A chronic illness?

addiction
addiction (Photo credit: Alan Cleaver)

Bill White responds to a recent article that has gotten a lot of attention by Gene Heyman, a disease model critic. Heyman (and a couple of other recent articles) question whether it’s accurate to call addiction a chronic illness.

If there is anything that the full scope of modern research on the resolution of AOD problems is revealing, it is that the dichotomous profiles of community and clinical populations represent the ultimate apples and oranges comparison within the alcohol and other drug problems arena.

Conclusions drawn from studies of persons in addiction treatment cannot be indiscriminately applied to the wider pool of AOD problems in the community, nor can findings from community studies be indiscriminately applied to the population of treatment seekers.

Adults and adolescents entering specialized addiction treatment are distinguished by:

1) greater personal vulnerability (e.g., male gender, family history of substance use disorders, child maltreatment, early pubertal maturation, early age of onset of AOD use, personality disorder during early adolescence, less than high school education,  substance-using peers, and greater cumulative lifetime adversities),

2) greater problem severity (e.g., longer duration of use, dependence, polysubstance use, abuse symptoms co-occurring with substance dependence;  opiate dependence),

3) greater problem intensity (frequency, quantity, high-risk methods of ingestion, and high-risk contexts,

4) greater AOD-related consequences (e.g., greater AOD-related legal problems),

5) higher rates of developmental trauma and post-traumatic stress disorder,

6) higher co-occurrence of other medical/psychiatric illness,

7) more significant personal and environmental obstacles to recovery, and

8) lower levels of recovery capital–internal and external resources available to initiate and sustain long-term recovery.

Bill points out the real world consequences of these arguments.

This is not merely an academic question.  Are families reading the headlined summaries of such reviews to conclude that the prolonged addiction of their family member results from moral and character defects of self-control that prevent “maturing out” of such problems that most people, according to these reports, achieve?  Should such chronicity render one unworthy of family and community support?

Read the rest here.

6 sessions of chronic care management for addiction is not effective

evidenceJAMA published a study of a primary-care based chronic care management model (CCM) for addiction. The test group did no better than the control group.

The headline is a big bummer for any of us who want to see chronic disease models developed and implemented for addiction. What should we make of it?

Many headlines suggested that chronic care management for addiction doesn’t work.

A prominent writer described the model as “exquisitely tailored” and went further, stating that CCM didn’t work and the real problem is a lack of good treatments for addiction.

Are these fair representations?

Bill White emphasizes that this was NOT a study of recovery management. (Recovery Management is the chronic care management approach that he has advocated. It is the most frequently discussed chronic care model. Adaptations of it are being are being implemented across the country.)

Bill points out that there are important differences between the approach that was used and Recovery Management (RM). Those differences include:

  1. The service setting was a primary care clinic, a setting that it would make it challenging to establish a culture of recovery that kindles hope, normalizes long-term recovery.
  2. The treatment staff “consisted primarily of a nurse care manager and a social worker, with consultations available from internists and an addiction psychiatrist. Conspicuously absent from this list and key members of RM support teams are peer-recovery support specialists (e.g., recovery coaches), volunteers and alumni who are in recovery, and culturally indigenous healers.
  3. The core ingredients of the model did not include many elements of RM, including a focus on recovery capital, patient-developed recovery plans; assertive engagement of family and extended family; peer-based recovery coaching, service thresholds of at least 90 days, extending service delivery into the natural environment of the patient/family;  mobilization of indigenous recovery support resourcesassertive linkage to recovery mutual aid groups; and long term monitoring and support and early re-engagement and recovery re-stabilization.
  4. The duration of the intervention was one year, not the five year window that Bill has advocated.

Over at Addiction Inbox, Dirk Hanson had another important observation. He noted that the patients had an average of 6 visits.

When I looked for those details in the original article, here’s what I found:

Of the 282 participants assigned to the intervention group, 281 (99.6%) attended at least 1 CCM clinic visit, 75.9% attended at least 2, and 64.5% attended 3 or more visits (median, 6 visits; interquartile range, 2-16 visits). Most reported scores consistent with receipt of high-quality CCM at 12 months (75% had scores ≥3.3 on a scale adapted to assess addiction CCM; possible range, 1-5).37Most (62%) received 1 or more motivational enhancement therapy sessions and 27% completed 4 sessions.

Here’s the more detailed description of the model they used:

Intervention participants were asked to attend 2 AHEAD clinic visits (90 minutes each), separated by 3 to 4 days, receiving substance use, psychiatric, medical, and social assessments by all 4 clinicians. The main focus of these visits was to engage participants so they would return for ongoing care. Treatments for addiction and for medical and psychiatric conditions were begun depending on participants’ diagnoses and readiness/priorities. Clinicians were provided with the CIDI-SF and 9-item Patient Health Questionnaire results but no other research assessment results. Participants were escorted to their first visit as soon as possible after randomization. Participants were offered 4 sessions of motivational enhancement therapy with a social worker (who used the Mini-Mental State Examination, SIP, and liver enzyme measurements for patient feedback),32 relapse prevention counseling at every contact by whichever clinician they saw, usually the NCM or social worker (which includes assessment of substance use),33 a primary care appointment, and referral to specialty addiction treatment and mutual help groups, all tailored to clinical needs and patient preferences. Addiction pharmacotherapy (naltrexone, acamprosate, disulfiram, buprenorphine, and referral for methadone) and psychopharmacotherapy were offered as appropriate.

To me, the real question is, why would anyone think this would be an effective intervention for people that were not even seeking treatment? (The fact that the subjects were not seeking treatment has not gotten the notice it deserves.)

So, what conclusions can we draw? That a model that is primary care based, low-intensity, relatively passive, is not linked to communities of recovery and only manages to deliver an average of 6 sessions over the course of a year,  is not effective for people with relatively severe dependence who are not seeking treatment.

Why do knowledgeable reporters frame it as evidence that treatment is ineffective? Especially when the researchers, themselves, said, “Among people with addictions seeking treatment, favorable outcomes are already good without CCM”? It’s hard to understand, isn’t it?

Thanks to Bill White and Dirk Hanson for digging a little deeper and setting the record straight!

 

Recover from ==> Recovery to

wellness_wheelCommenter Web Servant responded to the a recent “Sentence to Ponder” from Bill White about the need to expand the scope of treatment and recovery services that create pathways to natural community supports and adopt a wellness model. His comments seem worthy of a post of their own.

The place of treatment in recovery is to help people stop using (ie “recovery from”), the place of mental health and primary care in recovery is to address other issues which may undermine recovery and the place of community in recovery is to help people stay stopped and help sustain and maintain the full change in lifestyle and thinking that is needed “recovery too” – and can only only take place within the community.

I responded:

I like this. And, I’m thinking that this is probably true for any chronic illness where the most effective treatments are behavioral. The chronic disease burden threatens to crush the American health care system. Maybe the biggest factor is not better pills, procedures and systems, but it’s the absence of communities of recovery to support those behavioral changes.

Web Servant responds back:

Your right, nothing about this approach is specific to addiction – it applies equally to mental health, diabetes, obesity, disability maybe even ageing. So many of the struggles we have with these health conditions in the West risen from the professionalization of health care. While professional health care is essential and has had led to great achievements, it has stepped way outside of its rightful place. Especially the notion that professionals have a monopoly on human healing – a notion that has radically undermined and dis-empowered individuals and their communities from what they used to do for themselves.

This phenomenon is beautifully documented in the book The Careless Society: Community and Its Counterfeits by John McKnight where describes how the best efforts of experts to rebuild and revitalize communities can in fact destroying them through the four “counterfeiting” aspects of society: professionalism, medicine, human service systems, and the criminal justice system.

“These systems do too much, intervene where they are ineffective, and try to substitute service for irreplaceable care. Instead of more or better services, the book demonstrates that the community capacity of the local citizens is the basis for resolving many of America’s social problems.”

Bill White has talked about the need to differentiate treatment and recovery. If we fail to make this distinction, we’re more likely to drift into treatment-oriented treatment rather than recovery-oriented treatment. After watching the video below, I’ve often wondered what American health would look like if the health care system invested a little less heavily in stents and more heavily in supporting creating community/social pathways for patients to integrate more physical activity into their lives.

Recovery coaches for chronic disease management

charles outreach accept

We’ve been talking about talking about peer supports and recovery coaches for more than a decade. The use of para-professionals in the field goes back several decades.

Now, a new study evaluates a similar role for enhancing management of other chronic diseases.

Disease Management Care Blog provides a little analysis:

There is increasing interest in incorporating lay-persons in the outpatient care of persons with chronic conditions.  That makes sense, because much of the educational “payload” may be deliverable using far cheaper and more engaging “peer” members of the community who – literally – speak the patients’ language.  This is a nicely done randomized clinical trial done in a real world setting that adds to our understanding of this care option. The bottom line is that this study showed that the care guides had a real impact.

 

 

2012’s most popular posts #10 – Almost Alcoholic

This article demonstrates a big problem in understanding addiction and the a big problem in the current diagnostic categories.

…when we think about alcohol abuse or alcoholism, our thoughts often go to situations like this where someone is at a stage where they are doing immediate damage to themselves or others, but what about the stage many people go through before getting to full-blown alcoholism? What about the pain and suffering, not to mention health damage, that occurs in this almost alcoholic stage? If we had more awareness of this area on the drinking spectrum, could we prevent situations like this from occurring?

It is estimated that 22 million Americans suffer from an addiction to alcohol or drugs. Helping professionals have long viewed the problem of alcoholism and addiction in absolute terms: either you are addicted, or you are not. The official psychiatric diagnostic category — alcohol dependence — is what is commonly called alcoholism. The alcoholic must drink more or less continuously to maintain a level of alcohol in his or her body. If all the alcohol is metabolized the alcoholic goes into withdrawal and experiences severe, even life-threatening physical symptoms.

What’s the issue?

Let’s start by stating that addiction/alcoholism is the chronic and relapsing form of the problem characterized by loss of control over their use of the substance.

Problems with the current DSM categories include:

  • DSM dependence has often been thought of as interchangeable with addiction/alcoholism, but this is not the case.
    • The current DSM dependence criteria capture people who are not do not have the chronic relapsing form of the problem—many of them will experience spontaneous remission.
    • The current DSM dependence criteria capture people who are not experiencing loss of control of their use of the substance.
  • The word dependence leads to overemphasis on physical dependence which, in the case of a pain patient, may not indicate a problem at all.
  • The word abuse is morally laden.
  • For me, there are serious questions about whether abuse should be considered a disorder at all.

Same kind?

My problem with the spectrum approach is that it frames all AOD problems as one kind of problem that occurs in varying degrees. The problem here is that addiction and non-chronic dependence are different kinds of problems with vast differences in appropriate treatment approaches.

Your cousin Bob who drank way too much in college and got into some trouble but then cut back when he started a family has a problem that is a different kind or type from Aunt Suzie who has multiple treatments, has had the problem for decades and it’s severely impaired her work, family relationships, friends, housing, etc.

The article illustrates my concern with this sentence [emphasis mine]:

Alcohol abuse is the diagnosis used when an individual is not yet physically dependent on alcohol but has nevertheless experienced one or more severe consequences directly attributable to drinking.

What’s the solution?

One option would be to add addiction as a third category to separate the those with the chronic and relapsing form and those with loss of control from the others.

Another option might be to create two spectrums, one for forms of misuse (abuse to non-chronic dependence) and another for addiction (the chronic relapsing form with loss of control).

Keep only 2 categories, but eliminate abuse and add addiction.

I’m sure there are a lot more options. I’m concerned about the spectrum approach, but I fear the train may have already left the station. We’ll see.

Related articles

Non-medical treatments are essential

 


Love First linked to this article on the role of non-medical interventions in treating addiction.

I’m more and more convinced that the key to managing costs and improving outcomes for all chronic diseases are behavioral or lifestyle strategies. We’ve got a lot to learn about helping people make important changes in their lives that will help prevent relapses in cardiac care, joint replacements, weight loss, respiratory care, depression, etc. We’ve got even more to learn about helping people maintain these changes for decades.

Addiction treatment is ahead of the curve on a lot of this. We have a lot to offer the rest of medicine and I’m certain we’ll have a lot of opportunities to learn from their research and innovations.

 

Disease and choice

A NY Times philosophy blogger challenges the hijacked brain metaphor for addiction:

It might be tempting to claim that in an addiction scenario, the drugs or behaviors are the hijackers. However, those drugs and behaviors need to be done by the person herself (barring cases in which someone is given drugs and may be made chemically dependent). In the usual cases, an individual is the one putting chemicals into her body or engaging in certain behaviors in the hopes of getting high. This simply pushes the question back to whether a person can hijack herself.

There is a kind of intentionality to hijacking that clearly is absent in addiction. No one plans to become an addict.

My problem with this is that it assumes the hijacking occurs only after the first dose is consumed. AA insightfully broke the problem of loss of control into two parts, a physical allergy that causes loss of control once one takes the first drink and a mental obsession that leads to the first drink. She is only addressing the physical allergy. Of course, if the physical allergy were the only problem, jails and detoxes would be churning out recovered alcoholics and addicts.

She seems to operate from the premise that the addict is in control at the time of the first dose. But it’s a little like a person who is in full control who loves and craves strawberries with rare intensity but is allergic to them. AND, they have some sort of memory impairment that periodically interferes with their ability to recall the misery and danger of their allergic reaction and while the craving for strawberries is greatly intensified. Is that person in control?

Her solution is to reject the binary choice we’re so often presented with. It’s not choice or disease, it’s choice and disease.

A little logic is helpful here, since the “choice or disease” question rests on a false dilemma. This fallacy posits that only two options exist. Since there are only two options, they must be mutually exclusive. If we think, however, of addiction as involving both choice and disease, our outlook is likely to become more nuanced. For instance, the progression of many medical diseases is affected by the choices that individuals make. A patient who knows he has chronic obstructive pulmonary disease and refuses to wear a respirator or at least a mask while using noxious chemicals is making a choice that exacerbates his condition. A person who knows he meets the D.S.M.-IV criteria for chemical abuse, and that abuse is often the precursor to dependency, and still continues to use drugs, is making a choice, and thus bears responsibility for it.

Linking choice and responsibility is right in many ways, so long as we acknowledge that choice can be constrained in ways other than by force or overt coercion. There is no doubt that the choices of people progressing to addiction are constrained; compulsion and impulsiveness constrain choices. Many addicts will say that they choose to take that first drink or drug and that once they start they cannot stop. A classic binge drinker is a prime example; his choices are constrained with the first drink. He both has and does not have a choice. (That moment before the first drink or drug is what the philosopher Owen Flanagan describes as a “zone of control.”) But he still bears some degree of responsibility to others and to himself.

The complexity of each person’s experience with addiction should caution us to avoid false quandaries, like the one that requires us to define addiction as either disease or choice, and to adopt more nuanced conceptions. Addicts are neither hijackers nor victims. It is time to retire this analogy.

The concern I have is that she reduces addiction to being like any other chronic illness that may require difficult to make lifestyle changes, like diet and exercise.

The hijacked brain metaphor may be flawed, but it’s attempting to communicate that the addiction uses the addict’s own self-preservation instincts, desires and will to maintain addiction. For the active alcoholic who is sober at the moment and wishes to stay that way, it might be thought of as a struggle between a present self and a future self. He knows and fears that his future self will drink and will, once again, be off to the races. The question is who or what is in control of his future self’s taking of that drink?

Almost alcoholic?

This article demonstrates a big problem in understanding addiction and the a big problem in the current diagnostic categories.

…when we think about alcohol abuse or alcoholism, our thoughts often go to situations like this where someone is at a stage where they are doing immediate damage to themselves or others, but what about the stage many people go through before getting to full-blown alcoholism? What about the pain and suffering, not to mention health damage, that occurs in this almost alcoholic stage? If we had more awareness of this area on the drinking spectrum, could we prevent situations like this from occurring?

It is estimated that 22 million Americans suffer from an addiction to alcohol or drugs. Helping professionals have long viewed the problem of alcoholism and addiction in absolute terms: either you are addicted, or you are not. The official psychiatric diagnostic category — alcohol dependence — is what is commonly called alcoholism. The alcoholic must drink more or less continuously to maintain a level of alcohol in his or her body. If all the alcohol is metabolized the alcoholic goes into withdrawal and experiences severe, even life-threatening physical symptoms.

What’s the issue?

Let’s start by stating that addiction/alcoholism is the chronic and relapsing form of the problem characterized by loss of control over their use of the substance.

Problems with the current DSM categories include:

  • DSM dependence has often been thought of as interchangeable with addiction/alcoholism, but this is not the case.
    • The current DSM dependence criteria capture people who are not do not have the chronic relapsing form of the problem—many of them will experience spontaneous remission.
    • The current DSM dependence criteria capture people who are not experiencing loss of control of their use of the substance.
  • The word dependence leads to overemphasis on physical dependence which, in the case of a pain patient, may not indicate a problem at all.
  • The word abuse is morally laden.
  • For me, there are serious questions about whether abuse should be considered a disorder at all.

Same kind?

My problem with the spectrum approach is that it frames all AOD problems as one kind of problem that occurs in varying degrees. The problem here is that addiction and non-chronic dependence are different kinds of problems with vast differences in appropriate treatment approaches.

Your cousin Bob who drank way too much in college and got into some trouble but then cut back when he started a family has a problem that is a different kind or type from Aunt Suzie who has multiple treatments, has had the problem for decades and it’s severely impaired her work, family relationships, friends, housing, etc.

The article illustrates my concern with this sentence [emphasis mine]:

Alcohol abuse is the diagnosis used when an individual is not yet physically dependent on alcohol but has nevertheless experienced one or more severe consequences directly attributable to drinking.

What’s the solution?

One option would be to add addiction as a third category to separate the those with the chronic and relapsing form and those with loss of control from the others.

Another option might be to create two spectrums, one for forms of misuse (abuse to non-chronic dependence) and another for addiction (the chronic relapsing form with loss of control).

Keep only 2 categories, but eliminate abuse and add addiction.

I’m sure there are a lot more options. I’m concerned about the spectrum approach, but I fear the train may have already left the station. We’ll see.

Identity and addiction

The White Noise had a post on identity and addiction. The blogger ends up expressing some discomfort with the way many recovering addicts make their addiction and recovery so central to their identity:

I have mixed feelings on AA. I believe in camaraderie and community in times of strain and crisis. I believe in cultivating the knowledge that addiction is not character weakness. However, I’m not so sure as to the continual efficacy of defining oneself as an addict day in and day out. As much as it’s all-consuming, it’s a facet of life, not a definition of being. Does it take this definition to cope?

I tend to think that recovery from any chronic illness involves an identity change, particularly for those people who are successful in the lifestyle changes that are associated with recovery from many chronic illnesses.

People who have had a heart attack or been diagnosed with type 2 diabetes and change their activity levels and diets often make this part of their identity and a very important part of their life narrative.

They also often go through some developmental stages with this where they can go through periods of being pretty obnoxious–”Do you know how many calories are in that?” and “You should start working out, you’ll love it. I swear. I was just like you! You need to do it!” They often find a little more balance over the years that follow. However, when we’re talking about lifestyle changes that we want to sustain over a period of decades, isn’t an identity shift going to be an important maintenance strategy for many, if not most, people? Isn’t easier to maintain a behavior when it’s not just something we do, but, rather, who we are?

I’m reminded of this post and this quote:

“Once I became my diagnosis, there was no one left to recover.”

I think this might get at what some people, like the White Noise blogger, fear when they hear people making addiction and recovery central to their identity. I guess the question is whether they organize important parts of their identity around their addiction or their recovery.

Spending the rest of my life defining myself as someone who has type 2 diabetes might not be so good, but defining myself as a fit, healthy person who successfully manages a serious illness strikes me as a pretty good thing.