Friday, April 22, 2011

Addiction: A Potentially Fatal Behavioral Disease

A few months ago, an article in the St. Paul Pioneer Press described a "wet house," where people who were unable to stop drinking were able to get housing and access to services without requiring that they stop drinking. A very typical response, especially from people in 12-step programs and in treatment programs, was that this was "giving up" on these unfortunate individuals, that the proper treatment or 12-step participation would result in their being able to sustain abstinence. A number of people have asked me about this. Here's my response to a recent inquiry.


I actually did research on this in the late 1980s and got quite deep into what the best approach was for chronic public inebriates. The problem we were trying to address was that these folks would cycle through the detox center over and over. A minority of users accounted for the majority of visits to detox, which is expensive. In addition they are frequent guests in emergency rooms and hospitals. Here's what we found:

1. Many of them were using detox as a shelter. They were homeless, couldn't maintain a home, and shelters wouldn't take anyone who appeared to be drinking. Some of them would drink a little alcohol and fall down in front of a police car to get transported to detox.
2. For about 1/2 of them, a case manager was able to work with them and get them housed and help them with their food purchases, housekeeping, money management and so forth. This group saw dramatic drops in detox and emergency room usage.
3. The other half were so damaged from their early lives (including many American Indians who were dependent before age 12, and grew up in chaotic environments) that they couldn't form a helping relationship with a case manager. For this group there was nothing we could do to help. Trying to coerce them (e.g., attempt to get control of their disability payments) was counterproductive.
4. All in all providing housing even though people kept drinking was highly cost effective and resulted in better health for the individuals.

There is a similar place in Minneapolis and I know of one in Portland, possibly Seattle.

Here's the sad fact: a small proportion of people with alcohol or drug dependence are unable to quit and will die of their disease. After decades of working with them, I have concluded that any of them would quit drinking or using if they could. Most make multiple efforts. We accept that heart disease, neurological disease and cancer often lead to death in spite of our best efforts and treatments. We have trouble accepting that there are fatal behavioral diseases. This is because we don't think of the brain as an organ. What happens when this organ gets dysfunctional, cannot do its normal job of regulating thinking, feeling, perception, memory, communication, and most importantly here, behavior? Severe, progressive addiction is a result of multiple social, personal, and genetic factors, but the end result is that the individual loses control over their behavior, much like the diabetic loses control of her blood sugar. If you reflect on it, most of our behavior is regulated by unconscious processes that are automatic. It is difficult under good conditions to alter that. Think of smoking, exercise, diet, aggression, how we behave towards our spouses or boss. Our (rational, deliberate) control over our behavior is at best partial. How often do we do something when we are angry that we regret later? Don't all of us have repetitive behavior patterns that are clearly dysfunctional but persist in spite of our best efforts to change them? An example: the fall of Elliot Spitzer, governor of New York, who got caught with a stripper. This was not a rational decision on his part. Another: President Bill Clinton, whose compulsive sexual behavior destroyed his second term.

In addiction, the brain loses the ability to regulate behavior relative to a specific intoxicant. In really severe addiction this loss of control may lead to death. I think that people in this situation are horrified at what is happening to them and terrified that they can't stop it. I've never met an addict who liked being addicted. (They want intoxication, but not addiction.)

In the 1990s, there was a group of us in Minnesota who regularly met to discuss what the optimal approach was to helping public inebriates. We examined everything from locking them up in the state hospital (which is what used to be done), to case management, housing, offering medical and psychiatric services, etc. We concluded that having a safe place for people to live when they can't stop drinking was the best overall solution, most cost effective, most protective of human rights, and most humane.

The idea that someone can stop if they really want to, or if they really work a 12 step program, is a terrible thing. It's not true. Why would brain dysregulation be 100% curable merely by the individual wanting it to be so? We blame obese people for their problems, we blame people who get heart disease for eating too many hamburgers and not exercising enough, we blame people with cancer for not doing the right preventive thing. We do this because it protects us from the terrifying reality that these things occur in spite of everything we can do to prevent them, that our own behavior is not well controlled, that our environment is often responsible for our predicament, or worst of all that it's simply a gene-environment interaction over which we are powerless.

There are many other potentially fatal behavioral disorders, including antisocial personality disorder (death from violence,) anorexia nervosa, depression (suicide,) schizophrenia (suicide, heavy smoking,) obesity and lack of exercise (the second most important cause of preventable mortality,) reckless or distracted driving or speeding, overwork and sleep deprivation, post traumatic stress disorder (suicide, addiction, violence,) uncontrolled aggression (assault and murder,) and addiction to pain killers and sedatives (unintentional overdose.)

I have (clinically) stayed with many people as they died of their addiction. I didn't abandon them because they "didn't get the program" or "didn't really want to get sober." They all did, desperately. But they couldn't. And I couldn't help them. And they died.

1 comment:

  1. Beautiful post – I couldn't agree with you more. I was livid when public radio's "This American Life" did a story on this house with similar reactions to those you describe to the Pioneer Press article: that wet houses signify "giving up" on people who are severely dependent on alcohol. The notion that we should keep sending such people for "more treatment"– particularly when it's the same treatment over and over again – until they "get it" is faulty. In the interview, the director of the wet house talked about how skilled the men who live at the house are at "treatment" because they've been through it so many times.

    Taking care of these people is not only the just and humane thing to do, there is also evidence that it saves society money. A recent study in the Journal of the American Medical Association showed that in a group of chronically homeless people with severe alcohol problems, a Seattle-based "wet house" program was associated with a marked decrease in cost of services (such as use of hospitals and jails) compared with people on a waiting list after 6 months.


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