I appreciated the intent of Stuart Gitlow, MD, MPH, MBA, and Mark S. Gold, MD, in “The Inadequacies of the Evidence” (March/April 2007 issue). Good research is needed more than ever, to help the provider sift through the variety of clinical approaches available (e.g., BRENDA, Stages of Change, Motivational Interviewing, etc.) as well as the variety of tools available for the patient (e.g., “Minnesota Model” treatment, 12-Step support groups, secular support groups, etc.).
Regarding the fallacy of “diagnosis,” the authors state, “A variety of published definitions of sedative dependence exist.” Some researchers do clearly define their subjects as having met the criteria for substance dependence (À la the DSM-IV). But researchers who enlist substance-dependent individuals do not always clarify the degree of severity in such individuals. One subject might minimally meet criteria for dependence (and with very mild symptoms), while another might carry the same diagnosis with all seven symptoms shown to a chronic, severe degree. Both may be studied in the same research project, but an approach that might work with one might not work with the other. As health care providers, we are trained to apply research-based treatment initiatives and procedures to the specific patient in our office.
Regarding “outcome measures,” the authors state, “In order for disease improvement to be detected, one must measure relevant aspects of the disease.” To that I would add, “…as applied to each patient's life.” Who are we to define what a “relevant aspect” is when it comes to a particular patient? Again, what works for one might not work for another. Harm reduction might be extremely valuable and relevant for someone who minimally meets criteria for dependence, just as full-fledged sobriety would be for someone demonstrating severe and chronic symptomology. It is up to the patient to determine what the next best (relevant, valuable) step is for them. If the patient does not know what to do, we can offer research-based options—as long as these alternatives fit the specific patient. And if the patient chooses otherwise, we can celebrate the patient's success or help him/her learn from any setbacks.
The authors also point to a failure to recognize a longstanding treatment approach of combining pharmacological treatment with behavioral treatment. But the National Institute on Drug Abuse's Principles of Effective Treatment includes the statement “No single treatment is appropriate for all individuals.” Who are we, then, to discourage the use of a medication alone, without behavioral therapy/counseling, when it comes to a young opiate addict whose history and chronicity differ greatly from that of a long-term, middle-aged addict who may need months of behavioral therapy along with the medication?
I compliment the authors in promoting accurate research. And I'm trying to remind us all that, evidence-based approaches aside, we are not just treating a disease. We are treating individuals who display their own unique sets of symptoms, which have developed to varying degrees over varying lengths of time.
Doug Moser, MA, LLP Traverse City, Michigan