As addiction is a chronic disease and medicine has been treating chronic diseases for years, we actually have something to look at in this case. We can look at how the rest of the medical world measures their chronic diseases and compare that to what we’re measuring in Addiction.
The first thing measured in any chronic disease is adherence to the care plan. For Diabetics it’s taking medicine, a good diet, and moderate exercise, etc. For addiction it’s don’t use, don’t use anything else, and participate in a recovery program. That’s actually as far as we’ve gotten. What we’ve been measuring isn’t relapse, though we call it that. Relapse is the return of previously suppressed symptoms and we’ll get to that in a minute, but what we’ve been measuring is only the patients adherence to the plan of care. At least we were doing that much.
But adherence isn’t very good in any chronic disease, something like 30-40% is about as good as it gets. People get tired of being sick. They long for a vacation from abnormality. They want to behave and feel like a normal person. They want to forget they’re ill, and to do that, they have to forget the care plan. Are addicts any different? Not in the least. Addicts get tired of having to know they’re different. They just want to feel normal and so, like diabetics, they forget they’re ill and try to live without the care plan from time to time. And it’s important to adhere to the care plan, because, hopefully, it’s what’s keeping those symptoms suppressed.
Has it been a minute yet? We’re ready for the symptoms. For a diabetic the symptoms would be loss of control of blood glucose levels. In addiction the symptoms, are not drug use, but the expression that led to the use of drugs in the first place. Those are largely the low dopamine symptoms I’ve written about elsewhere so I won’t go into a big discussion here. I only want to mention that when we have measured these in our field, since the role of symptom was already being mistakenly taken by drug use, we had nothing to call these symptoms but co-morbid illnesses. We’ll get back to measuring co-morbidity in another minute.
So we have adherence to the care plan and symptom suppression. They actually exist in a kind of circle. If you don’t adhere, you get symptoms. As you suppress symptoms the urgency of adherence goes away and you tend to non-adherence. Any understanding of outcomes of a chronic disease has to take into consideration the non-linear nature of the natural history of a chronic disease. We’ve been trying to measure a donut’s circumference with a yard stick, perhaps possible, but needlessly difficult.
We need to also measure function. Treatment of symptoms doesn’t do the patient or society a whole lot of good unless we restore the patient to full function, or as close as we can get. Here we have things like relationships, work, ability to take care of the normal duties of life. Addiction outcomes have measured some of these, and it’s becoming more popular to do so. One thing we rarely do is ask the patient’s spouse how they are doing. That would be an eye-opener I’ll bet. So, how’s the relationship? How’s work? That’s an outcome of treatment for a chronic disease as well. Has it been another minute already? Time flies when you’re talking about outcomes. So now on to co-morbidities.
With co-morbidities we actually have two subjects: those illnesses that naturally travel with the chronic disease who’s outcome we’re measuring and those illnesses caused by the disease we’re measuring. Of course, we’ll look at the last one first. In diabetes we’d look for changes in vision and any sign of developing heart disease among other things. For addiction we may look for sequelae of drug use or of the use of compulsive behaviors (gaining weight, losing money, etc). Those we’re used to, but are there really illnesses that are naturally co-morbid with addiction? I personally doubt it. When you look deeply at what we’ve called commonly co-morbid illnesses, you find the primary symptoms of Addiction. Sure people have Addiction and Major Depression, but no more often than a population under stress gets Major Depression. Sure you see Bipolar Mood Disorder and Addiction, but no more often than you see Bipolar Mood Disorder in non-addicts, if you understand the bipolar nature of addiction itself. OCD? Schizophrenia? All about in the same amounts you’d see in anyone else. The closest I can come to understanding a true co-traveler with Addiction is PTSD and the only mechanism I can imagine is the consequence of the patient’s parent having Addiction so, it too, is a sequela, not a fellow traveler.
So, what should we measure? Not using? Certainly. But it can’t end there. We need to measure not only adherence but symptoms. And we need to measure them in a way that is informed by the circular nature of their relationship. We also need to measure function, both social and occupational. What Addiction outcomes lack most is the surveillance of sequelae. We can’t measure 6 month outcomes, it’s a chronic disease. We need to measure outcomes for life.
One other thought on outcomes, and here, even the rest of medicine is behind. We need to consider the patient’s goal in their recovery from a chronic disease. We may have the ethic that the patient should function as well as possible for as long as possible and die of something else. That may not be what the patient wants. If we decide to measure things that are not in the direction of the patient’s wishes, we will not likely show success. Our field needs a vigorous discussion about this, as we are particularly resistant to hearing the patient’s goal when we come up with a treatment plan.
© Howard C Wetsman MD FASAM