Substance Dependence Disorder: Acute or Chronic?

1. Substance Dependence Disorder:Acute or Chronic? August 2009

2. What This Presentation Is Not About • Yours or my family history • The suffering experienced by the children and families you work with • Moral failings or character flaws • Weakness of will or intellectual capacity • Heaven, hell, forgiveness, retribution, or condemnation

3. What This Presentation Is About Understanding the phenomenon of substance dependence disorder in a way that provides us with new understandings and tools useful in our collective work to ease individual and family suffering and reduce harm to our communities

4. WHY IS THIS IMPORTANT? • Placement decisions in dependencies often rely on compliance reports and reports of treatment completion from treatment agencies • There is an emerging lack of consensus among those treatment agencies regarding what treatment completion – indeed, what recovery – looks like for many individuals

5. A Dynamic Tension in the Field of Addiction (and in the management of many other chronic diseases) Abstinence Only VS Medically Assisted Chronic Disease Management • From our roots (1938): abstinence is the only legitimate treatment goal, the only outcome offering hope to the addict… • From emerging science and social policy: We accept the refusal or inability of some patients to do the best thing, so we try our hardest to have them do the next best thing…

6. Our Nice Simple Treatment Model Treatment Substance Abusing Patient NON- Substance Abusing Patient

7. Characteristics of an Acute Illness Time limited Involves an identifiable, single, or a discreet group of causative agents Once those causative agents are identified, targeted treatments effectively defeat them Post treatment, patients recover Recovery is generally viewed as a state or condition in and of itself

8. Characteristics of a Chronic Illness • Has behavioral, genetic, and environmental etiologies (causes) • Can both cause and result in chronic physiological changes (which themselves can potentiate relapse) • Characterized by cycles of relapse and remission • Involve variable adherence to care • Earlier onset generally means more challenging management • Medical and psychiatric co occurring disorders are common

9. Chronic Disease Model Treated with an Acute Care Model Substance Abusing Patient Treatment Episode Remission Relapse Treatment Episode Remission Relapse

10. THE BIG 3 Hypertension Diabetes Asthma

11. No doubt they are illnesses • All are chronic conditions • Influenced by genetic, metabolic, and behavioral factors • No cures, but effective treatments are available

12. Role of Personal Responsibility in Chronic Disease • Voluntary choice affects many illnesses as far as initiation and maintenance, especially when the voluntary behavior interacts with genetic and cultural factors. • Salt sensitivity in males: genetically transmitted risk factor for the eventual development of one form of hypertension. • Not all who have this inherited sensitivity develop hypertension as the use of salt is determined ultimately by individual choice. • Obesity may be inherited but individual activity levels, food intake, and cultural factors will play a role in the actual development of the disorder.

13. Heritability Estimates • Eye Color 1.00 • Asthma (adult onset) .35 -.70 • Diabetes (Type 2 - males) .70 -.95 • Hypertension (males) .25 -.50 • Alcohol Dependence (males) • Opiate Dependence (males) .55 - .65 .35 - .50

14. Asthma • Adherence to Medication  30% • Retreated in 12 months • Physician, ER or hospital 60 – 80%

15. Diabetes • Adherence to medication  50% • Adherence to diet/exercise  30% • Retreated in 12 months • Physician, ER or hospital 30 – 50%

16. Hypertension • Adherence to medication  60% • Adherence to diet/exercise  30% • Retreated in 12 months • Physician, ER or hospital 30 – 50%

17. 50 to 70% 50 to 70% 40 to 60% 30 to 50% Relapse Rates Are Similar for Drug Dependence And Other Chronic Illnesses 100 90 80 70 60 Percent of Patients Who Relapse 50 40 30 20 10 0 Drug Dependence Type I Diabetes Hypertension Asthma Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.

18. RelapsePredictive Factors – All 3 Illnesses #1 -Lack of adherence to diet, medications, or behavior change #2 -Low socioeconomic status #3 -Low family supports #4 -Psychiatric co-morbidity Familiar?

19. In Chronic Illnesses • The effects of treatment do not last very long after care stops • Patients who are out of treatment or contact are at elevated risk for relapse

20. For what other chronic diseases do we use terminology like “treatment completion”? When we manage other chronic diseases, when do we treat in terms of phases defined by specific periods of time rather than specific health milestones?

21. Family Treatment Courts: A Treatment Model • Development of a “Longitudinal Disease Management Plan”, including: • Acute Phase: • Individualized Assessment • Abstinence • Medical Management • Stabilization • Environmental Factors • Social Factors • Psychological and Other Medical Co Morbidities • Comprehensive Safety Planning

22. Family Treatment Courts: A Treatment Model • Chronic Symptom Management • Pre negotiated telephonic case management • On going problem solving • Open invitation to re engage with primary clinician • Monthly (?), open recovery groups (in the treatment setting) • Community sober support participation • Continued monitoring of safety plan

23. Finally… “It is interesting that relapse among patients with diabetes, hypertension, and asthma following cessation of treatment has been considered evidence of the effectiveness of those treatments and the need to retain patients in medical monitoring. In contrast, relapse to drug or alcohol use following discharge has been considered evidence of treatment failure”. Tom McLellan et al, JAMA, 2000

24. David Asia, PhD Skagit County Human Services 360.336.9309 davidasia@co.skagit.wa.us