TIPS & TOPICS from David Mee-Lee, M.D.

Volume 9, No. 5

August 2011

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In this issue
— SAVVY – A new definition of addiction from ASAM
— SKILLS – What the new definition means to you, your program and systems

— SOUL – Charley horse
— SHARING- Readers’ comments

— Until Next Time

Welcome to the August edition of Tips and Topics (TNT). Glad you can join us.
SAVVY

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This month, the American Society of Addiction Medicine (ASAM) released a new definition of addiction. In the August 15, 2011 press release, a few of the “talking points” were highlighted:

  • Addiction is a chronic brain disorder and not simply a behavioral problem involving too much alcohol, drugs, gambling or sex.
  • This is the first time that ASAM has taken an official position that addiction is not solely related to problematic substance use.
  • Outward behaviors are actually manifestations of an underlying disease that involves various areas of the brain.

In SAVVY this month, I will discuss some of implications of the new definition.

TIP 1

Addiction is primary disease, not just the result of emotional or psychiatric problems.
Addiction, at its core, is not just a social problem or a problem of morals. “Addiction is about brains. Not just about behaviors” (FAQ #3). A major thrust of the new definition is that it is not the substances a person uses that makes them an addict, nor is it even the quantity or frequency of use. It is about what happens in a person’s brain when they are exposed to rewarding substances or rewarding behaviors. These substances and behaviors “turn on” the reward circuitry in the brain and related brain structures. (FAQ #1).
In the Reference list below, you can find links where you can read a longer definition of addiction. Reference Number 4 will take you to all the Frequently Asked Questions.
Here is the short version definition.


Short Definition of Addiction:
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.
Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.

TIP 2

Check to see if you still harbor these common and counterproductive attitudes and beliefs about addiction and about those afflicted and affected by addiction.

1. If you just look at the behavior of a person with addiction, you may see a person who lies, cheats, breaks laws and appears to lack good moral values.

    • The counterproductive reaction of society is to punish such antisocial behaviors and approach a person with addiction as “a bad person” to be punished.
    • The productive attitude to have is to “realize that good people can do very bad things, and the behaviors of addiction are understandable in the context of the alterations in brain function.” (FAQ #3)

 

2. So if you say a person has the disease of addiction, are they not still responsible for their behaviors? Or in other words are you letting them off the hook by saying they have a disease?

    • The counterproductive reaction to understanding addiction as a primary disease is for a person with addiction to say, “Don’t blame me, it was my disease that made me go into the bar and relapse.” They may not be as blatant as that, but even addiction treatment professionals are ambivalent about how to balance responsibility for relapses with addiction as a relapsing disease (See SKILLS below).
    • The productive attitude to have is to recognize “personal responsibility is important in all aspects of life, including how a person maintains their own health…..You are not responsible for your disease, but you are responsible for your recovery.” Just as people with diabetes and heart disease need to take personal responsibility for how they manage their illness, those with addiction need to do the same. (FAQ #4)

 

3. If healthcare professionals, facilities and insurance benefits packages only focus on the substance use and related complications, the underlying addiction illness is not treated. As a result, people with addiction keep presenting with complications and can switch in search of other rewarding substances and/or addictive behaviors.

    • The counterproductive result of focusing just on the substance use and associated complications is this: Physicians and other healthcare professionals think their work is done when they manage withdrawal symptoms and detox a person, or stabilize someone’s substance-induced psychosis, or fix a broken leg from injuries in a drunk driving accident. Insurance benefits may cover only detoxification in a medical facility, as if addiction is an acute illness needing just stabilization of the substance use, rather than ongoing treatment like other chronic diseases.
    • The productive attitude to have is this: To see the need for comprehensive addiction treatment of the “underlying disease process in the brain that has biological, psychological, social and spiritual manifestations.” (FAQ #8)

References

  1. www.asam.org/pdf/Advocacy/PressReleases/20110815_DefofAddiction-PR.pdf
  2. www.asam.org/DefinitionofAddiction-LongVersion.html
  3. www.asam.org/1DEFINITION_OF_ADDICTION_SHORT_4-11.pdf
  4. www.asam.org/pdf/Advocacy/20110816_DefofAddiction-FAQs.pdf
SKILLS

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If the healthcare system really embraced this new definition of addiction, what would be some of the implications?

TIP

Check if you, your treatment team or your community really embraces addiction as a primary disease.

Here’s what it would mean to clinical skills, healthcare and criminal justice systems’ change, funding and managed care organizations:

Attitude or
Belief
Still too Often the Usual Practice or Policy Enlightened Practice or Policy
1. People with addiction are antisocial, immoral and liars Clinically, approach a person assuming they are lying and conning Approach person with an open mind; Avoid documenting: “Client denies substance use” or “Client claims she only uses occasionally” – this perpetuates negative attitudes towards people with addiction;
Assess more fully through collateral sources of family, work, legal or school
Punish them with consequences for any substance use Hold people accountable for their use and negative consequences of use as in drunk driving, domestic violence, missed work and poor productivity. But assess if there is addiction illness needing treatment rather than punishment.
Incarcerate them for illegal, antisocial behavior As above, hold people accountable for their behavior. However, if such antisocial behavior is the result of addiction, provide treatment while incarcerated. Continue care upon release and re-integration into the community.

Attitude or Belief Still too Often the Usual Practice or Policy Enlightened Practice or Policy
2. If you call addiction a disease, you are letting people blame their illness and avoid taking responsibility for their behavior. Clinically, we tell clients that addiction is a disease characterized by “inability to consistently abstain” and treatment is needed. Then when they use again while in a treatment program, we have them leave treatment for that session or day to come back when they are sober. Sometimes we even discharge them from care. Occasionally we transfer them to a more intensive level they may not medically need. Upon admission, some programs even tell a person that if they do happen to use, “don’t come to treatment that day until you are sober.”
“Oh, and by the way, this is an honest program, but if you use, we’ll report you to your probation officer who will then sanction you.”
Clinicians and programs are ambivalent about how to balance: “You are not responsible for your disease, but you are responsible for your recovery.”
Treat addiction as an ongoing illness that “often involves cycles of relapse and remission.” Thus, if a relapse occurs this indicates a poor outcome that needs reassessment to identify and shape an improved service plan. If the client is making a good faith effort in treatment doing the best they can relevant to their stage of readiness, then treatment continues. So long as each treatment plan adjustment is moving in a positive direction and the client is taking responsibility to adhere to that collaborative plan, then you are not “enabling” a person even if there is continued substance use and relapses.
However, if you allow a client to sit in a program “doing time”, not adhering to a stage-based treatment plan on which s/he collaborated, then you are “enabling” irresponsible behavior and not “doing treatment”.
Attitude or Belief Still too Often the Usual Practice or Policy Enlightened Practice or Policy
3. Healthcare professionals, facilities and insurance benefits packages only focus on the substance use and related complications. The underlying addiction illness is not treated. Emergency rooms take care of the acute intoxication; suture lacerations from a drunken brawl; stop the alcohol-related gastro-intestinal bleeding, but don’t arrange for ongoing care of the underlying addiction illness.

Mental health units stabilize the substance-induced psychosis or impulsive suicidal or cutting behavior while intoxicated. Then they refer the client out for continuing mental health treatment and medication. Unfortunately they don’t link the person to addiction treatment for the co-occurring illness or the underlying addiction.
Insurance benefits exclude residential treatment for addiction. They severely limit the number of days or sessions as if ongoing care is not necessary (something that would never be done for other chronic illnesses like diabetes, heart disease, asthma or even Schizophrenia, or Bipolar Disorders)

Develop Screening, Brief Intervention, Referral and Treatment (SBIRT) in all healthcare, mental health and criminal justice facilities to identify addiction for early intervention.

If addiction is identified, arrange comprehensive treatment of the “underlying disease process in the brain that has biological, psychological, social and spiritual manifestations.”.

Design, develop and fund a broad, flexible continuum of care. Use standardized criteria for admission, continued service and transfer/discharge as in the ASAM Patient Placement Criteria.

If we only treat the manifestations and complications of addiction, and incarcerate people without opportunity for treatment, we waste resources. This creates revolving doors of acute and expensive care. Legal recidivism and criminal justice costs increase. Outcomes worsen for people who then become terminal in their addiction.

SOUL

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A “charley horse” is a popular North American colloquial term for painful spasms or cramps in the leg muscles, typically lasting anywhere from a few seconds to a few hours (Wikipedia). A few weeks ago “charley” visited me in the middle of the night -uninvited, unannounced and definitely unwelcome. He visits only occasionally, but always with a jolting, attention-grabbing, wake-up call. Every time, I gain a fresh appreciation for people who suffer pain – especially racking, chronic and debilitating pain.
If you’ve ever experienced a “charley horse” you know the helplessness for those few seconds or minutes – all you can do is be riveted by the pain which catches your breath and immobilizes you. I can’t imagine what it would be like to have severe pain almost all day, every day. Well, I can imagine a bit. Fifteen years ago, I had several bouts of severe lower back pain where I could hardly walk. Carrying my brief case or getting in and out of a car was almost impossible. And being there for the birth of my three children, I got to see what labor pains are like…. and from all the swearing…. I got it that they are pretty painful. I don’t minimize the pain of birthing, but it is time limited and we were rewarded with three fabulous prizes at the end of the pain.
Fortunately, my back pain is contained by daily, preventive, lower back muscle strength-building abdominal crunches and pelvic tilts; and there have been no labor pains to witness for decades. However when “charley” visits, it all floods back quickly and I remember what a “pain” pain is. I still don’t know the underlying cause of my charley horses, or what I should do about it as it is infrequent and comes and goes quickly – out of sight, out of mind.
But with addiction, the physical, emotional, mental, social and spiritual pain does not come and go quickly; it usually worsens without treatment of the underlying cause of those manifestations. And like a charley horse that cannot be ignored, it should not be ignored.
SHARING

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Last month’s Tips and Topics on Amy Winehouse’s untimely death and Stump the Shrink question grabbed the most attention and reader responses in quite a while.

Here is a comment on the Stump the Shrink question last month about a father wanting advice on how to help his daughter suffering from addiction and my response to their comments.

Comment #1

Tough love and detach…..sure, that is the staid wisdom. But, without financial resources, the tough love won’t help her get into treatment. I’ve met with a prior client who is now very bitter because of past debt of well-meaning treatment efforts. These bills go to collection. Now, although she may need assistance again, she is so bitter about the financial mess she will not benefit from treatment–only resent it. She is not an isolated instance.”

My response

Thanks for your comments.  You make some good points. Without good health insurance or universal healthcare (or independent wealth that can afford to pay out of pocket), people can’t afford the care they need for addiction treatment and every other acute and chronic illness.  The bitterness your client and many other patients feel can be re-told over and over – for huge bills when receiving care in emergency rooms; procedures for surgical, cancer, heart and lung conditions, hip replacements…. and the list goes on. Until this country figures out how to commit to universal healthcare, there are over 50 million people without healthcare coverage and many others with inadequate insurance. So your client is not alone.

What I would say about addiction clients and their bitterness about treatment costs is the following:

1. That treatment facilities ought to be flexible and individualized in their approach with clients- to collaborate with them on which treatment is best for the client’s outcomes and finances etc.  Too often addiction programs plug people into pre-determined programs and fixed lengths of stay.  Clients do not feel empowered to question the treatment recommendations and make an informed decision which takes into account their cultural, financial preferences and goals.

2. Increasingly addiction treatment programs will need to look at “value” (i.e. cost of services + quality and outcomes). What does “value” look like for a person who relapses? It looks like an arrangement where it can be worked out so services for the person can be continued, without subjecting him to an unnecessary ‘re-entering’ a program as if he was a brand new client.

3. Addiction clients may be bitter at the costs of care. However as they recover, hopefully they will see that financial loss (along with all the other losses) is all part of the devastating illness of addiction.   In retrospect, we hope they will remember all the times they have probably spent equal (if not more) resources on getting drugs, and repairing the costs of this to their family.  Let’s hope they start to acknowledge the financial costs due to their illness, the employment income lost from job problems due to addiction, the legal costs they’ve incurred etc.  Keeping this context in mind, if the individual can arrest those human and financial costs by entering treatment and recovery, they will make up the financial costs of treatment by arresting their addiction. They will also gain back much of what they have lost socially, physically, spiritually and financially if they keep active in recovery.

When viewed from that perspective, the investment in treatment will bring a far greater return on those financial resources than the return on investment in the years and dollars spent on addiction.

 

David

Comment #2

“Hello, Dr. Mee-Lee.

I am the mother of a 35-year-old son with bipolar disorder and meth addiction.

I was especially interested in your last newsletter.  I run a NAMI (National Alliance on Mental Illness) support group for families with a loved one with co-occurring disorders, and the letter that you responded to could have been one that any of us could have written during our journey.  There were two specifics that I wanted to address.

While talking about Amy Winehouse you talked about her family’s need for education.  What we have determined in our public behavioral health system is that unless your family member is actively involved with a treatment provider, you are not eligible for education and/or support.  Hence why we went to NAMI to see if we could get support.  I find that often the family is blamed for “enabling” their loved one when in reality, they are unsure what to do and have little availability for assistance.  Also, in my experience, I’ve found many families that found the stigma of substance use even more threatening than mental illness, and would not accept that the substance use was anything more than a person “self medicating” and therefore the result of a disorder rather than a disorder itself.  So, just as a client may be pre-contemplative, so are many family members!

You also spoke about interventions and I currently am not well-versed in this process.  Is there a reference that you can provide me to allow me to research this more?

I forward your email to my support group members every month and it often leads us to discussion.  I appreciate the information you provide.  I only wish the information you do share was more evident in our system of care.  Thanks again.”

My response

Thanks for taking the time to write and you raise some important points about blaming families and how to help families.  As regards to Intervention in addiction treatment (and other process addictions), if you go to Google and type in “Intervention in addiction” you will get more information that will help.  If not, let me know.

David

Until Next Time

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Thanks for joining us this month. See you in late September.

David