”. For example, long wait times have historically been problematic for the VA, with the need outweighing their capacity. The VA is doing what it can to address this need and has recruited excellent treatment providers. My brother, for example, left his private practice to work as a gastroenterologist at the Albuquerque VA. He loves his work there and recommends working at the VA to his friends. However, shortages remain.
I would like to see our veterans be able to seek care from outside providers that may be able to see more quickly, but still be able to use their healthcare benefits. For example, I had a patient a few years ago who was a veteran, and for various reasons, had a difficult time trying to get help for his opioid addiction through the VA. He opted to receive care from my private practice, but finances were a rate-limiting factor. His medication also was not covered, and the reason given was because it had not been prescribed by a VA provider. I think about him a lot and wonder, had he received prompt and appropriate care, how would things be different for him?
From your perspective how does the US care for veterans compared to other comparable countries?
While I don’t have direct knowledge of how other countries care for their veterans I can tell you that I suspect no other country has as much dedication to supporting research and technological advances to improve a veteran’s health. Having worked as a physician at the VA and other health care systems, I can relate how my experience differs. At the VA the primary goal of the system is the health and well-being of the veteran. In non-VA health systems, one works in the constraints of private insurance companies. Insurance companies are tasked with the goal of keeping health care costs down by reducing fraud and unnecessary expenses. But to clinicians working with patients, it often feels like a battle to get insurance companies to pay for much-needed medical care. In my private practice, my biggest clinical challenge is not in finding the correct diagnosis or treatment for a patient but in finding a way for the patient to pay for that treatment.
What exciting new technological or methodological innovations are being used to improve veterans’ health outcomes?
As I discussed above, the VA is committed to integrating new digital technologies into clinical care. There are several examples of this but one that I am familiar with is the use of a digital therapeutic to treat depression. Veterans can now receive free access to Deprexis® through the VA. It’s a digital therapy for depression that helps people move forward in their own way, using proven cognitive behavioral therapy (CBT) based techniques. The overall aim is to teach useful skills that can be applied in everyday life to overcome depression. The program has been studied with more than 2,800 patients and was proven to help reduce symptoms of depression.
This option is a major milestone for veterans because they can receive confidential mental health support 24/7. It’s easy to access when someone wants to engage, and it tailors support based on a person’s responses to questions about their symptoms and challenges with depression.
The Veterans Affairs Federal Supply Schedule signed a contract to make Deprexis® available by the federal government for use within the Veterans Affairs Health System, Indian Health Service and Department of Defense as of July 2022. VA patients will be fully reimbursed for the cost of using Deprexis®.
This is our signature question that we ask in many of our interviews. What are your “5 Things I Wish Someone Told Me When I First Started My Career”?
1. Learn finances. I learned and practiced medicine in privileged environments, an academic (nonprofit) setting, and at the VA where I was salaried. In these environments, I did not have to be concerned with financial aspects of medicine. When I left Penn and the VA to set up my own program, I discovered the many challenges to set up and run a clinical practice and the importance of understanding finances to make a program viable.
2. Watch out for politics. If you mix politics with medicine, you get politics. I had always assumed that the clinical practice of medicine is based on objective facts based on scientific research. Unfortunately, politics from outside the practice of medicine and even within medicine can affect health care choices. This can affect the types and quality of clinical services we offer patients or even how these services are reimbursed by private insurance companies.
3. Be aware of diversity. Many of my patients find it difficult to start addiction treatment because they feel there is something fundamentally sinful or shameful about their behavior. In the early days of Acoholics Anonymous, many of the first members came from privileged backgrounds and they needed to be held accountable for how their addictive behavior affected other people. The basic premise of treatment was to look beyond themselves for help in overcoming their defects of character. In the course of treating patients, I have come to see people from various backgrounds, some of whom have felt discrimination based on religion, gender identity, or ethnic background. They have a lifelong issue of feeling discriminated against and so the additional shame that society places on people with addictions makes it difficult to engage in treatment. For some people, it is important to focus not on their powerlessness or character defect, but on their agency to change and the more positive aspects of their character. Treatment proceeds best in an environment where people feel safe and unjudged. Others from minority positions may have a life of feeling shame and so the approach is very different. They need to feel safe and secure that they can share their mistakes.
4. Much of what you learn as you start your career will turn out to be wrong. It’s important to be flexible in your assumptions and not take your theories too seriously. In the field of addiction medicine, it was assumed that any drug or alcohol use was a relapse and treatment failure. We know now that reductions in heavy drinking is beneficial for patients and a slip can be an opportunity to learn. So it is important to keep up with clinical research and be prepared to discard old assumptions as clinical evidence teaches us something new.
5. Watch out for burnout. As they say, the first thing to do in a crashing plan is put on your own oxygen mask. You need to take care of yourself if you are going to take care of others.
You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. 🙂
My message is clear and simple. If you want to be effective as a health care provider, pharmaceutical business, clinical program, or even a family member, you need to address the needs of the person or group you are working with. For example, I recently had the opportunity to advise a residential addiction treatment program. They were concerned, like many residential programs today, about the high rate of people who left treatment prematurely. They described a very credible program designed to help teach the patient effective coping strategies to deal with stress and avoid drug and alcohol relapse. When I asked what their patients wanted, they said they just wanted to leave the facility to get high. When I have directly talked to patients who left treatment early, what they described was they left because they couldn’t get to see the doctor and felt withdrawal or anxiety symptoms were not being addressed.
Addressing the needs of the patient is not the same as giving in to unreasonable patient demands. As health care professionals we have a responsibility to address both the immediate and long-term health needs of our patients. Our treatment recommendations reflect a collaboration between our best knowledge and the expressed needs of the patient. In this way we can offer the right treatment to the right person, at the right time.
This patient-centered approach to addiction treatment has served me well in clinical practice and I suspect is a good model in our everyday interactions. Too often in healthcare as well as our daily lives we retreat into our own silos of information. We fail to understand the perspectives and needs of others. If I could inspire a movement, it would be to hold on to your theories lightly. Learn from others and don’t be afraid to throw your old assumptions out as you learn new facts.
How can our readers further follow your work online?
Readers can stay up to date with my work by visiting my clinical practice website at www.volpicellicenter.com or our nonprofit research institute website at www.instituteaddictionmedicine.org
Thank you so much for these insights! This was very inspirational and we wish you continued success in your great work.
About the Interviewer: Eric L. Pines is a nationally recognized federal employment lawyer, mediator, and attorney business coach. He represents federal employees and acts as in-house counsel for over fifty thousand federal employees through his work as a federal employee labor union representative. A formal federal employee himself, Mr. Pines began his federal employment law career as in-house counsel for AFGE Local 1923 which is in Social Security Administration’s headquarters and is the largest federal union local in the world. He presently serves as AFGE 1923’s Chief Counsel as well as in-house counsel for all FEMA bargaining unit employees and numerous Department of Defense and Veteran Affairs unions.
While he and his firm specialize in representing federal employees from all federal agencies and in reference to virtually all federal employee matters, his firm has placed special attention on representing Veteran Affairs doctors and nurses hired under the authority of Title. He and his firm have a particular passion in representing disabled federal employees with their requests for medical and religious reasonable accommodations when those accommodations are warranted under the Rehabilitation Act of 1973 (ADA). He also represents them with their requests for Federal Employee Disability Retirement (OPM) when an accommodation would not be possible.
Mr. Pines has also served as a mediator for numerous federal agencies including serving a year as the Library of Congress’ in-house EEO Mediator. He has also served as an expert witness in federal court for federal employee matters. He has also worked as an EEO technical writer drafting hundreds of Final Agency Decisions for the federal sector.
Mr. Pines’ firm is headquartered in Houston, Texas and has offices in Baltimore, Maryland and Atlanta, Georgia. His first passion is his wife and five children. He plays classical and rock guitar and enjoys playing ice hockey, running, and biking. Please visit his websites at www.pinesfederal.com and www.toughinjurylawyers.com. He can also be reached at eric@pinesfederal.com.
Veterans Care Today: Joseph Volpicelli Of Volpicelli Addiction Treatment Center On How The US Has… was originally published in Authority Magazine on Medium, where people are continuing the conversation by highlighting and responding to this story.