Monthly Archives: August 2016

Why it’s wrong to call addiction a disease

addiction as diseaseThis piece and image was in The Guardian in June and was tackling the issue of addiction and why it’s wrong to call it a disease.  Written by Mark Lewis  PhD who is a developmental neuroscientist known for dynamic systems approaches to understanding the development of emotions and personality. He is currently a professor at the Radboud University in Nijmegen in the Netherlands.

Is addiction a disease? Most people think so. The idea has become entrenched in our news media, our treatment facilities, our courts and in the hearts and minds of addicts themselves. It’s a potent concept: if you’re an alcoholic or a drug addict, then you’re ill. And you’re going to remain ill. According to Nora Volkow, head of the National Institute on Drug Abuse, “addiction is a chronic, relapsing brain disease,” and that definition has been adopted by medical researchers and policy makers everywhere.

Two huge benefits of the disease concept are frequently touted by Volkow and others. First, addicts need treatment, and if we don’t define addiction as a disease, they won’t get the help they require. Second, addicts don’t deserve to be scorned or denigrated: they have a disease, and we don’t put people down for being sick.

Recently, the supremacy of the disease model was highlighted by an article in the New England Journal of Medicine. Volkow and colleagues proclaimed that “research has increasingly supported the view that addiction is a disease of the brain”. But they also inserted a caveat: “Although the brain disease model of addiction has yielded effective preventive measures, treatment interventions, and public health policies to address substance-use disorders, the underlying concept of substance abuse as a brain disease continues to be questioned … ” Those words triggered an allergic reaction in me. Effective? Could anyone deem society’s response to addiction effective? As you might guess, I’m one of the questioners.

There is good reason to ask whether addiction actually is a disease. If it is, then we might expect it to have a specific cause or set of causes, an agreed-on repertoire of treatment strategies, and a likely time course. We might wonder how the disease of addiction could be overcome as a result of willpower, changing perspectives, changing environments, mindfulness or emotional growth. There is evidence that each of these factors can be crucial in beating addiction, yet none of them is likely to work on cancer, pneumonia, diabetes or malaria.

Neuroscience is a young discipline, and the distinction between brain development and brain pathology remains muddy (think ADHD, autism, depression) – ideal terrain for drawing arbitrary lines in the sand. For example, the brain changes observed in long-term substance abusers are nearly identical to those seen in people struggling with obesity, porn aficionados, gamblers, internet “addicts”, compulsive shoppers and simply those involved in intense romantic relationships. They involve overactivation of a part of the brain that directs goal pursuit (the striatum) in response to cues predicting their preferred rewards, and long-term desensitization in response to rewards more generally.

Along with an assortment of other psychologists and neuroscientists, I’ve been challenging the disease model for years. One result has been a volley of counter-attacks: how dare I pull the rug out from under the feet of addicts who rely on the disease label to get help and avoid stigmatization? So, I’m going to put the scientific debate aside for now and challenge the idea that calling addiction a disease is beneficial for addicts. On the contrary, I think it increases their burden.

Do people have to have a disease in order to get help?

People in today’s world face a vast array of problems, including violence in all its forms (for example, child and spousal abuse, bullying), unemployment, poverty, obesity, social isolation, unplanned pregnancy, and plain old unhappiness. But we don’t need to call these problems diseases in order to tackle them. Instead of medical interventions, we implement inventive, humanistic, often community-based measures, including education, social and psychological support, financial aid, access to special programs, specialized personnel, and other public resources. Nor must we call these problems diseases to justify funding for prevention and intervention. For example, anti-racism policies and bullying prevention initiatives embody extensive, often expensive means for confronting pervasive social ills. The equation help = medical care only makes sense for medical diseases.

It’s true that health care systems in the US and Europe provide various services for people struggling with addiction. However, patient advocates, judges, clinical researchers, and those seeking help almost unanimously point out the inadequacy of these services. In the US system, such inadequacies seem directly tied to the profit motive. The majority of patients relapse, not once but repeatedly, following residential programs that typically run between $10,000 and $100,000 per month. (State-run facilities are notorious for long waiting lists, inadequate resources, and a shocking absence of supervision.)

Volkow and others argue that discarding the disease label would cut addicts off from the services presently available to them. However, not only are those services generally inadequate and financially ruinous. They also embody a profound logical flaw – the idea that the current healthcare landscape should determine our definition of addiction. Shouldn’t it be the other way around?

What about reducing stigma?

If we don’t call addiction a disease, don’t we risk going back to the bad old days of denigrating addicts as self-indulgent, spineless pariahs? Not necessarily. Despite the anger and confusion many feel when confronted with the ravages of addiction, we’ve gotten better at recognizing that life circumstances can dictate personal suffering and tragedy. Many of our favorite public figures have crossed the line into addiction, from Elton John to Philip Seymour Hoffman to Robin Williams to Prince. Social norms seem to be advancing (rather than regressing to Victorian settings) as personal struggles are made public in the internet age. We are also starting to recognize addiction as a consequence of social ills rather than individual flaws. Yet the disease label locates the problem of addiction in the individual. It’s hard to see how that counteracts stigma.

Why do we even imagine that a medical diagnosis makes addicts feel better? Being diagnosed with a chronic brain disease is hardly something to celebrate. Pointing to a disease doesn’t necessarily diminish stigma, as exemplified by attitudes toward Aids patients. Even the designation of “mental illness” provokes stigmatization. Apparently, emotional associations color people’s judgments far more than rational reflections on health v illness.

I have heard from hundreds of addicts who recoil at the notion that they have a life-long disease. Especially addicts who are determined – and successful – in galvanizing their willpower and rejigging their habits, their personal goals, and their capacity for self-control. Once they recover, as most addicts eventually do, it becomes confusing and debilitating to be told they are chronically ill. Recovered addicts want to feel that they have developed beyond their addiction and become better people as a result. Many would prefer respect for that achievement over the pity bequeathed by the disease definition.

Where do we go from here?

A remarkable solidarity has emerged between some addicts and the authorities responsible for treating them (as sometimes occurs between doctors and their patients, regardless of treatment quality, and more generally between those who have power and those who lack it). These are the addicts who insist that they have a disease and any attempts to dislodge that definition are hurting them. Other addicts and, importantly, former addicts, see their problems in an entirely different light. For them, the disease label is a damaging sentence and an additional cross to bear.

I don’t expect this debate to be resolved any time soon. But until it is, I urge anyone who has struggled with addiction or who loves or cares for someone who has to keep an open mind. Calling addiction a disease has had its benefits (like the discovery of new drugs that help a subset of addicts, often temporarily). And the disease label continues to simplify our conceptualization of an extremely messy issue, making it appear easier to understand and resolve. But the net value of the disease definition needs to be questioned. It may be time to move on.

I really liked this piece and the bolded sentence encapsulates my view.  What do you think?

A letter to my late husband, who was an alcoholic

late husband alcoholicThis was featured in The Guardian in May – a letter to a late husband who was an alcoholic.

The day you died, I thought, will someone now tell me what the hell has been going on? It was like a film with a complicated plot, then at the end they tell you what was really happening. Except that no one did.

What on earth were the last 12 years about? No explanations for the chaos that had defined our lives together. The times you went walkabout and I called the police, what did you do when you said you were going to an AA meeting and didn’t, what were you up to the day I was at work and you were “working from home”.

For a man who told the whole world, whether they wanted to hear or not, how much you loved me, what an amazing woman I was, you always chose the bottle over me.

You were a bright, intelligent man who had everything and more. You told me you were going to be a millionaire. We were both from Scottish working-class families so statements like that were bold. I think I laughed. But you weren’t just clever, you were a genius – and the no-common-sense variety of clever. Anything earthly was of no interest – organising a mortgage, clothes, planning our future – but give you a tome on gravity and your nose would be stuck in it until you’d finished. I’ll never forget when you shouted – right through to the living room – to tell me that there was a mistake in one of the equations, which was pages long. Really, I said, she who had failed first-year university maths.

I still go to Al-Anon meetings and its nearly 17 years since you died. The story is the same – lives destroyed though booze. It’s no different if it’s in an upper-class borough in London where I used to live or in a working-class suburb of Glasgow.

I only told a few members of our family and friends about what was going on. I was constantly lying for you. Even on the day of the funeral, I was talking to your colleagues about your “depression”.

There was little laughter in all of this, but we used to have an adorable Polish cleaner who told me that, after you died, she couldn’t figure out why there were bottles of vodka in your shoes under the chest of drawers.

But the day that will remain in my mind for ever wasn’t long before your death. You were starting to go yellow as your liver began to fail. We’d not long had the conversation that went along the lines of, “Look, there’s a bottle of vodka” (in the cupboard where the tea and coffee were) and you replied: “Well, I didn’t put it there.”

It was too exhausting to argue by then and solved nothing. So I remarked on the change in your colour and tried to persuade you to go to the doctor. You said, “I’ve got an appointment next week, I’ll see about it then.”

That was a lie.

You said, “I’ll take some milk thistle, that’ll help.”

Too late for that, I thought.

You said, “I know what it is – I’ve been drinking too much Fanta.”

To laugh, or to cry …

It doesn’t matter if I believe alcoholism is a disease or not. That day, I realised how gripped you were by it and how much control it had over you. For this bright, intelligent man to stand there, say that and expect me to believe it. To be so deluded, words fail me. You died a few days later. Was it grief or relief that I felt?

Christina

Saturday Sober Jukebox – When Everything Was New

G’day sober lovelies!  Long time no write but boy have I been busy exploring lots of new things.  Getting up early with the sunrise and the sound of kookaburra’s as my alarm clock, going to bed early and happily exhausted from so much travelling, doing and seeing; watching possums crawl across my tent roof at night, sand tobogganing, running along beaches, stroking kangaroo’s, eating concrete – an extra hard ice-cream (and how about liqourice flavour? – it’s delicious!), snorkelling among the turtles, rays, reef sharks and tropical fish with my children at the Great Barrier Reef and watching hump back whales and their calves.  I could go on and on and on  🙂

Australia was AMAZING.  I love everything about the place, the people and the food – being eaten alive by sand flies not so much.  I won’t bore you with all my holiday photos but will share these three which sum up the whole experience so well.  Magical beaches, sunsets and memories – like seeing pods of wild dolphins 5 times and feeding them by  hand not once but TWICE!!

Did the thought of drinking cross my mind?  Maybe fleetingly once or twice.  Did the thought of managing a hangover with all the activities we were doing puncture my consciousness?  God yes.  I would have wanted to stay up late after the kids (we went to bed at the same time as them pretty much all holiday) drinking.  Those early morning wake-ups would have been a nightmare and I would have been a grumpy tired resentful parent.  My focus would have been finding an excuse to drink at all times and time, activities and experiences would have been prioritised around that or the resulting hangover.  I suspect we wouldn’t have done half as much as we did or travel as extensively as we did.  We were so lucky as the family member we were travelling with also doesn’t drink and decaff tea was the drink of choice for all of us.  Yes the family we were staying with drank but when we went out for dinner at another of their friends houses my sis in law said we were teetotal and that was that 🙂

Australian supermarkets are very sensible and you can only buy alcohol free products in them – I found and sampled a couple of AF beers which were very nice and saw a small selection of AF wines.  You have to go to a bottle shop or liquor store for booze – although there were plenty about including drive through!   Plus RBT (random breath tests) are a big thing both on the roads and water at any time of day.  And my new favourite AF drink?  Lemon, lime and bitters (from Bundaberg the biggest rum distillery in Oz who do a great range of AF drinks too).

brew-lemon-lime

 

 

 

 

 

 

And as for sober treats?  How about an organic doughnut with macadamia nuts, mascarpone and fresh strawberries (this was sampled at Byron Bay)  😉

organic doughnut oz

 

 

 

 

 

 

 

And as it’s a Saturday sober jukebox an Aussie tune too by Flume aptly titled When Everything Was New.  It’s nice to be back, but truth be told I’d have happily stayed ……

Will be back tomorrow as taking my daughter to see Little Mix tonight!

Detecting alcohol use disorders with a single question

QuoteMarksSo we fly back into the UK from Australia today and I’m writing this in May!  I’m guessing I’m going to feel pretty tired and jet-lagged and will have an overflowing email inbox from the cyber break too to contend with once my sleep and time zone’s are realigned so I’m cutting myself some slack and lining this up to give me a bit of breathing space 🙂  It’s important and valuable research about the power of a single well-defined question to boot from Drug and Alcohol Findings.  Here’s the research abstract:

A US study of young people in rural primary care settings finds that alcohol use disorders can be identified with a single question about frequency of drinking.

Summary In the United States, a national study of young people aged 12 to 18 found that past-year drinking frequency was an accurate proxy for alcohol-related problems – considerably more so than quantity of alcohol per occasion or frequency of heavy episodic drinking. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) subsequently adopted the use of alcohol frequency to screen for problematic drinking in young people. This study explored the accuracy of NIAAA drinking frequency screening thresholds for detecting alcohol use disorders (as defined by Diagnostic and Statistical Manual of Mental Disorders, 5th Edition or DSM-5 diagnostic criteria).

1193 young people (aged 12–20) attending six rural primary care clinics opted into the study. They were provided with a tablet computer and asked to enter information about past-year drinking and alcohol-related symptoms. This took around three to six minutes of their time.

The researchers gauged the accuracy of the screening thresholds using measures of “sensitivity” (the proportion correctly detected as having an alcohol use disorder), and “specificity” (the proportion correctly ruled out of having an alcohol use disorder). Together, sensitivity and specificity (reported as percentages) tell us how well a screening tool can pick up on risky drinking, without drawing into the net large numbers of non-risky drinkers.

From the sample, 2% of younger adolescents (aged 12–14), met DSM-5 criteria for an alcohol use disorder in the past-year, compared with 10% of those aged 15–17 and 10% aged 18–20. When applied to the same age range as the earlier national study (i.e. 12–18), the NIAAA thresholds for moderate risk showed acceptable levels of accuracy (85% sensitivity and 87% specificity) as a screen for any DSM-5 alcohol use disorder symptom; and the NIAAA thresholds for the highest level of risk showed acceptable levels of accuracy (91% sensitivity and 93% specificity) as a screen for severe DSM-5 alcohol use disorders.

In practice, “an alcohol use frequency screen followed by an [alcohol use disorder] evaluation among those who screen positive would constitute a simple, brief, and cost-effective clinical assessment procedure” – and it would enable practitioners to check whether those who have screened positive, do indeed have an alcohol use disorder. The researchers found that, for those in the age band 12–17 years, around 44% of those who screened positive could be expected to have an alcohol use disorder (based on a calculation of a statistical measure called the “positive predictive value”), and around 99% of those who screened negative could be expected to not have an alcohol use disorder (based on a calculation of the “negative predictive value”).

Overall, the findings suggested that drinking frequency can be a useful and accurate indicator of alcohol use disorders among young people, and that at-risk young people can be identified with a single question on alcohol use frequency.

CommentaryThe study considered here used computer-based self-assessments to screen young people for alcohol use disorders. Modern technologies present new opportunities for increasing rates of screening among young people, as explored in other Effectiveness Bank analyses including assessment and feedback by email for university students, web-based alcohol screening and brief intervention for university students, and text-message-based drinking assessments and brief interventions for young adults discharged from the emergency department.

Clark D.B., Martin C.S., Chung T. et al. (2016) Screening for underage drinking and Diagnostic and Statistical Manual of Mental Disorders, 5th Edition alcohol use disorder in rural primary care practice. Journal of Pediatrics: In press

‘Modern technologies present new opportunities for increasing rates of screening among young people’  I completely agree and hope that this work is built on to put these new screening tools into place!