Wednesday, September 26, 2012

Response to Dr. Willenbring

I wrote this response to Mark Willenbring's post on his blog.  I reposted it here because the links do not work in the reply section of his blog in case anyone is interested in the references:

I generally agree with what you are saying.  I think the no fault aspect of the illness is very difficult for many to grasp - most importantly the policy makers and health plan administrators.  I think it is captured very well in the latest ASAM definition.  I think that Sellman’s Top Ten list and the responses to it are also instructive especially item 7 “Come back when you are motivated” is no longer an acceptable therapeutic response’ is part of your message.

From a systems standpoint, the lack of a full array of services to treat addiction is striking.  Over the course of my career I have seen detox services essentially moved to mental health units and then to the street.  I wrote a post about this several weeks ago that was read by current detox staff who agreed with it.    It is hard to believe that in many if not most cases people with addictions are sent home from the ED, sent home with a handful of benzodiazepines, or sent to a facility with no medical coverage for a complex detox process.  I think the test of any health care system is whether a primary care doc can ask themselves if they have a safe detox procedure for any of their regular patients who are addicted to opioids and benzodiazepines and needs surgery.

Medical systems in general have a very poor attitude toward people with addictions.  I think that these healthcare systems and their personnel are much more likely to take a moralistic attitude toward addicts and not treat them well.  I have seen that theme repeated across multiple care settings.  Many rationed care settings disproportionately reduce resources necessary to treat addiction.  I think it is safe to say that most cardiology patients with suspicious chest pain get a $10,000 evaluation and reassurance or appropriate treatment.  Most patients with addictions do not even get a $300 evaluation.  They may actually see a physician who provides them with medications that fuel their addiction.  Institutionalized stigma plays a big role in that.  There are no billboards in the Twin Cities advertising state-of-the-art addiction treatment.  There are many advertisements for heart centers.

I am less pessimistic about the effects of 12-step recovery and time in a residential setting whether it is a high end recovery facility or a state hospital.  I think if you are in a setting where there is no active treatment or sober environment you are probably wasting your time.  I have seen people who were declared hopeless recover with time away from alcohol and drugs on the order of months.  Vaillant’s study of severe alcoholism is a great example of the different paths to recovery and there are many.  His subsequent analysis of how AA might work suggests that affiliation rather than blaming may be the most curative element.  AA is difficult to study but I think that the message is positive and embodied in #3 of the Twelve Traditions.  Up to that point the founders were looking at the issue of exclusion but decided against it because alcoholism was a life threatening disease and they could turn nobody away. 

George Dawson, MD, DFAPA

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