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Today's treatments oversimplify the disease of addiction

January 16, 2018
by Roland Reeves, MD
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As a vascular surgeon, I learned to care for an extremely complex disease. More often than not by the time I saw a patient with a vascular problem, the disease was fairly advanced. A clot or a blockage in a vessel was causing severe symptoms that needed treatment. Complex interactions between inflamed vessel linings and body reactions culminate in symptoms that must be addressed. Clots are removed, blockages are repaired, or a substitute artery is used. Relief is provided and recovery can now begin. After the repair, aftercare instructions are given to the patient in the hope of avoiding recurrent episodes, but the suggestions may not be faithfully followed.

Many people are more willing to have a surgical repair of the problem once symptoms can no longer be ignored than to adhere to a longer process addressing diet, stress or lifestyle. A timely and expedient bypass graft has saved the day, but it has done nothing for the underlying disease of atherosclerosis that led to the problem. Medicines are used to help recovery and prevention, and they do help. Patients are better than they were before treatment with these medicines, but not as well as they could be if they followed suggestions. The disease process is relentless and progressive.

We follow this same pathway with addiction treatment. Symptoms eventually crescendo into some unacceptable situation demanding stabilization. Actions are taken and medicines are used, in the hope of replacing a substance or blocking it. Today we call this medication-assisted treatment (MAT). We have named the use of medicines for addiction as if this use is unique in disease treatment. Later, aftercare suggestions are given, and variably followed. MAT improves the complications and ramifications of addiction, similar to what a vascular graft does for vascular disease. These are beneficial treatments, and no one is suggesting they not be used. Worse problems are averted, and function improves. New bandages are placed on the underlying disease, giving hope that it will not happen again. The disease still smolders, however.

What exactly is this disease of addiction that we are acutely treating? An excellent review of this brain disease was provided in a 2016 article in the New England Journal of Medicine by Volkow et al., called “Neurobiologic Advances From the Brain Disease Model of Addiction.” The article underscores the complexity of the disease of addiction, a complexity matching or exceeding that of vascular disease. Changes in the brain leading to the symptoms of the disease go far beyond the oft-quoted dopamine problem given in standard neurobiology lectures.

The article describes important areas of the midbrain and frontal cortex that are affected. Many areas of the brain that once allowed rational thinking and reasoned behaviors are changed. The same survival part of the brain that mandates breathing and drinking water has now elevated a substance to being just as important as air and water. “Flow” in the brain progresses unimpeded from bottom up, acting as a gas pedal to the part of the brain that makes us human: the cortex.

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Hello Dr. Reeves,
Thank you for your blog post. I just reviewed the new TIP 63, which was released by SAMHSA this month. I barely began the read and came across a statement that caused me great concern. In the executive summary of the document it states “patients taking medication for OUD are considered to be in recovery.” Talk about oversimplification! Taking a medication for the treatment of a disorder or disease does not in and of itself constitute recovery. This is a gross overstatement. I am surprised by this statement, because in 2012 SAMHSA released an updated working definition of recovery that acknowledged the multifaceted and complex nature of recovery. Recovery is “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.” If a person with type two diabetes is taking oral insulin as prescribed, but they weigh 350 pounds, have a sedentary lifestyle, eat a high fat and high sugar diet, they are not in recovery. This clearly is not an individual who is improving their health and wellness and striving towards their fullest potential. An individual with OUD who is taking methadone or suboxone to treat their disorder, but continues to use illicit substance, drink alcohol excessively, engage in criminal activity, and lacks a healthy support system also is not in recovery. I am a person in long-term recovery and a long-term Addiction Professional. I have seen thousands of people recover without medication, or with responsible use of it followed by detoxification, and who exemplify SAMHSA’s definition of recovery. The current “silver bullet” mentality being propagated is irresponsible, and even on some level unethical. I am deeply saddened by this paradigm shift. I hope we can continue the dialogue.

Unfortunately the view that you site from Samhsa TIP 63 is another example of the oversimplification and superficial two dimensional views of addiction and recovery that hinder real progress. Prescribed opiates may help engage a patient in treatment and begin the journey toward recovery, but this is only the start of the journey. People climb a mountain to get to the top. Getting dropped their by a helicopter does not make them a mountain climber any more than taking a pill makes them recovered. The purpose of my article was to highlight the complexity and widespread nature of disease that happens to the brain itself with addiction. By inference, it also suggests the complexity of recovery. Accepting that a medication allows recovery ignores many aspects of the disease. Addiction is more complex than opiate receptor occupancy. How the brain perceives and processes information is damaged, and as far as I am aware, there is not a medicine or a pill that fixes this. The disease creates a social and emotional autism, a person separated in mind and body from everyone and everything nullifying our biological need to connect. Recovery must include actions that change the brain. Medicines can certainly promote the ability to begin these actions, but the mountain still must be climbed. Climbing the mountain reactivates long unused pathways allowing a restoration of connection and awareness and pruning of pathologic pathways. Some would call this a Spiritual answer. I agree.
Thank you for your post. It is thoughtful and on target.
Terrance Reeves, MD

I'm an individual in recovery. I doubt your intentions were to increase the already mounting stigma surrounding MAT, but that's exactly what I read. So, since you agree that addiction is multifaceted and complex, why is it so hard to understand that addiction affects everyone differently? Just because you were able to recover without the use of medication doesn't give you the right to say every one else is doing it wrong. It's because of people like you that my addiction continued for so long. Do you think I enjoyed living to use and using to live? Knowing that everyday I woke up I was physically and mentally unable to care for my kids or go to work unless I had opiates. Many of us are not as fortunate as you, we have responsibilities that cannot be ignored. I didn't have the luxury of someone to help pay bills or watch my kids while I went off to rehab. When I sought help, the medical professional judged me without knowing anything about my life, she simply said "well you got yourself into this mess, now it's going to take 6 months or more for you to get out of it". She refused MAT saying that it was simply replacing one addiction for another. The next week was the worst week of my life, I contemplated suicide as the withdrawal only seemed to worsen. I made it just one week before relapsing. It was another two years before I'd seek help again. I was lucky to have found a provider that saw me as a person and not as another junkie or lost cause. I was prescribed Suboxone for 9 months in addition to CBT. The medication wasn't a cure but it did save my life. Individuals using MAT are not all criminals, alcoholics, and believe it or not many of us have families. As I approach my final semester in BAS addiction counseling, I hope I never discriminate or degrade people as you just have.

Hello Hope4Recovery,
Thank you for your response. Open communication and dialogue is exactly what’s needed around this issue. It sounds like our addiction and recovery processes are much more similar than different, and our perspectives are much more similar than different, too. The key for us all is not to get caught up in one-size-fits-all or silver bullet thinking. Another analogy might be helpful. If a person quits drinking and goes to AA meetings, but continues to steal, beat their partner, and gamble the family’s finances away, are they in recovery? Yes, going to AA and stopping drinking is an important step, but stable recovery is about much more than biology. The psycho-social-spiritual dimensions must also be addressed. I support all paths to recovery. Medication is but one element, just as is abstinence, or 12 step meetings, or exercise, or education, or therapy, etc. As a recovering person and a female, I’ve felt the stigma over and over through the years or my addiction and recovery, but I am committed, just as you, to reduce the stigma associated with addiction. Not until people like us who have achieved long-term, stable recovery, and live productive and meaningful lives speak up, will the stigma go away. Once again, thank you for your response, and keep talking!
Namaste

Enjoyed the article. Geoffrey Rose (1981,1985) would ask "Why did this patient get this disease at this time?" In order to move the needle on SUDs, the cause, not symptoms, must be understood. Maybe we are overcomplicating this.

What if SUDs are a development problem? This would explain risk, behavior and symptoms at every level of SUD. The theory that Severe SUD clients are developmentally delayed is correct. The reason why makes all the difference world in terms of either treatment or prevention.

Delayed development is not because of drugs. It's because there is more than one way to develop. This was discovered (Moore, 2016) by using attributes of the variable perception. The attributes are called perception risk factors.

One kind of perception development prevents SUDs and results in autonomy. The other is the necessary and sufficient cause of SUDs and results in dependence.

The research can be seen at www.duncanparkpress.com or the book PREHAB Leveraging Perception to End Substance Abuse.

Sustained action always results in change. Asking someone to change without addressing their perception process is lethal. This is why surrender and adult spirituality works when nothing else will for some.

With a new model, assessment and measurement, we can get ahead of this process - if we keep it simple.

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Roland Reeves MD

Physician, T R Reeves

@TRReeves2

TRReevesMD.com

Roland Reeves, MD, provides medication assisted treatment for the practice T R Reeves, MD, in...

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