Will the truth hurt?

Keith Humphreys offers a personal anecdote to illuminate what we know and don’t know about addiction:

For a brief period of my life, I consumed far more opioids than the most hardened heroin addict. After a freak injury that left me with my femur broken into two jagged pieces that spiraled past each other, shredding my muscle and flesh, I was in so much pain that my doctors attached a self-controlled morphine pump to my body. For the next five days I voluntarily consumed an amount of morphine that literally would have been fatal before my injury. But the day after the surgery that pinned my femur back into one piece, my pain lessened enormously and I immediately lost all interest in using morphine. So, was I addicted for those five days or not? And if so, did my doctors do me a disservice by letting me take large doses of powerful drugs?

In addiction, something happens in the brain that did not happen in mine during my hospital stay: An enduring change to the structures and systems that shape memory, learning, emotion and reward. Although both genetic and environmental factors are known to be implicated, no one knows precisely why some people undergo these changes when they extensively use psychoactive substances and other people do not. But scientists do know that once these changes have occurred, they persist long after the substance use has stopped. Once someone is addicted, they will, even during periods of non-use, think about the psychoactive substances more often, overestimate their value (i.e., feel they are more important than eating, sleeping, work and family responsibilities) and have urges to return to use.

He also offers his fear about the new ASAM definition of addiction:

Speaking as a friend of many of the people involved with producing the ASAM statement, I know that in addition to their medical and scientific goals, a number of the ASAM statement writers hope that by highlighting that addiction has a biological basis in the brain, they can persuade the public to become more sympathetic to addicted people rather than blaming addicts for their lack of willpower. They further hope that this decrease in public disapproval will make more addicted people comfortable admitting they have a problem and seeking treatment for it.

I’m all for being compassionate towards addicted people and for providing quality addiction treatment, but I’m not as sure as are many of my colleagues that an emphasis on the brain mechanisms involved in addiction will bring such good things about. If the public believes that addicts are permanently brain-damaged people who have no control over their own behavior, they might just as well hate and fear addicts more than ever rather than be more compassionate towards them.

I tend to think that we can’t avoid the facts out of fear that people may adopt unintended beliefs. So… what’s missing ? Sounds like it’s an emphasis on recovery and the treatable nature of the illness? One problem with communicating this is that we still don’t know enough about the neurobiology of recovery. Is it just a matter of emphasis, or is something completely missing?

Bill White has shared this fear but offered some ideas about messaging to address these concerns. (Imagine that. Noting a problem and offering a possible solution!):

Things NOT Implied or Suggested by the Concept of Addiction as a Chronic Illness

  • All AOD problems are NOT chronic, most do NOT have a prolonged and progressive course – some do and research is needed to identify early signs of chronic progression.
  • All persons with AOD problems do NOT need specialized, professional, long-term monitoring and support – many recover on their own, with family or peer support; again research is needed to identify who is most likely to need intensive, professional care.
  • Among those who do need treatment, relapse is NOT inevitable and all persons suffering from substance dependence do NOT require multiple treatments before they achieve stable, long-term recovery.
  • Even among those who do relapse following treatment, families, friends, and employers should NOT abandon hope for recovery. (Community studies of recovery from alcohol dependence report long-term recovery rates approaching or exceeding 50% Dawson, Grant, Stinson, et. al., 2005).
  • Having the serious chronic illness of addiction, DOES NOT reduce personal responsibility for continuous efforts to manage that illness – just as those with serious diabetes or hypertensive disease must also manage their illnesses.
  • Appropriate treatment for chronic addiction is NOT simply a succession of short term detoxifications or treatment stays. Appropriate continuing care requires personal commitment to long term change, dedication to self management, community and family support and monitoring.
  • Current addiction treatment outcomes are NOT acceptable simply because they are comparable to those achieved with other chronic disorders.

Things that ARE Important In Considering the Concept of Addiction as a Chronic Illness:

  • Chronic Diseases Vary
  • Chronic diseases require prolonged and active management
  • Both full and partial recoveries are possible
  • Recovery processes vary
  • Lapses after recovery initiation are common but not inevitable.
  • Natural support matters
  • Intervening early makes a difference.
  • Personal and family recovery take time
  • Professional and peer support helps
  • Recovery is a marathon that can bring unexpected gifts