Tuesday, November 13, 2012

Living With Success and Failure in Treating Addiction

A number of my recent postings have focused on chronicity, treatment-resistant disease, and staying connected with people who are not doing well no matter what. These are important principles to me and to others who are dedicated to helping people with addictions overcome them if possible, but to continue to work with them if it is not. It is so important to talk about this, to advocate for this, because too often people who have addictions unresponsive to current treatment are condemned, abandoned by their families and friends in the guise of "tough love," prosecuted for crimes and imprisoned, unemployed and homeless because background checks reveal a criminal history. They deserve our care and compassion in spite of, indeed because of, their plight. This service is informed by our humility in the face of a difficult, complicated problem that too often defies effort, faith and science.

However, I witness a lot of successful outcomes, and I need to share those too. As an addiction psychiatrist, I don't see run-of-the-mill patients, I see those with multiple, usually chronic, addictive, mental and physical disorders who have failed to respond to multiple rehabs, or to other approaches. Many patients are referred from hospital based physicians who are seeing the most treatment-refractory group of patients with addictions.

But most of the time, a change in antidepressants, treating a previously undiagnosed disorder, or changing pain medication makes positive difference. Sometimes it is dramatic. I've had patients with chronic pain who were on the edge of despair, even suicide, whose lives turned around dramatically by simply changing the pain medication. Others have depression, anxiety, post-traumatic stress disorder or borderline personality disorder, but where a sophisticated diagnosis and change in treatment results in dramatic improvement.

For most of us, I think our challenges are more salient, bothering us. We fell short. We didn't solve the problem. We failed our patients. But in the majority of cases, we can make a difference. Sometimes that difference is relatively small but meaningful. For example, one patient was able to pick up her grandchild for the first time because of adjustments in pain medications. Another one was able to establish and maintain long-term sobriety for the first time because of a combination of psychotherapy and anti-relapse medications over a 3 year period (but not without some early recurrences.)

Last week, a colleague of mine, a very compassionate family physician called me. He is seeing a patient who has several ongoing chronic illnesses, one of which is alcohol dependence. In spite of everything he and others, including his physician, have tried, he continues to struggle with his drinking. My colleague called to ask, "Am I enabling? Should I send him away, somewhere else?"

My answer came from my own experience more than 25 years ago: "Who is better situated than you to stay with him, and continue to work with him to overcome his disease? Do you discharge people with diabetes, heart disease or arthritis because their disorders don't respond to treatment? How would it help him get better if you were to abandon him? Isn't he demoralized enough by his own 'failure' to respond to treatment?"

He was grateful for my advice and support, and then he added, "I feel like I'm all alone out here [in my primary care clinic.]" I told him I understood, I felt the same way.

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