A chronic illness?

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.

Diagnosing ADHD in detox?

fear_false_evidence_appearing_realUnreal. Someone’s got an awful lot of faith in their diagnostic skills. Diagnosing ADHD with addicts in a detox unit? Really?

And, now that it’s published, it’s “evidence”.

Rates of undiagnosed attention deficit hyperactivity disorder in London drug and alcohol detoxification units


ADHD is a common childhood onset mental health disorder that persists into adulthood in two-thirds of cases. One of the most prevalent and impairing comorbidities of ADHD in adults are substance use disorders. We estimate rates of ADHD in patients with substance abuse disorders and delineate impairment in the co-morbid group.


Screening for ADHD followed by a research diagnostic interview in people attending in-patient drug and alcohol detoxification units.


We estimated prevalence of undiagnosed ADHD within substance use disorder in-patients in South London around 12%. Those individuals with substance use disorders and ADHD had significantly higher self-rated impairments across several domains of daily life; and higher rates of substance abuse and alcohol consumption, suicide attempts, and depression recorded in their case records.


This study demonstrates the high rates of untreated ADHD within substance use disorder populations and the association of ADHD in such patients with greater levels of impairment. These are likely to be a source of additional impairment to patients and represent an increased burden on clinical services.

Even more on the DSM-V

The Fix follows up on the previous piece about the coming changes in the DSM-V.

The writer captures my concerns:

I don’t foresee any negative results from dropping those two misguided terms. (abuse and dependence) But what does concern me is the fact that rather than still having two separate and distinct conditions—one, a short-term, self-limiting disorder and the other a condition likely to be chronic and relapsing—there will now be only one way to have a drug problem. The gradations of the condition will likely be delineated as “mild,” “moderate” or “severe” substance use disorder. While the word “addictive” will appear in the heading that labels the overall category, it will not figure in the diagnoses themselves. For example, you could have mild, moderate or severe opioid dependence disorder or gambling disorder. (So far, gambling is the only behavioral addiction to make the DSM cut.)

But this elision of the problems formerly known as abuse and dependence will, I fear, cause major problems for many people, especially teenagers and young adults. What it means, in a worst-case scenario, is that every college binge drinker will be at risk for being labeled an alcoholic and every high school stoner, an addict.

It’s unfortunate that the author trots out gross stereotypes and caricatures in paragraphs 9 through 12. She falls into the cognitive errors that Kathryn Shultz describes so well at 9:59 through 11:17 of this great talk:

Good thing we don’t use Jayson Blair, Stephen Glass, Jack Kelley and partisan medial outlets to slander writers in general 😉

A New Paradigm for Substance Abuse Treatment

From Robert DuPont, MD:

Substance abuse treatment is committed to abstinence from nonmedical drug use. Yet, continued nonmedical drug and alcohol use and relapse are so common that they are often defined as part of the disease itself.

A “new paradigm” for care management has been pioneered over the past four decades by the state Physician Health Programs (PHPs).PHPs provide diagnostic evaluation, treatment referral, close monitoring and support services to health care professionals who have conditions, including in particular substance use disorders, which can impair their ability to practice medicine with reasonable skill and safety. In dealing with substance use disorders, PHPs use a zero tolerance standard for any alcohol or other drug use, enforced by intensive random testing and close linkage to the 12-step programs of Alcoholics Anonymous and Narcotics Anonymous to produce remarkable long-term outcomes. These outcomes set a far higher standard for success in treatment and they cast doubt on the definition of addiction as being characterized by relapse. They demonstrate that the environment in which the decision to use or not to use alcohol and drugs is a powerful determinant of outcomes.


While some may dismiss the PHP results because physicians are a uniquely advantaged patient population, a similar approach has produced outstanding results in a dramatically different population of addicted people — convicted felons on probation. A randomized control study of the pioneering HOPE Program showed that compared to a control group of standard probationers, HOPE participants were 55 percent less likely to be arrested for new crimes, 72 percent less likely to use drugs, 61 percent less likely to miss appointments with probation officers and 53 percent less likely to have their probation revoked.3 HOPE probationers were sentenced to 48 percent fewer days of incarceration.

The new paradigm of long-term monitoring with swift, certain and serious consequences for any detection of drug or alcohol has the potential to substantially improve long-term outcomes for substance abuse treatment.

Now, I’m not interested in a paradigm that makes consequences a central element.

However, what’s important here is that there is a very effective treatment for this chronic illness and, like most treatments for chronic illnesses, we struggle with engagement and compliance. In the case of addiction, why do we respond to those struggles with a lowering of the bar?