Treating Substance Abuse Disorders in the Medical Model

Last post, I discussed how we can view substance abuse through the framework of a chronic relapsing-remitting disease. This post, we will explore what that means for treatment. 

First, the goal of treating any relapsing-remitting disease is to induce remission— make the flare-up, or the relapse, stop. This is often (though not always) achieved through medications. Once the disease is in remission, the goal is to keep it there. 

So, how do we keep diseases in remission? Well, it depends on the disease. Hopefully, we have medications that patients can take to keep the disease at bay. Often, the first question that comes up with this is, “Does that mean I have to be on medications for the rest of my life?” The answer is not simple, and involves weighing the risks of taking a medication (with its potential side effects) against its benefits (a higher likelihood the disease remains in remission). This is not a one-size-fits-all question, and really involves discussions about the risks and benefits. 

So, if remission is the goal, what about relapses?

Well, they happen. I wish they did not. I do not encourage them. The reality, however, is that they do happen, and when they do, its vital important that they are recognized as soon as possible, and addressed as soon as possible. This is true whether we care talking about Ulcerative Colitis or Opiate Abuse. The longer the relapse continues, the more damage is done; the sooner it is recognized, the faster we can intervene and get things back on track. 

The goal with relapses is to make them as short as possible (an hour is better than a day, a day is better than a week, a week is better than a month), as infrequent as possible (once a month is better than once a week, once a year is better than once a month) and as little destructive as possible, both in terms of health and in terms of damage to those around us. 

While this model is not perfect, it is helpful. And the good news, when it comes to treating opiate or alcohol dependency in particular, is that we have some very good medications that generally do not come with a lot of side effects. However, as with pretty much any chronic disease, the best outcomes are really achieved through a combination of medications and behavior change. Its not either/or, its both.

-Justin Altschuler, MD

The Medical Model for Substance Abuse

The statistician George box would say, “All models are wrong but some are useful.” Its a helpful phrase to remember when thinking about substance use disorders and addiction. There is not one right way to think about this problem, as every approach— medical, law enforcement, spiritual— contains both useful insights and significant flaws. However, I am a doctor, so my training teaches me to think about substance use disorders through the medical model. 

As doctors, we treat many conditions that are characterized as chronic, relapsing-remitting diseases. There are many diseases fit this mold, from Crohn’s disease to multiple sclerosis. Thinking about opiate use disorder, or any substance abuse disorder through this lens provides some useful insights: 

Chronic simply means it does not go away. It will always be there. It does not necessarily mean it will be a problem. I However, just because something is not bothersome at this moment does not mean it doesn’t exist. Other chronic illnesses include things like high blood pressure, diabetes, and heart disease. People with chronic illnesses do not necessarily feel bad all the time; often, the illness barely gets in the way of life. 

Relapsing-remitting means the disease goes through periods where it is bad and flared-up, is a problem, then goes through periods where it is not acting up, is not an issue, is in remission. The goal of treatment then becomes to induce remission, and keep the disease in remission for as long as possible. 

Viewed through this lens, the goals of treatment become much easier to understand: to induce remission, to maintain remission, and to ensure that any relapses are as short as possible, as infrequent as possible, and as little destructive as possible. This framework is true regardless of whether the disease is a substance use disorder, a neurological disorder, or a gastrointestinal disorder. However, given how loaded and stigmatized substance abuse disorders are, this framework also helps both patients and doctors approach the problem as a solvable issue, rather than an inherent failing in the patient. 

The question then becomes, how do we achieve this? That will be the topic of a future post.

Dishwasher Issues

Some of the patients I see  have challenges with relationships. Sometimes, these challenges grew from the substance abuse, sometimes these challenges were a big part of what started the substance abuse. Sometimes, they have nothing to do with substance abuse. 

It should not be controversial to say, but relationships come with disagreement— and that’s ok. In fact, it’s normal. But learning how to disagree with someone, particularly a romantic partner, can be a challenge.

In fact, most of us have probably been in a situation where we have had an enormous fight with someone over something trivial— like, for example, how to load the dishwasher. So, let’s focus on this for a moment. 

We all have an opinion about how to load a dishwasher. The plates go on the bottom, they face toward the silverware, the cutlery faces up, the glasses have to be on the edges… you get the idea. More importantly, exactly how we load the dishwasher is probably not too important; after all, worst case scenario, the dishes don’t come out sparkling. However, people can get into knock-dawn, drag out, screaming-at-the-top-of-my-lungs fights about… how to load the dishwasher. 

“Honey, I told you, the plates go on the back row.”

“NO, they go ON THE FRONT ROW.”

“They go on the BACK ROW.”


Guess what…its not about the dishwasher. Its about the relationship, and the dishwasher is just a symptom. 

Here’s the same conversation, with what is said, compared with a hypothetical set of issues someone may be experiencing:

“Honey, I told you, the plates go on the back row.” Why don’t you ever listen to me?

“NO, they go ON THE FRONT ROW.” Why are you being overbearing. 

“They go on the BACK ROW.”  You don’t listen to me, my parents never listened to me, you ignoring what I think is important, just like I’ve always been ignored. 

“NO. THEY. DON’T. FRONT ROW.” My mother was overbearing all my life, and now you. All I want is the freedom to do things on my terms.”

The issues will vary, but, the problem of big fights over trivial things (like how to load the dishwasher) won’t go away until the underlying problem, or issue, is addressed directly. If you find yourself in this situation, take a step back, let everyone cool off, and try and address the actual problem… not how to load the dishwasher.

Upcoming Series

I am hoping to be a bit more consistent with the blog-- and to start publishing some of the more common themes and issues that come up when I am meeting with my patients. I plan for these to be fairly wide ranging-- from thoughts about substance abuse treatment to chronic pain to explanation of how the direct primary care practice works. 

First post will be coming out in a few days, and will be about dishwashers. 


Justin Altschuler, MD

Group Visits and Happy Holidays

Happy Holidays! For a lot of people, it is most decidedly NOT the most wonderful time of the year, but I hope your holidays have been good so far.

I will be out of the office quite a bit over the next couple of weeks visiting family. If you need anything, please get in touch on my cell phone. 

Group visits have been going well so far-- thank you to those who have attended. I think they have been helpful addressing some of the challenges patients with substance abuse disorders face. In fact, I am planning on adding an additional group on January 25 in the afternoon. Please let me know if you are interested in attending. 

I emailed a while ago as well regarding RubiconMD, a service I subscribe to that increases access to specialists. I am happy to report this has been a great addition to the care I am able to provide, and has allowed very rapid second opinions and guidance regarding tricky problems. 

Lastly, I would like to share my gratitude for you, my patients for being a part of the practice. It is off to a great start. Leaving work every day, I feel like I am able to do the right thing for every patient who have entrusted their care to me. It is a wonderful feeling. As Warren Buffett says, "I tap dance to work." 

I am looking forward to seeing you in the new year, and thank you for the privilege of being your doctor. 

Happy Holidays,

Justin Altschuler, MD

Introducing... the blog (and group visits)

We are always trying to innovate, and find better ways of doing things. So, as an experiment, I am planning on starting a small blog to update new happenings at SequoiaMD. In this first post, I am happy to introduce yet another new change to the practice-- group visits.

Many patients that I am seeing for substance abuse issues have expressed interested in meeting other people who facing similar challenges. This program is a direct response to conversations I have had with many of you, and I hope they are helpful!

The plan will be for a pilot program, initially limited only to people who I see for substance abuse. This is an opportunity to build community, friendship and fellowship with other people who have been there. Regardless of where you are on your journey, come connect with others who are walking the same road. 

Some specifics:

  • Group visits are optional. You are not required to attend
  • I will be present, and facilitating, every visit
  • This is included in your monthly membership— there is no extra fee
  • You may attend a group visit AND continue our regular appointments, you don’t have to give anything up to attend.
  • If there is enough interest, I will add additional groups.
  • These visits will not follow a traditional 12 step model. If you would like a 12-step style meeting, there are many available in the community. This is something different.
  • You MUST RSVP for these. You know how to get in touch with me.
  • Each visit will have a minimum of 3 people, and a maximum of 8. If there are less than three people Interested, I’ll cancel the appointment. 
  • To start, these will occur once per month, on the second Wednesday of the Month, at 9:30 AM. Currently scheduled November 8, December 13, and January 10. 

This is a pilot program, and will evolve with time. The goal is to be helpful, and so we learn what works and what doesn’t, the visits will likely change. If you would like to attend, please get in touch!

-Justin Altschuler, MD