As I mentioned in my previous post, the next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) will significantly change diagnoses related to alcohol and drugs. No longer will the diagnosis of abuse exist, but instead we will have one category or diagnosis of problematic substance use behavior with varying degrees of severity. At issue is what to call this disorder.
Presently, the term addiction does not appear anywhere in the DSM, but instead the term dependence is used to describe behavior that traditionally invovles compulsive use, loss of control, and continued use despite consequences. Unfortunately, the term also describes a normal process that has nothing to do with problematic behavior or addiction, such as a person who becomes “dependent” on insulin for diabetes, or pain medicines for chronic pain. In these instances, the term dependence describes something entirely different than what is in the DSM. So what to do?
It sounds likely that the upcoming new version of the DSM will use the term addiction and drop dependence because of its dual meaning. Other terms including appetitive disorders have been thrown around, but this label would require significant public education. Those who are against using the term addiction say: (1) it carries too much stigma, (2) has no clear scientific definition, and (3) is overly identified with drug abuse instead of capturing the full range of excessive behavioral problems (e.g., sex, food, gambling).
In truth, there is no perfect term, but at least addiction is a commonly used term that most understand, even if it presently is not associated with a universally agreed upon definition. I support using the term, but also believe the field needs to evolve its thinking and define addiction more broadly to include the full range of problematic behaviors that go beyond just drugs and alcohol. At CPDD speakers suggested gambling will be included in the new diagnosis, and potentially internet addiction in the near future, but sex and food - perhaps the two most powerful addictions due to their link with our survival - will likely not make the cut.
What does this mean? It means that politics win over science and many folks who need help will not receive it because insurance companies will have a reason not to pay for something if it is not officially in the DSM and/or does not have the right diagnostic codes.
This past week I attended the 71st Annual Scientific Meeting of the College on Problems of Drug Dependence in Reno, Nevada. As usual, many of the world’s leading addiction scientists attended the conference to bat around the latest ideas in the field. One of the most memorable sessions for me was focused on the work group responsible for alcohol and drug diagnostic categories in the upcoming new edition of the Diagnostic Statistics Manual (DSM5) of Mental Disorders.
Presently, problems with alcohol and drugs fall into two general diagnositic categories - abuse and dependence. It turns out that these categories are largely the product of researchers sitting around a table and theorizing, and not so much on sound science. Substantial data now suggests that these categories do not represent distinct diagnoses, but instead should be combined to reflect a unidimensional continuuam of substance-problem severity. In technical terms, factor analysis revealed they load on the same factor and using Item Response Theory suggests the curves all stack on top of each other. What does all this mean?
It means that in the new DSM5 there will be no “abuse diagnosis” and only one diagnositic category with varying degrees of severity. This brings up the loaded topic of what we call this category - an issue I will write about in my next post. But for now, I want to conclude on three points:
Labels have power, and for years while doing clinical work I labeled folks as having abuse/dependence diagnoses. For many clients these labels took on great meaning - both positive and negative - and may continue to influence their life today. Now I learn that my labeling was likely incorrect at times, and it teaches me that perhaps we need to not forget that labels are socially constructed, even when influenced by science. What we label as a disorder may be entirely normal in another culture or time.
We diagnose and label people largely because of politics and money. Diagnoses determine what insurance will pay for, who gets treatment, what gets researched, and how as a society we want to understand and talk about specific problems.
Diagnoses, labels, and categories of behavior are beneficial when they link to specific interventions that have been shown to be scientifically valid.
For more details on this issue, see: Martin CS, Chung T, Langenbucher JW (2008). How should we revise diagnositic criteria for substance use disorders in the DSM-V? J Abnorm Psychol, Aug; 117(3):561-75.
Once a year I am fortunate to have the opportunity to teach a graduate level class at the university on the foundations of addiction treatment. And every year I struggle with how best to organize the class time, materials, and lectures in a way that optimizes students retention and liklihood that they will “act” on what they learn. This of course is an age-old topic, but recently two guys, Chip and Dan Heath, wrote a best seller called “Made to stick: Why some ideas survive and others die” that sheds some light on what is important.
They propose that getting ideas to stick , and more importantly increasing the chances that people will act on those ideas, is enhanced when they are: simple, unexpected, concrete, credible, emotional, and expressed in stories (SUCCESs). The book is well-written and provides numerous examples of how these principles play out in the real world.
After devouring the book, I decided to use the principles in my teaching efforts. The results were very positive, as my students reported that story writing (instead of tests) and a final paper based on using class experiences to illustrate the SUCCESs principles resulted in an exciting, fun, and very different class. Whether I can say for sure that the material they learned will be retained and acted upon in the future would require an outcome study that I may consider in the future.
These ideas can be translated into many settings: teaching, counseling, coaching, translational research, and implementation science. Here is my summary of the ideas applied to addiction: Making Addiction Education Stick.
When working with those who wish to change addictive behavior I am often struck by how many issues require attention after conducting an evaluation. Not only do most struggle with multiple addictions, but there are often mental health, legal, financial, social, housing, and employment issues to grapple with as well. Combined, these problems can easily seem overwhelming, particularly if you are of a mindset that every issue needs some specific intervention.
Here is where systems thinking plays a key role in successful treatment and long term management. In short, systems thinking helps us to understand that addictive behavior is an outcome of a complex system of interacting issues, for example:
In this diagram, mutliple mental health, addiction, physical and environmental problems combine to create many problems for this individual. In treatment, we identified the different issues, and then spent time drawing arrows between them and talking about how they all relate. We then uncovered a key leverage point for change that in all prior treatment episodes had been missed - an undiagnosed sleep apnea. Turns out it is hard to make progress on much in life if you are constantly in a daze. After a night at the sleep disorders lab and a confirmed diagnosis, we started treating the sleep problem and within days were making progress on the other issues.
Of all the problems listed for this patient, would you have thought the key to making significant progress was a sleep issue? The most powerful leverage points are most often not obvious.
I wrote a paper about this topic some time ago, but thought I would post a more parsimonnious version of the top ten reasons treatment fails patients. The point is not to suggest that treatment is always ineffective, just that we have a long way to go to optimizing it for those who struggle.
Treatment focuses on select objects of addiction and does not address the entire package of addictive behavior (see previous post).
Treatment time is way too short - often lasting days or a few months, instead of years like other chronic medical conditions.
Treatment relies heavily on group therapy, an abstinence-based approach, and use of 12-step principles instead of indivdiualizing treatment to patients needs and using a wide range of evidence-based practices.
Underlying mental health, trauma, and developmental deficitis/constrictions go unaddressed or undertreated.
Use of medications specifically approved by the FDA to treat addictions, including naltrexone, acamprosate, buprenorphine, and methadone, are underutilized in treatment.
Treatment overly focuses on the pathological side of the equation, and does not encourage interventions based on positive psychology and creativity.
Treatment programs forget they are running a business, and that patients really are customers, even when they are mandated to treatment. What would treatment be like if funding was based on outcomes specific to customer satisfaction?
Too much emphasis is placed on stage models of treatment when there is a much stronger base of evidence for universal processes of change.
Treatment programs see less than 10 percent of those in need of help. How can programs better align themselves with the needs of thier community and broaden the use of their resources to help a greater number of people (i.e., population-based medicine).
Treatment often remains disconnected from other important healthcare and community stakeholders. Disconnects between crimminal justice, primary care medicine, policy makers, and others mean many people fall through the cracks and ultimately fail treatment.
Addiction comes in packages - not the type of packages you want on your birthday or for Christmas, but packages that develop over periods of time and involve excessive behavior with more than one object of addiction. Rarely in my clinical work and research have I experienced patients that struggle with only one addiction. If you abuse methamphetamine or cocaine, chances are good you have struggled with out-of-control sexual behavior. If you gamble, chances are good you also drink or smoke. If you use drugs of any kind, you likely drink and use cannabis as well.
And of course the packages usually include a lot of other issues as well: mental health problems (trauma, depression), physical health problems (chronic pain, diabetes, hypertension), and a wide range of psychosocial problems (relationships, debt, unemployment, legal problems). When we combine all the issues with addiction what we see clinically is a complex mess. What makes treatment so difficult is really understanding how all the issues interact with each other, and where to start with intervention. Many who receive treatment from a private practice clincian rely on what happens in just one hour out of 168 in a given week. Not much time to intervene when so many issues are present.
One of the best descriptions of the “packages” is a chapter written by Patrick Carnes, Robert Murray, and Louis Charpentier titled “Addiction Interaction Disorder” found in the Handbook of Addictive Disorders: a Practical Guide to Diagnosis and Treatment, edited by Robert Coombs (2004). In the chapter, the authors define 11 dimensions in which different addictions interact with each other. For example, masking occurs when “an addict uses one addiction to cover up for another, perhaps more substantive addiction.” Such is the case when a patient says “I did all those sexual things because I was high on methamphetamine.”
The key point of all of this: to successfully intervene it is necessary to address the package of addictive behavior, and the co-occurring issues that go alone with the addictions as well. We must move away from treatments and interventions that focus exclusively on specific objects of addiction, and learn to think systemically about all of the various issues causing problems. This is why I am not a fan of certifications focused exlusively on drugs, gambling, or sex. What we need are clinicians who can treat the entire package.
One of my most memorable patients was a middle-aged man named Mike who came to treatment for his third drinking and driving offense. At the time, I was a young intern just learning how to connect with patients. He sat down in my office and before I could even begin my customary introduction to the clinic, he proceeded to tell me that I could not possibly have anything to offer him. During the last decade his wealthy parents had invested over 150K in the nations most prestigious alcohol treatment programs, and none of them had helped him. “Nothing against you,” he said dismissively, “but you’re an intern. Just tell me what I need to do to get out of here.”
I may have been an intern, but I was already deeply engrossed in understanding how science and research could inform my clinical work. My internship took place at a community-based treatment program which was part of a large university teaching hospital. On days where my patient load was light, I headed for the library and read the latest addiction journals. The year was 1997 and my curiosity led me to a facinating medication called naltrexone that had been used for a number of years to treat opiate addiction, but was now approved for the treatment of alcohol dependence. The only other drug available at the time was Antabuse (disulfiram) that caused sickness when alcohol was ingested. Most of the studies I read about naltrexone suggested that when combined with psychosocial therapies, outcomes were significantly improved.
As Mike sat there in front of me, half expecting that his deep resevoir of treatment experience would get him off the hook, I said flatly “how did naltrexone work for you?” At first he looked at me quizzically, but then quickly became more serious and said, “Oh yea, that stuff…I tried it but was still able to drink on it.” Calmly I replied, “I think you mean Antabuse. No, I am talking about naltrexone, the medication approved by the FDA a few years ago to treat alcoholism.” Now he really looked confused. “You’re shitting me aren’t you? If there was a new drug that would help me stop drinking don’t you think I would have heard about?” he said with frustration. I too was actually amazed that despite all the treatment episodes this guy had been through, and the fact that he had done time at some of the best in the country, that he would have heard about naltrexone. But he hadn’t. I went to my file cabinet and began pulling out journal articles to make my case. By the end of the session we had arranged an appointment for him to see our psychiatrist for a trial of naltrexone, and I was no longer just an intern in his eyes.
I would like to say that more than ten years later things have dramatically changed and addiction medications are well known and used appropriately in treatment programs across the country. But sadly, many who struggle with addiction still have no clue that a handful of powerful medicines have been approved by the FDA. My doctoral dissertation explored this topic in some detail, but if you want to skip to the chase I have also extracted the section that provides an overview of these medicines. Recently, Dr. Gupta from CNN interviewed a man who experienced success with naltrexone. The interview is short and worth watching.
Although I strongly believe those who struggle with addiction should be made aware of addiction medications and decide for themselves whether to try them, let me be crystal clear that no medication will solve the problem of addiction. As I have discussed in other blog posts, addiction ultimately is about relationships. Medications can help manage cravings and decrease relapse so that therapy can more successfully focus on the developmental catch-up work necessary for long-term success.
This past Friday I took a rare day off from work and visited Our Lady of Guadalupe Trappist Abbey in Lafeyette, Oregon. This beautiful monestary was built in 1955 and is nestled among green fields in the heart of the wine country. Having never been to a Trappist monestary before, and having had a number of past clients with addictions participate in weekend meditation retreats at the Abbey, I was interested in seeing the place for myself. Within minutes of arriving, I noticed my body calming down, and felt a sense of peace just walking around.
After some time in the chapel observing the monks in silence, I visited the zen meditation room where a priest approached me. Unlike the others I had seen who clearly were engaged in their vow of silence, this one gave me a big grin and said “how are you?” Surprised that he spoke, I took the opportunity to ask questions about life at the monestary. He had lived there for over 50 years, had spent time with Mother Teresa in Isreal, and was full of colorful life stories. But what I remember most from our discussion was his answer to my question, “what has been the most profound thing you have learned from living the monastic life?”
He bowed his head and took my question to heart, and then after some time looked me in the eyes and said “Life is transitory, but we want things to be permanent.” He went on to explain that we spend a significant amount of time fighting the natural flow and rhyhm of life. The key to happiness, from his perspective, was accepting the impermance of our situation and going with the flow.
Addictive behavior hampers the flow of life. It is energy that gets misdirected into actions that have temporary pay-offs but long term consequences. It also is a way many escape the pain of change. Most of us like routines, habits, consistency. When life is changing, chaotic, or unpredictable, we experience stress. More stress, more addictive behavior. As a result, successfully dealing with addiction requires learning how to accept the impermance of life, go with the flow, and remain calm in the face of change - challenges for us all whether addiction is present or not. Daily meditation, solitude, time in nature, prayer, chanting, drum playing, mindfulness activities - all provide opportunities for evolving how we approach life and its transitory nature.
Although the common theme these days is to understand addiction as a brain disease with contributing “psychosocial” factors, I believe there is a more useful way to think about this problem that directly links with how we go about solving it. Addictions are about relationships with objects instead of people. Let me explain.
In all my years doing clinical work and research, I have yet to come across anyone who struggles with addiction that does not also struggle in their relationships with people. This is because addiction typically does not happen overnight, and involves multiple reinforcing experiences that basically tell the brain “keep it up.” Unfortunately, as a person invests more time and energy into their relationship with objects (alcohol, food, drugs, porn, video poker, the list goes on) less time is spent engaging with people in healthy human relationships. The result is that important developmental skills necessary to initiate, develop, and maintain intimate human relationships become significantly constricted. In sum, many adults who struggle with addiction are child-like in their ability to be in relationships with other people.
This suggests that our treatments and interventions very often miss the mark. We focus so much energy on stopping the problematic behavior that we miss the importance of helping those who struggle developmentally catch-up. We know well from work with autistic children, trauma victims, and others, that no matter how significant the developmental gaps, we can intervene effectively and help people create intimate, emotionally mature, and nurturing relationships that take the place of object-relationships. This work is not easy, and in future posts I will provide a lot more details about the specific developmental problems we see in those with addictions, and the treatment necessary for healing.
