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.

 

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.

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.

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

 

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.

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.

 

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.

 

 

 

Response to Why Addiction is NOT a Brain Disease

English: Magnetic resonance imaging (MRI) of t...

In a thoughtful post, Marc Lewis questions the disease model of addiction.

He doesn’t dismiss it out of hand. He seems to look for ways in which it’s right and useful.

It’s accurate in some ways. It accounts for the neurobiology of addiction better than the “choice” model and other contenders. It explains the helplessness addicts feel: they are in the grip of a disease, and so they can’t get better by themselves. It also helps alleviate guilt, shame, and blame, and it gets people on track to seek treatment. Moreover, addiction is indeed like a disease, and a good metaphor and a good model may not be so different.

He offers two objections.

Spontaneous Recovery

First the existence of spontaneous recovery:

What it doesn’t explain is spontaneous recovery. True, you get spontaneous recovery with medical diseases…but not very often, especially with serious ones. Yet many if not most addicts get better by themselves, without medically prescribed treatment, without going to AA or NA, and often after leaving inadequate treatment programs and getting more creative with their personal issues.

My first reaction is that we’re not very good at distinguishing misuse, dependence and addiction. These studies include people who met diagnostic criteria for alcohol dependence in college and reduced their use as they moved into other stages of life. The other frequently cited group are heroin dependent Vietnam vets. Again, it’s important to distinguish between dependence and addiction.

So, I think, the problem is not the disease model, but rather, our diagnostic categories and their application. I suspect that if those studies finding high rates of natural recovery limited subjects to those with true loss of control (addiction), the prevalence of spontaneous remission would drop dramatically.

Further, I’m not sure this this is a strong argument at all. Wouldn’t this exclude hundreds of viral and bacterial diseases? These are generally acute illnesses, but don’t other diseases have acute and chronic forms?

Dopamine responses are normal

His second objection is that addiction uses natural brain mechanisms that are shared by many other life experiences.

According to a standard undergraduate text: “Although we tend to think of regions of the brain as having fixed functions, the brain is plastic: neural tissue has the capacity to adapt to the world by changing how its functions are organized…the connections among neurons in a given functional system are constantly changing in response to experience (Kolb, B., & Whishaw, I.Q. [2011] An introduction to brain and behaviour. New York: Worth). To get a bit more specific, every experience that has potent emotional content changes the NAC and its uptake of dopamine. Yet we wouldn’t want to call the excitement you get from the love of your life, or your fifth visit to Paris, a disease.

I have a couple of thoughts about this. First, lots of diseases are characterized by natural body processes turning against the body, many cancers for example. Second, when we’re talking about addiction, we’re not talking about one brain mechanism. (He focused on dopamine release.)

Several brain mechanisms have been identified and, I suspect, better understandings of these will lead to better typologies for AOD problems. Some people may have only one or two of these neurobiological factors, while others have ten.  Some factors may be associated with a more chronic form, others may be associated with a more severe loss of control and overall severity may be associated with the number of factors the person has. (Also, some might be primary to addiction, others secondary.)

What is a disease, anyway?

I think the biggest barrier to responding is that the writer did not offer a definition or boundaries for understanding “disease.” Merriam-Webster offers this definition:

a condition of the living animal or plant body or of one of its parts that impairs normal functioning and is typically manifested by distinguishing signs and symptoms

WebMD offers Stedman’s Medical Dictionary’s definition as:

A morbid entity ordinarily characterized by two or more of the following criteria: recognized etiologic agent(s), identifiable group of signs and symptoms, or consistent anatomic alterations.

Is the writer arguing that addiction does not meet these definition? I’m having a hard time seeing how. And, why does the idea of classifying addiction as a disease bother people so much?

 

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?

Why we can’t agree

Official portrait of United States Director of...

The Obama administration just released their annual drug control strategy report and all the headlines say it emphasizes treatment over incarceration.

Sounds great, but the stories are short on details.

Others, from the Drug Policy Alliance are dismissing it as more of the same.

More of the same? Really? I think Obama’s safely within the herd on this, but one doesn’t have to go back very far to reach a time when it would be a certain death sentence for a national politician to say that we should incarcerate fewer people for drug crimes. Change may not be coming as quickly as the DPA would like, but to say that the current state of affairs is “same old, same old” is pretty silly.

All of this is mildly interesting. What is was much more interesting was this quote:

Is it a disease of the brain? I asked Columbia University psychology professor Carl Hart, who is also a board member of Drug Policy Alliance. Hart laughed. “A behavioral disease, therefore the brain is involved? OK, we can say that about everything.”

I admit, the addiction-is-an-illness line never worked for me. It leaves out personal will. It sanitizes destructive decision making. It suggests that people cannot get clean without a health care professional.

Art Caplan, director of the Center for Bioethics at the University of Pennsylvania, came up with the best explanation I’ve heard for the disease argument. People don’t want to see addicts jailed, he said, so they’ve come up with a scenario to spare users from incarceration. Ergo: “The whole drug establishment is invoking the disease model as an antidote to the criminal-justice model.”

I think it goes a long way toward explaining the difficulty in explaining the difficulty in finding any common ground on drug policy.

  • The question of free will is an important and under-addressed matter. Though I’m pretty confident it’s under-addressed because it’s not empirically knowable.
  • The suspicion of the disease model is a huge barrier. If there are profound disagreements about the nature of the issue, it’s very difficult to even begin to come up with solutions that address each other’s concerns.
  • The suspicion of each other’s motives is a huge barrier—”so they’ve come up with a scenario”. This paints advocates of the disease model as disingenuous. We’re manufacturing the model we need rather than describing what is.