Like underwater reefs, hidden barriers can rip the bottom out of a patient’s ship as he tries to sail into safe harbor. And like any harbor manager, treatment programs like to look down and see their port filled with busy and vigorous ships producing lots of commerce. In the case of the treatment centers, it’s lots of healthy recovering patients staying sober. And in both cases, the harder you make it to get into your harbor, the more likely it will be that only the better equipped ships with the least damage will get in.
Of course there’s a constant tension between profit and outcomes. The harder you make it to get into your treatment program, the fewer people you’ll be able to treat. A good port changes itself to fit its customers by providing berthing and services that are varied and can accommodate a wide range of ship types. That’s what we ought to do as well, let in everyone and make ourselves flexible enough to handle the diversity.
If you ask treatment providers, 90% will tell you they already do that. If you ask drivers, 90% say they are above average drivers, too. So let’s not ask treatment providers, let’s think about this from the patient’s perspective.
What if I don’t want to go to AA? What if I really don’t want to try for full abstinence? What if I don’t believe I’m ill and should stop drinking? Our traditional answer has been, “Well you’re not ready. Go back out and drink some more until you’re ready to do it my way.” How arrogant can we get?
So we only take patients when they’re ready, and we show our outcomes to the world as if they were our creation. It reminds me of a line in a poem by New Orleans poet, Brod Bagert, “Born on third-base and think they hit a triple.” That’s us, working with a selected population and thinking we did all the work. I guess we did do the work; we set up the barriers.
The one thing we most commonly ask is, “Are you ready to stop?” And what’s the one thing we measure? Staying stopped. That’s a little self-serving isn’t it? What if the patient got to pick the outcome? What would he pick? And what’s the point of our treatment?
We’ll start with the last one first. The point of treating any chronic illness is to suppress symptoms and prevent progression. If you’ve been reading this blog you know that I think addiction symptoms start before the first “drug” use and, in fact, lead to the drug use. What most people with addiction will pick as a goal is to feel better, to be able to function normally, and, if given the choice, at the beginning of treatment they would probably not pick spiritual enlightenment as a goal. Does your doctor say things like, “Alright lady, if you don’t lose 100 pounds I’m not treating your diabetes,” or, “Cut out the salt or you and your high blood pressure are out of my practice,” or, “Buddy, get rid of the dog, or I’m not giving you your asthma medicine.” What if Buddy’s goal is to do the best with his asthma that he can while still keeping the dog he loves?
Someone’s out there saying, “That Wetsman guy just wants to give people medicine and let them drink if they want to.” No he doesn’t. Let me tell you about Carlos (obviously, I’m not using his real name), a guy I saw this week. He came in for opiate dependence and has stabilized on Suboxone. He’s been in the IOP but has had trouble making it to sessions and individuals because of work and because he’s not sure he needs treatment. He’s almost finished the IOP portion of the program now and saw me this week for his medication follow up. He asked when he could get off of Suboxone. When I asked Carlos what, if anything he had used to alter his mood or his mind in the last month he said, “Nothing, just a couple of beers but that’s alright, right?” I told him that we have statistical studies showing that people who use any drug will more likely relapse onto the one they’re trying to avoid and since his goal is to not use opioids he would be wise not to use anything, including alcohol. We also talked about meetings outside of treatment which he had not been attending for the last couple of weeks. I told him that recovery changes his brain and if he stopped his medicine now without having a strong recovery program he be most likely to have the brain he had before treatment. He said, “And that’s the brain that used drugs, huh?” Sounds kind of good, like Carlos is making progress. But only if you think Carlos’s goals are important. If my goals of no drug use and working a strong recovery program are the goals, he’s taking his sweet time. Where would Carlos be if I’d said weeks ago, “If you’re not ready to work a program, you’re not ready, so get out.”
Some may fantasize that Carlos would be sitting in a 12-step room listening to a speaker, but, while I’d love to believe I’m that powerful and persuasive, it’s more likely that Carlos would be out of treatment and using again, if not in jail. As addiction treatment has been divorced from medicine for a long time, it will be a difficult reconciliation. The fields have different languages and different ethics. In medicine it would largely be considered unethical to refuse treatment if a patient didn’t follow instructions. What would be required is an intervention aimed at making sure the patient understood the instructions and was competent to make a decision to ignore the advice. So, what does all this have to do with outcomes?
We’re going to have to change how we think of outcomes. Six months of no drug use isn’t going to cut it. We’re going to have to understand that this is a chronic disease and the success of treatment is suppression of symptoms and prevention of progression, and not just for 6 months. The first outcome starts before treatment; how many people who call actually get assessed? Then how many assessed actually enter the program? While low percentages getting in may make for better six month sober rates, they mean less people with the disease get help and that’s a bad outcome. Then, once people are in the progam, do they stay in care. I’m not saying do they stay in inpatient care, or IOP; I’m saying all care. It’s not bad if the patient decides to leave inpatient care after a week. Maybe he’s right and it’s not for him. Are people who make money off of his staying in the best position to decide? But does he stay in care when he leaves? “Yes” is good, “no” is not. So another outcome that starts before treatment is how we design our program. Are we a hammer that only treats nails or are we a toolbox full of solutions for people suffering from this disease?
As we move forward to make sure that we’re comparing apples to apples in outcomes we have to recognize that programs that only take a small percentage of people who call are not better programs because they have higher 6 month sober rates. We should be judged by how many ships that approached our harbor are still safely inside, not the percentage of nice clean vessels that have carried gold to our shores. That’s enough on how barriers effect outcomes. Next time I’m going to write about how we actually need to measure different things after treatment than we’re measuring now.
© Howard C Wetsman MD FASAM
Dr. Wetsman, your blog has brought up a number of questions for me, largely academic in nature. Is it possible for me to email you regarding them, or would you prefer to keep such conversation limited to this blog (a boundary I can completely understand and respect, should you feel that way)? I am trying to fully internalize the model of Addiction you have described, but I cannot find a comprehensive explanation of said model, for either academic or clinical purposes. A sample of my questions can be found below.
Thank you very much for your time.
Sincerely,
Owen Rachal
1. If Addiction is a chronic, progressive brain condition characterized by inadequate dopamine tone and associated behaviors, including substance abuse, is it a congenital condition?
2. Is the condition’s genesis purely genetic or more likely epigenetic in nature?
3. Can “recovery” be defined in purely biological?
4. Are there subtypes of the condition that can be modeled?
Owen,
Sure, email me. I think the link is on the right of the blog.
But to answer your questions:
1. Yes, largely, but we lose dopamine tone as we age as well, so the risk of addiction rises with age. This is in contradistinction to the common belief that addiction is a young person’s illness. We largely don’t recognize elders’ addiction, because they aren’t out stealing hubcaps or TV’s. But there is a large geriatric addiction population that is unattended now.
2. I have seen a lot of “genetic” evidence that actually points to the epigenetics of drug taking. I don’t see that as actually being the cause. Now if you are referring to even earlier epigenetics then there may be some effect. There have been no studies to look for it. However the Scandinavian adoption studies suggest that genetics trump epigenetics as least as far as the epigenetics of environment go. I have no doubt there are epigenetic factors, but I think they’ll be much more subtle than those suggested by the epigenetics of drug taking.
3. Well sure, but trying to do so will miss a fundamental process, at least the way “biology” is defined now. As there is no neurobiology of serenity or spirituality that has been established, it’s doubtful that any biological definition of recovery will fit the bill. My own definition is clearly reductionistic and probably oversimplified. However , for me, the increased dopamine receptor density and resulting increase in dopamine tone allowing the person to become less self-centered, is the biological pathway I use to explain the spiritual effect of recovery. My experience in treating patients is that those who’s recovery is via medication alone, and have no spiritual program and no lessening of self-centeredness, do not maintain the gains through the life cycle. Increased medication is needed until it can no longer be increased. I have found it much easier to treat the illness for long periods in those who have had a change of thinking and personality so that their drives are no longer centered on themselves.
4. I believe so. I think Cloninger’s typology is close. There will be also subdivisions of his typology based on genetics. I have tried to do that and have had some success. I’m not a modeler or mathematician and really can’t do it. It’s only in setting up clinical algorithms based on genetic changes that has been successful for me.
Hopes that helps.
Have you read Questions and Answers on Addiction?
thanks
h