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