10 Jun Addiction Treatment, Recovery and Relapse – A Practitioner’s Perspective
South Pacific Private recently interviewed Dr. David Mee-Lee, a board-certified addiction specialist Psychiatrist. In this interview David focused upon recovery and relapse in co occurring disorders specifically from a practitioner point of view.
How do you define recovery in mental health treatment?
I like the definition developed by the Substance Abuse and Mental Health Services Administration (SAMHSA) in the USA that defines “Recovery from Mental Disorders and/or Substance Use Disorders” as follows: “A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.
Through the Recovery Support Strategic Initiative, SAMHSA has delineated four major dimensions that support a life in recovery:
Health: overcoming or managing one’s disease(s) or symptoms—for example, abstaining from use of alcohol, illicit drugs, and non-prescribed medications if one has an addiction problem—and for everyone in recovery, making informed, healthy choices that support physical and emotional wellbeing.
Home: a stable and safe place to live;
Purpose: meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavours, and the independence, income and resources to participate in society;
and Community: relationships and social networks that provide support, friendship, love, and hope.”
What I like about this definition is that it defines recovery as being broader than just stabilization of signs and symptoms of mental illness and/or addiction; and is more than just abstinence or medication compliance. It puts the focus on wellness and helping people be the best they can be physically, mentally, socially and spiritually in the context of home and community with a sense of purpose and meaning.
What challenges do you think we face attitudinally around recovery and relapse?
It is easy when patients and families come troubled and distressed to put the focus on pathology and problems; and of course it is necessary and important to stabilise and address acute concerns. But recovery and wellness is not just the absence of acute signs and symptoms. Recovery is helping a person grow beyond their diagnostic label and to make positive life changes consistent with their goals and potential.
As regards relapse in particular, instead of seeing flare-ups of a mental or addiction disorder as a failure, it is more fruitful to see these are poor outcomes of the current treatment plan. Then the “relapse” becomes an assessment and learning opportunity to find what can improve the treatment plan and the outcomes of the service plan.
What stigma do you think is attached to jargon we use in addiction treatment e.g. relapse?
Actually “relapse” is a term that we question in the latest edition of the American Society of Addiction Medicine (ASAM) Criteria for the Treatment of Addictive, Substance-Related, and Co-Occurring Conditions (Mee-Lee D, Shulman GD, Fishman MJ, and Gastfriend DR, Miller MM eds. (2013). The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. Third Edition. Carson City, NV: The Change Companies. For more information on the new edition: www.ASAMcriteria.org)
We don’t really use “relapse” for flare-ups of any other chronic disease in healthcare. If someone’s blood pressure goes up, we don’t say it is a “relapse”. Or if they have an asthma attack or increased blood sugar in diabetes, we don’t say it is a “relapse”. Or if someone gets depressed or manic or psychotic we don’t usually call that a relapse. So in The ASAM Criteria we suggest we start transitioning to language that fits chronic diseases of which addiction is one such illness.
So we could say a patient is having an acute exacerbation of signs and symptoms of addiction; or an acute flare-up; or a recurrence of their addiction illness; or a poor outcome to be assessed so a better service plan can be developed. Also, instead of “dirty urines” for the results of urine drug screens, we would day that the laboratory test for substance use was a positive urine drug screen result. We don’t say to a patient: “Your cholesterol is dirty”. “Dirty urines” can easily raise attitudes that the person is “dirty” and bad.
What are the discrepancies between concepts and practice when it comes to the treatment of addictions?
A major discrepancy is that we teach that addiction is a chronic illness like asthma, diabetes and hypertension, but then often have policies and attitudes that treat patients who have a recurrence or flare-up as if it is wilful misconduct needing consequences. Some programs ask a person who shows up to an outpatient group session having drank alcohol or used some other drug to leave and come back when they are stable. We would never do that for someone who came with a flare up of depression or suicidal thoughts or a panic or asthma attack.
If a patient uses drugs while in an inpatient program, some agencies have a zero tolerance policy that requires the person to be discharged, when we would never do that if someone with cutting or self-mutilation impulses scratched their wrist or used a razor blade or knife to hurt themselves.
Another discrepancy is that while we want to have an addicted person work on abstinence, some programs require a person to commit to abstinence as a condition for treatment and to be perfect and not “relapse” or else discharge is the consequence of use while in treatment. We would never require a patient with psychotic or depression illness to commit to being non-depressed or non-psychotic as a condition for treatment; and them discharge them or tell them to come back when they are stable if there was a flare-up.
How do you recognise patients in crisis?
A “crisis” can be viewed as any outcome in the course of treatment that puts the person at imminent risk for harmful or dangerous consequences to self and/or others. So a flare-up that has a person struggling with impulses to drink or drug is a “crisis” in addiction; or struggling with impulses to cut or hurt oneself is a “crisis” in mental health; or a flare-up of very high blood pressure or blood sugar is a “crisis” for hypertension or diabetes and so on. A crisis signals that reassessment and a change in treatment plan is urgent to avoid further impairment and poor outcomes.
What are the common dilemmas faced by health care practitioners working in the field of addiction diagnosis and treatment?
For most illnesses, patients are grateful if you diagnose their cancer, heart disease, arthritis, asthma or depression and want to work with you to not get worse or die. But the dilemma with addiction is that people usually resent it if you ask questions about alcohol and other drug use to diagnose their illness. They think they can take care of it on their own if they even acknowledge a problem with addiction; and might even dropout of treatment if you keep asking them or pursuing them to get addiction treatment.
They are as much a victim of negative societal attitudes about addiction as health care practitioners are due to lack of education and understanding about what addiction is in aetiology, signs and symptoms and treatment. This is why there is more interest in helping health care practitioners learn about and improve skills in Screening, Brief Intervention, Referral and Treatment (SBIRT).
What improvements or updates in treatment for addictions have taken place in the last year of significance?
Besides a greater awareness of the importance of SBIRT, there is increased use of anti-addiction medications in conjunction with psychosocial treatments. But there is also increased awareness of the dangers of narcotic analgesic medications that have seen spiking levels of use creating at least in the USA, opioid use disorders of almost epidemic proportion. There is greater understanding of addiction as a primary, chronic disease of brain reward, motivation, memory and related circuitry that creates the pathological pursuit of reward and relief through the use of substances and addictive behaviours. This understanding sets the foundation for improved chronic disease management that underlies many of the principles in the new edition of The ASAM Criteria (2013).
What are the current challenges we face that we need to work to resolve?
There are many, but a major challenge is that the majority of people with addiction have either not been diagnosed or if they have been told they suffer from addiction, do not accept that and therefore don’t reach out for treatment. In the USA, an estimated 23 million people 12 years and older need addiction treatment. But 95% of those don’t know or think they have an illness and therefore never reach out for definitive addiction treatment. (Substance Abuse and Mental Health Services (SAMHSA) Results from the 2012 National Survey on Drug Use and Health (NSDUH) Summary of National Findings. Sept., 2013).
They may be in prisons, general and mental health care or just not even being seen, yet suffering from the consequences of undiagnosed and untreated addiction. The human, social, family, legal and health care financial costs of untreated addiction are staggering.
Can you share with us some tips and tricks?
I don’t know about “tricks”, but an easy way to share some “tips” might be the ABCs – Taking a look at our Attitudes about addiction, recovery and “relapse”. Notice the terminology we use when we talk about addiction versus other chronic diseases.
Examine our Beliefs about addiction, recovery and “relapse”. What do we believe about the aetiology, expression and treatment of addiction – moral, social, behavioural, psychiatric or public health problem? Punishment, consequences, behaviour therapy or psychotherapy or medication?
Clinical skills, practices and policies in assessment, treatment, program policies about “relapse”. How do we attract and engage people in recovery when they may not even agree that they have such an illness? What do we do when a person uses while in treatment? How do we keep the milieu safe for other patients while seeing such use as a crisis needing treatment not discharge?
David Mee-Lee, M.D. is a board-certified psychiatrist, and is certified by the American Board of Addiction Medicine (ABAM). Based in Davis, California, he trains and consults both nationally and internationally. Dr. Mee-Lee is Chief Editor of the American Society of Addiction Medicine’s (ASAM) Criteria for the Treatment of Addictive, Substance- Related, and Co-Occurring Conditions and is Senior Vice President of The Change Companies. He also has over thirty years’ experience in person-centred treatment and program development for people with co-occurring mental health and substance use conditions.