Transcript Is Addiction an Acute or Chronic Illness?

Substance Dependence
Disorder:
Acute or Chronic?
August 2009
What This Presentation
Is Not About
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Yours or my family history
The suffering experienced by the
children and families you work
with
Moral failings or character flaws
Weakness of will or intellectual
capacity
Heaven, hell, forgiveness,
retribution, or condemnation
What This Presentation
Is About
Understanding the
phenomenon of substance
dependence disorder in a way
that provides us with new
understandings and tools
useful in our collective work
to ease individual and family
suffering and reduce harm to
our communities
WHY IS THIS IMPORTANT?
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Placement decisions in
dependencies often rely on
compliance reports and reports
of treatment completion from
treatment agencies
There is an emerging lack of
consensus among those
treatment agencies regarding
what treatment completion –
indeed, what recovery – looks
like for many individuals
A Dynamic
Tension in the
Field of Addiction
(and in the
management of
many other
chronic diseases)
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Abstinence
Only
VS
Medically
Assisted
Chronic
Disease
Management
From our roots (1938): abstinence is
the only legitimate treatment goal, the
only outcome offering hope to the
addict…
From emerging science and social
policy: We accept the refusal or
inability of some patients to do the best
thing, so we try our hardest to have
them do the next best thing…
Our Nice Simple
Treatment Model
Treatment
Substance
Abusing
Patient
NON Substance
Abusing
Patient
Characteristics of an Acute
Illness
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Time limited
Involves an identifiable, single, or
a discreet group of causative
agents
Once those causative agents are
identified, targeted treatments
effectively defeat them
Post treatment, patients recover
Recovery is generally viewed as a
state or condition in and of
itself
Characteristics of a Chronic Illness
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Has behavioral, genetic, and
environmental etiologies (causes)
Can both cause and result in chronic
physiological changes (which
themselves can potentiate relapse)
Characterized by cycles of relapse
and remission
Involve variable adherence to care
Earlier onset generally means more
challenging management
Medical and psychiatric co occurring
disorders are common
Chronic Disease Model Treated with
an Acute Care Model
Substance Abusing Patient
Treatment Episode
Remission
Relapse
Treatment Episode
Relapse
Remission
THE BIG 3
Hypertension
Diabetes
Asthma
1. No doubt they are illnesses
2. All are chronic conditions
3. Influenced by genetic,
metabolic, and behavioral
factors
4. No cures, but effective
treatments are available
Role of Personal Responsibility in Chronic
Disease
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Voluntary choice affects many illnesses as far as
initiation and maintenance, especially when the
voluntary behavior interacts with genetic and
cultural factors.
Salt sensitivity in males: genetically transmitted
risk factor for the eventual development of one
form of hypertension.
Not all who have this inherited sensitivity
develop hypertension as the use of salt is
determined ultimately by individual choice.
Obesity may be inherited but individual activity
levels, food intake, and cultural factors will play
a role in the actual development of the disorder.
Heritability Estimates
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Eye Color
1.00
Asthma (adult onset)
.35 -.70
Diabetes (Type 2 - males) .70 -.95
Hypertension (males)
.25 -.50
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Alcohol Dependence (males)
.55 - .65
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Opiate Dependence (males)
.35 - .50
Asthma
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Adherence to Medication  30%
Retreated in 12 months
• Physician, ER or hospital
60 – 80%
Diabetes
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Adherence to medication  50%
Adherence to diet/exercise  30%
Retreated in 12 months
• Physician, ER or hospital
30 – 50%
Hypertension
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Adherence to medication  60%
Adherence to diet/exercise  30%
Retreated in 12 months
• Physician, ER or hospital
30 – 50%
100
90
80
40
30
20
50 to 70%
50
30 to 50%
60
50 to 70%
70
40 to 60%
Percent of Patients Who Relapse
Relapse Rates Are Similar for Drug Dependence
And Other Chronic Illnesses
10
0
Drug
Type I Hypertension Asthma
Dependence Diabetes
Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.
Relapse
Predictive Factors – All 3 Illnesses
#1 -Lack of adherence to diet,
medications, or behavior
change
#2 -Low socioeconomic status
#3 -Low family supports
#4 -Psychiatric co-morbidity
Familiar?
In Chronic Illnesses
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The effects of treatment do not
last very long after care stops
Patients who are out of
treatment or contact are at
elevated risk for relapse
For what other chronic diseases do we
use terminology like “treatment
completion”?
When we manage other chronic
diseases, when do we treat in terms
of phases defined by specific periods
of time rather than specific health
milestones?
Family Treatment Courts: A Treatment
Model
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Development of a “Longitudinal
Disease Management Plan”, including:
Acute Phase:
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Individualized Assessment
Abstinence
Medical Management
Stabilization
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Environmental Factors
Social Factors
Psychological and Other Medical Co Morbidities
Comprehensive Safety Planning
Family Treatment Courts: A Treatment
Model
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Chronic Symptom Management
• Pre negotiated telephonic case
management
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On going problem solving
Open invitation to re engage with
primary clinician
• Monthly (?), open recovery groups
(in the treatment setting)
• Community sober support
participation
• Continued monitoring of safety plan
Finally…
“It is interesting that relapse among
patients with diabetes, hypertension,
and asthma following cessation of
treatment has been considered
evidence of the effectiveness of
those treatments and the need to
retain patients in medical
monitoring. In contrast, relapse to
drug or alcohol use following
discharge has been considered
evidence of treatment failure”.
Tom McLellan et al, JAMA, 2000
David Asia, PhD
Skagit County Human Services
360.336.9309
[email protected]