Substance Abuse Treatment

YouTube

When I see patients, I often talk about the importance of taking risks, trying new things, and experimenting. So, I decided to take my own advice, and try something new… I’m on youtube. Yep, Dr. No-Social-Media is going to try and do something new, and see where it goes.

My goal is to post 2-4 times a month, and to post videos about things I often talk to patients about, or things that I think will be helpful. Topics will be on substance abuse treatment and recovery, as well as type 1 diabetes. I don’t know if this will work— its a grand experiment.

Video number 1: https://youtu.be/mswHwYC-kLA

Its the individual...

This article hits the nail on the head around a lot of the current issues around chronic pain and addiction. It also is another example of another huge challenge in healthcare.

 One of the biggest challenges I see in medicine is the idea that "someone else" knows better. For any individual patient, that patient, and the doctor taking care of him or her, are going to make the best decision. It won't always be right, but it will certainly be a better decision than one make for 2.000 miles away.  Politicians, insurance company administrators, bureaucrats, "policy makers." and a long list of other people are going to know less about any given situation than the patient and the doctor. And yet, they often have as much (if not MORE) influence, in how an individual patient gets treated. 

This is true with managing pain. For a long time, doctors were very concerned about the dangers of prescribing opiates. Then a whole host of other people got involved, and basically told doctors they were not doing a good job, because we weren't controlling patients pain, not prescribing enough. Now, those very same people, are coming back and telling us we are not doing a good job because they are being prescribed too much. 

How about we let doctors work with patients to come up with the best treatment for that individual person? Complicated? No. Revolutionary? Maybe...

Inertia

Isaac Newton’s first law says something to the effect of, “An object in motion tends to remain in motion, and an object at rest tends to remain at rest, unless acted on by an outside force.” This is true in physics. This is true in managing a chronic health condition. This is true in life. The course we are on (or that we set ourselves on) tends to remain, unless we make an effort to change it.

Most people will stick with a current job (even if its lousy!) unless really compelled to change for some reason. People will stick with a broken system (ahem, healthcare), unless really compelled to change. People will continue exercising (if that’s the habit) or not exercising (if that’s the habit), until something spurs change. The interesting thing is, even when you recognize that something is not working, the perceived effort to change it is often greater than the perceived benefit. 

Change is hard. Always has been, always will be. The good news is that the effort to change is not required all the time. For example, when I see patients who have been using opiates or alcohol, they have been using consistently for quite some time. Why? Because change is hard, and inertia is working against them. Inertia is pulling in the direction of continuing to use. However, once people start treatment, inertia is working for them.  While things don’t always go smoothly, life is now moving in a better direction, and inertia will likely keep things moving in that better direction. 

So, its important to get  on a good path, to let inertia be your ally, not your enemy. If your inertia, your habit, is to buy healthy food at the grocery, odds are you will continue to do that. If you habit is take your insulin regularly, odds are you will continue to do that. 

Is inertia working for you, or against you? Is your daily routine bringing you happiness, or bringing you closer to your goals? 

The Chains of Habit Are Too Light To Be Felt Until They Are Too Heavy To Be Broken (attributed to many people, including Samuel Johnson, Benjamin Franklin, and Warren Buffett)

Putting Leather on the World

Often, complex ideas are better explained with a story than with charts, graphs, or statistics. This story comes from Buddhism, and is one of my favorites. 

    There was once a man on a long journey. As he walked the path, he found he continued to cut his feet on the sharp rocks in the path he walked. His feet were painful and bloody, constantly being cut. Being a compassionate man, he realized if the sharp rocks were cutting his feet, they were probably cutting the feet of other travelers as well. Resolving to do something about this, so set about covering the sharp rocks with leather, so as to protect both his feet, and those of his fellow travelers. 

He resolved that this would be his great work-- covering the sharp rocks with leather, for himself and his fellow travelers. 

However, the more sharp rocks he covered with leather, the more sharp rocks he saw. No matter how many sharp rocks he covered, there always seemed to be more. He and others continued to have cuts on their feet. Despite his great exertions, and thousands of sharp rocks that were covered with leather, the cuts persisted. 

    One day, a monk was traveling the path, and stopped and asked what he was doing. The man explained, and showed the monk his progress, as well as the continued challenge he was facing. The monk replied, “Don’t you think it would be better to put leather on your feet, rather than putting leather on the world?”

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.