Tag Archives: disease

Personal Failure or System Failure?

Lowering_The_Bar_Cover_2010.09.22Bill White explaining why inadequate treatment may be worse than no treatment:

What we know from primary medicine is that ineffective treatments (via placebo effects) or an inadequate dose of a potentially effective treatment (e.g., as in antibiotic treatment of bacterial infections) may temporarily suppress symptoms.  Such treatments create the illusion of resumed health, but these brief symptom respites are often followed by the return of illness–often in a more severe and intractable form.  This same principle operates within addiction treatment and recovery support services.  Flawed service designs may temporarily suppress symptoms while leaving the primary disorder intact and primed for reactivation.  But now the treated individual has three added burdens that further erode recovery capital.  First, there is the self-perceived experience of failure and the increased passivity, hopelessness, helplessness, and dependency that flow from it.  Second, there are the perceived failure and disgust from others and its accompanying loss of recovery support–losses often accompanied by greater enmeshment in cultures of addiction.  Finally, there are the very real other consequences of “failed treatment,” such as incarceration or job loss that inhibit future recovery initiation, community re-integration and quality of life.

The personal and social costs of ineffective treatment are immense.  If we as a society and as a profession want to truly give people with severe and complex addictions “a chance,” then we have a responsibility to provide systems of care and continued support that speed and facilitate recovery initiation, buttress ongoing recovery maintenance, enhance quality of personal and family life in long-term recovery, and provide the community space (physical, psychological, social and spiritual) where recovery and sustained health can flourish.  Anything less is a set-up for failure.

via Personal Failure or System Failure? | Blog & New Postings | William L. White.

 

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The Unintended Consequences Of Medical “Maximalism”

Health

Health (Photo credit: 401(K) 2013)

The Health Affairs blog questions the American Heart Association’s maximalist approach with the use of statins. The issues sound familiar.

The policy implications of these guidelines are staggering. Estimates show that if these recommendations are fully implemented, close to a third of all Americans will be placed on a statin. But these developments beg the question: Is this the right policy? Is taking a statin the most effective way for the millions of Americans who are at risk of heart disease to reduce their risk?

When appropriately prescribed, evidence substantiates that statins do reduce heart attack risk, but how do they compare to other interventions? We know that lower cholesterol is better, and we know that statins help to reduce heart disease risk, but we also know that the most effective way to reduce heart disease is not necessarily by taking more pills in ever-increasing doses – it’s to engage in lifestyle change. The best way to reduce risk is by losing weight if overweight, quitting smoking if a smoker, exercising if sedentary, and eating a Mediterranean style diet. Over the past few decades, we have gotten less active, we weigh more, and we eat too much unhealthy food. The new guidelines may have the unintended consequence of de-emphasizing the things that we know reduce risk the most in favor of treatments that are less effective.

Lifestyle change is also emphasized in the guidelines, but it can be very difficult to change deeply embedded behaviors, no matter how unhealthy they may be. When people are unable or unwilling to make those changes, frustrated clinicians looking for another solution often turn to medication as the easy answer for their patients. But a blanket prescription that everyone who has heart disease, or who is at risk for it, take a statin may encourage those most at risk to be lulled into a false sense of security. As cholesterol numbers go down, patients may no longer feel at risk, but the truth is a lot more complicated. For individuals who fall into the four benefit groups, then, yes, the drugs will likely lower their risk of a heart attack; but they will still likely have a heart attack at some point in their life. Medications cannot effectively insulate us from the results of our unhealthy choices.

The parallels are not perfect, as exemplified by his emphasis on choice in his closing, but the parallels are close enough to make clear that addiction treatment providers are not alone with our questions about medical maximalism vs. lifestyle changes.

Guidelines like those released last month reinforce how far society and our health care system have swung away from prevention and towards the medical model, which treats disease, but often does an inadequate job of promoting public health. Lifestyle change won’t help everyone. Some may still need to take a statin, even after they change their lifestyle. But for many, making healthier choices is enough. As medical science advances, we will continue to have better drugs, and the tendency of providers might be to expand their use. But the solutions to many of the ills that plague large numbers of Americans—high blood pressure, high cholesterol, diabetes, and the heart disease that they cause—do not lie in taking more and more pills to treat more of our preventable chronic conditions. They lie in motivating the millions of Americans who are currently living an unhealthy lifestyle to make better choices.

While experts in other areas of health may neglect promoting lifestyle changes, I suspect most would acknowledge that, for most people, lifestyle changes are either the preferred way to resolve the chronic health problem, the front line response, or be a prominent feature of every treatment plan. In opiate addiction, the field has swung so far in the maximalist direction that we’ve gotten to the point where we can’t even agree on that.

David Katz addresses the questions this discussion begs:

As far as I’m concerned, the entire debate about statins is part of our societal static. It’s a background noise of cultural misdirection that favors the conflated interests of Big Food and Big Pharma while ignoring the compelling, consistent, signal of what lifestyle as medicine could do for us all.

We could prevent all those heart attacks, and more, without putting statins in the drinking water. We could add years to life, and life to years, and save rather than spend money doing it – if lifestyle were our preferred medicine. The signal has been there for literal decades that minimally 80 percent of all heart disease could be eliminated by lifestyle means readily at our disposal. There is a case that, but for rare anomalies, heart disease as we know it could be virtually eradicated by those same lifestyle means. And the same lifestyle medicine that could do this job would slash our risk for every other bad outcome as well, while enhancing energy, cultivating vitality, and contributing to overall quality of life. And unlike our statins, we could share these benefits with those we love.

But for the most part, we as individuals, and collectively as a culture, seem deaf to this signal. We watch our peers and parents succumb to heart disease, and wring our hands. We fret over the same fate overtaking us. We get prescriptions for drugs we wish we didn’t have to take, worry about serious side effects, suffer through minor ones, grumble about copays, and implicate ourselves in the unmanageable burden of “health” care costs.

via The Unintended Consequences Of The New Statin Guidelines – Health Affairs Blog.

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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.

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More on choice and addiction

why oh why by larryosan

why oh why by larryosan

From Kevin McCauley:

The argument against calling addiction a disease centers on the nature of free will. This argument, which I will refer to as the Choice Argument, considers addiction to be a choice: the addict had the choice to start using drugs. Real diseases, on the other hand, are not choices: the diabetic did not have the choice to get diabetes. The Choice Argument posits that the addict can stop using drugs at any time if properly coerced.

As evidence, the Choice Argument offers this scenario: a syringe of drugs is placed in front of an intravenous drug addict and the offer is made to “Spike up!” When the addict picks up the needle and bares his arm, a gun is placed to his temple and the qualifier is added that if the addict injects the drug his brains will be blown out. Most addicts given this choice can summon the free will to choose not to use drugs. The Choice Argument claims this proves that addiction is not a disease. But in real diseases – diabetes, for instance- a gun to the head will not help because free will plays no part in the disease process. So the Choice Argument draws a distinction between behaviors – which are always choices – and diseases.

This is a powerful argument. It is also wrong.

While it is true that a gun to the head can get the addict to chose not to use drugs, the addict is still craving. The addict does not have the choice not to crave. If all you do is measure addiction by the behavior of the addict – using, not using – you miss the most important part of addiction: the patient’s suffering. The Choice Argument falls into the trap of Behavioral Solipsism.

Just as a defect in the bone can be a fracture and a defect in the pancreas can lead to diabetes, a defect in the brain leads to changes in behavior. In attempting to separate behaviors (which are always choices) from symptoms (the result of a disease process), the Choice Argument ignores almost all of the findings of neurology. Defects in the brain can cause brain processes to falter. Free will is not an all or nothing thing. It fluctuates under survival stress.

Hat tip: Matt Statman

 

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Brain disease does not equal stigma reduction


Yesterday, I posted about The Anonymous People and Dawn Farm’s co-sponsorship of an upcoming screening of the film.

So…why is this message of recovery so important to stigma reduction?

We’ve spent 20 years trying to convince the public that addiction is a brain disease without too much attention to the potential for this message to backfire. Bill White outlines the potential pitfalls:

 My fears are captured in the following three propositions.  First, communicating the neuroscience of addiction without simultaneously communicating the neuroscience of recovery and the prevalence of long-term recovery will increase the stigma facing individuals and families experiencing severe alcohol and other drug problems.  Second, the longer the neurobiology of addiction is communicated to the public without conveying the corresponding recovery science, the greater the burden of stigma will be.  Third, the brain disease paradigm could create new obstacles for social inclusion of people in recovery and provide a rational for coercive, invasive and harmful interventions.

As I noted in my earlier paper, the vivid brain scans of the addicted person may make that person’s behavior more understandable, but they do not make this person more desirable as a friend, lover, spouse, neighbor, employee, or candidate for college entrance, military enrollment, or a car or home loan.  In fact, in the public’s eye, there is a very short distance between the diseased brain and the perception of a deranged and dangerous person. We should not forget that less than a century ago biological models of addiction provided the policy rationale for prolonged sequestration of addicted persons, their inclusion in mandatory sterilization laws and a host of other harmful interventions, including prefrontal lobotomies and chem- and electroconvulsive “therapies.” Further, christening addiction a CHRONIC brain disease without accompanying recovery messages, inadvertently risks further contributing to social stigma from a public that interprets “chronic” in terms of “forever and hopeless” (“once an addict, always an addict”)(See Brown, 1998 for an extended discussion of this danger).

Conveying that persons addicted to alcohol and drugs have a brain disease that alters emotional affect, compromises judgment, impairs memory, inhibits one’s capacity for new learning, and erodes behavioral impulse control are not communications likely to reduce the stigma attached to alcohol and other drug problems, UNLESS there are two companion communications: 1) With abstinence and proper care, addiction-induced brain impairments rapidly reverse themselves, and 2) millions of individuals have achieved complete long-term recovery from addiction and have gone on to experience healthy, meaningful, and productive lives.

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The memory disease

"It is by self-forgetting that one finds..." --St. Francis of Assissi

“It is by self-forgetting that one finds…” –St. Francis of Assissi

Authors Michael W. Clune and Tao Lin discussed their recent books for Believer magazine.

Tao Lin points out a theme of seeking to get outside oneself as a response to “internal malfunctioning or uncontrollable-seeming, undesirable behavior.”

He points to this passage from book, White Out:

The only way to recover from the memory disease is to forget yourself. You see, I was in a memory trap. In order to get out I had to forget myself. In order to forget about myself, I had to be sure there was something outside to grab on to. But the memory diseases had trapped all my senses. I couldn’t see outside. In order to get even a glimpse of what’s outside, I had to forget myself completely.

Clune frames it in the context of his recovery:

The practice of getting out of myself has been crucial for staying off dope, and I kind of wanted to protect it from analysis. My experience with addiction convinced me that there was no getting out from any place within myself. My memories, my impulses, my reflexes, my relationships, my goals, my future, past, and present were all terminally infected. So to escape the memory disease—to escape addiction—I had to start over, outside me. How to get outside?

The first step was forming new habits. Every night, I just wrote a list of things that are good to do, and the next day I read the list and did them—did them until I didn’t have to read the list anymore. Brush my teeth. Eat a banana. Work on my dissertation for three hours. Take a walk. Go to an NA meeting. Repeat. Pretty soon I’m a different person. The self isn’t really that solid; it’s mostly composed of things from the outside world. And habits are the tape and rope and staples that get things outside stuck in us.

Sometimes people tell me they’re scared to get into recovery, because they’re scared they’ll lose the “real me.” I’ve never been able to understand this. I’ve always been very happy to lose the real me, it’s just hard to find takers. Habit is a taker.

This really resonates with my experiences in early recovery.

I love the framing as a memory disease and self-forgetting via seemingly unrelated actions as a path to freedom. Very interesting. I’m looking forward to reading more from him and thinking more about it.

 

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Family, Secrecy and Addiction

Alone

Alone (Photo credit: Leni Tuchsen)

 

The NY Times recently had a personal piece on the impact of addiction on parents:

 

Addiction is, as we have learned, a family disease. The number of stories we’ve heard of wives, daughters, fathers, sons, nieces, nephews, brothers and sisters – not in counseling or therapy scenarios, but from people who recognize our pain and somehow want to comfort us, or to comfort themselves through us, is staggering.

What I do not know, and can only wonder about, is how many more stories remain untold. They need to be told. Secrecy and anonymity are part of the disease, for addict and family alike.

 

 

 

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