Monday, March 17, 2014

Is Addiction Always Permanent?

Recently, a colleague challenged what he perceived to be my "insistence that addiction is permanent." Here is my reply:

Dear John (not his real name):

As you know, I'm well aware of the studies regarding the life course of people who at some point in their lives meet dxic criteria for a SUD. And also, as you are aware, I've been talking about that, and therefore the need to have a wider continuum of care and to individualize approaches to SUDs for at least 10 years. In my presentation, Alcoholism Isn't What It Used to Be, which you frequently reference, I point out that 20 years after onset of DSM IV Alcohol Dependence, the most common outcome is low-risk drinking (40%), followed by abstinence (roughly 1/3), partial remission (about 20%) and then finally currently dependent (8%). So I'm not sure what the basis is for concluding that I have made blanket statements about ALL addicts in ALL circumstances.
 
What I do believe, and here I think the science and epidemiology are equally persuasive, is that in the case of severe addiction, there are brain neuroadaptations that are irreversible. For example, the likelihood of achieving non-abstinent recovery is inversely related to the severity of alcohol dependence. Conversely, abstinent outcomes become more likely as severity increases. This is as true in rodents as in humans. Since rehab and AA are populated almost exclusively by people at the very severe end of the spectrum, the likelihood of sustained non-abstinent recovery for current treatment seekers or AA members is relatively low. Thus, the AA stance is accurate for most AA members. Severity of dependence is the strongest predictor of AA affiliation, especially long-term affiliation, as opposed to a few weeks or months after a spell in rehab. Established heroin or other opioid addiction is another example; thus buprenorphine and methadone maintenance and the virtually complete failure of abstinence (or moderation) for treatment seekers. Those who could stop on the their own do so and therefore do not present for tx. That, of course, is a function of the awfulness, expense, stigmatization and disruption most current treatment includes.
 
At Alltyr Clinic, for example, I have seen many pts who come with a mild AUD who achieve non-abstinent recovery.
 
Just as abstinence is not a requirement for everyone who develops a SUD, neither is moderation possible for a sizeable proportion of them. The size varies by drug: Probably close to 100% of dependent smokers will require lifelong abstinence, whereas, most cannabis users will not, etc. Heroin, meth and cocaine addiction also probably have high to relatively high proportions where abstinence (which includes people taking opioid agonist therapy) is the only positive outcome option. In alcohol, I think it's probably somewhere in the middle, a large minority achieve non-abstinent recovery.
 
So the newer data simply seem to affirm the NESARC data, that conclusions have been based on clinical samples, and that if you look at community samples, the picture is very different. That's true for almost all common complex diseases, such as asthma or arthritis or even hypertension, the difference being that with SUDs there is a very high full remission rate, something that happens in very few other common complex diseases. Depression is very likely to be a pretty good analogue as well.
 
Finally, noting that many people have milder, self-limiting forms of SUDs doesn't mean they aren't brain disesases. How can you have a behavioral illness that doesn't include failures in brain regulation of behavior? It's just that in too many instances, people misinterpret "brain disease" to mean "permanent". Also, it hasn't helped that NIDA and SAMHSA keep stressing the chronicity of addiction, something I constantly fought against when i was at NIH. It's often not chronic. Neither is asthma, but I suspect you wouldn't have trouble thinking of mild, self-limited childhood asthma as a lung disease, or immune disease.

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