The NEJM "Addiction As Learning And Not Disease" Article - Clinical Realities

I had anticipated posting a piece on the biological realities that were minimized in this review but I am currently waiting for a graphic that I acquired permission to use.  I have not heard back from the publisher.  In the interim, I will post some information on the clinical reality of treating people with severe substance use disorders or addictions to illustrate why learning is really an inferior paradigm to use in analyzing the problem.   It really comes down to treating all of the features of a profound loss of normal functioning.  These features are not subtle and include insomnia, anxiety, depression, cravings, compulsive use, and protracted withdrawal.  The following comments considers only those people with addiction that is defined as DSM-5 severe substance use disorder and compulsive use of any addictive substance.  By definition that means I am not considering people with less severe problems, such as the average college drinker or cannabis smoker who lacks these features, can easily stop, and invariably stops when they move on with their life after college.  I could post a series of vignettes but for brevity - I can roll all of those problems into one problem, that is generally recognized as the most significant drug problem in American today and that is opioid use disorder.

Consider the following hypothetical and all of the potential solutions and the implications for addiction as a disease or a learning opportunity.

40 year old man with chronic back pain, benzodiazepine use disorder and opioid use disorder.  Prior to admission he was using 10-16 mg clonazepam per day and 240-300 mg of oxycodone per day for 5 years.  The use disorder developed as a direct result of prescriptions of oxycodone 10 mg TID for back pain and clonazepam 0.5 mg TID for back spasm.  The patient was admitted to a residential treatment facility and detoxified with buprenorphine and phenobarbital over a period of 10 days.  On day 15 he is referred for assessment of depression and anxiety.  

He has no history of insomnia, depression, or anxiety prior to the onset of the substance use problems. Since the detox was completed (on day 10) - his anxiety is "through the roof", he is unable to sleep, and he is depressed and somewhat hopeless.  His concentration and focus are so impaired at this point that he can't retain information presented in groups or individual discussion and he feels like treatment is a "waste of money" because he has not learned anything.  He is craving benzodiazepines but also opioids to some extent.  He has drenching night sweats and has to change his shirt 2 or 3 times a night.  He describes muscle and joint pain.  He is concerned that he will relapse immediately upon discharge due to all of these symptoms.  He asks about taking trazodone for sleep, an antidepressant for depression, and gabapentin for anxiety.  He suggests that if the problem cannot be solved - he will go back to his primary care MD and get another prescription for benzodiazepines and that he will "try to control it this time."  

At this point the best intervention (s) to address these symptoms include (choose as many as you like):

a)  Continued 12-step facilitation groups
b)  Cognitive behavior therapy for insomnia (CBTi)
c)  Cognitive behavior therapy for substance use, anxiety and depression.
d)  A family program to educate the patient and his family about the relevant dynamics
e)  An NA group to deal with cravings
f)  Prescribe trazodone for sleep
g)  Prescribe an SSRI for anxiety and depression
h)  Prescribe gabapentin for anxiety
i)  Prescribe a benzodiazepine for anxiety
j)   Prescribe buprenorphine/naloxone (BUP/NAL) for opioid withdrawal and medication assisted treatment (MAT) of opioid use disorder.

Numerous learning and medical interventions for the problem and I have seen several to most of them applied in this scenario.  I have seen many applied repeatedly well past the point of failure to the point that a person may be leaving treatment more symptomatic than they came in.  That is a significant failure because the patient leaving in that circumstance is highly vulnerable.  This scenario is highlighted generally ion the movement to make sure that persons with opioid use disorder are prescribed BUP/NAL and given naloxone intranasal or injection when they make the transition from treatment setting or secure environments where they have had no access to opioids like jails.  That emphasis is important because of the overdose risk with opioids but the risk for relapse to using any substance requiring treatment is very high and potentially leads to a fatal outcome.

The other clinical consideration of addiction as disease is that it is multidimensional.  As highlighted in this case - it is not a simple question of detox, stabilization and discharge.  Significant physical symptoms of illness, intoxication, and withdrawal can persist well beyond any expected period of detox.  Significant sleep problems can persist for years beyond the detox period.  Striking psychiatric symptoms are all part of the mix and physicians not suspecting these disorders can attempt to treat them as depression, dementia, bipolar disorder, anxiety disorders, panic attacks, and even attention deficit-hyperactivity disorder.  Some treatment literature talks about a vague syndrome of protracted withdrawal symptoms that is often used to described any unusual symptoms or perception during the recovery period.  Addiction is a modern day great imposter of psychiatric disorders.  Clinicians following people with all of these symptoms can discuss general guidelines with people about how long it takes various symptoms complexes to resolve before a psychiatric disorder should be considered.   In some cases the symptoms are of sufficient severity that they need to be treated acutely and the issue of disorder versus disorder cause by the substance needs to be worked out in the long term.

A long standing debate in the treatment of substance use disorders is the role of physicians and medical treatment.  Medicine has always had a role in detoxification especially when it comes to potentially life-threatening detox or detox that involves significant discomfort.  The epidemiology of addictive disorders and psychiatric disorders points to an obvious reason to try to treat both disorders at once and a place for psychiatric treatment. Medication assisted treatment to reduce relapse has been the most recent medical innovation.  All of these roles are consistent with a disease model that seeks to correct or address a loss of normal function in the human body or brain.

I am an advocate of psychosocial therapies not just in addiction, but in just about all areas of psychiatry.  Further I am an advocate of 12-step recovery because it is cost effective, it works, and it has the realistic long term goal of abstinence.  In addiction treatment, those therapies work best if a person is detoxified, cognitively intact, all of the associated comorbid symptoms are treated, and (where possible) craving and relapse potential are reduced as far as possible to break up the cycle of compulsive irrational substance use.

Given all of those considerations what is the correct answer to the question?  None of the verbal therapy or experiential (a though e) options work, but I have seen them applied even when the person was in significant distress and no progress was being made.  There are no known talk therapies that adequately treat intoxication, withdrawal, or many of the intermediate states associated with early recovery that in some cases extend for 1-3 years.  What about the symptomatic treatment of psychiatric symptoms?  Not the best options either.  In this case, I have seen patients on multiple antidepressant, anxiolytics, trazodone, atypical antipsychotics, and even stimulants for the symptoms described.  In many cases the associated medications led to additional morbidity.  So treating this multidimensional illness as a single or a collection of psychiatric disorders is also the wrong answer.

The correct answer in this case is  j) Prescribe buprenorphine/naloxone (BUP/NAL).  In practically every case like this that I have been involved with since the advent of BUP/NAL prescribing the anxiety, sleep disturbance, depression, and physical symptoms all resolve or at least the portion of the illness that is directly attributable to opioid use.  In this case the patient was also using a benzodiazepine with a long half life and may also need to address those symptoms.  Protracted withdrawal from benzodiazepines has been described since the late 1980s and the symptoms can also last for a long time.

The clinical approach to addictive disorders provides clear information on why addiction is a disease whether you happen to accept any of the models proposed by Volkow and Koob or not. At every step of the way in the above example, the underlying systems are described in either of the main addiction texts.  There is clearly a loss of normal functioning that does not respond to talk therapy or other learning interventions.  In fact, these interventions presented to a distressed person typically create more problems than solutions. Although it is possible to insert neurobiology into any medical or talking intervention these days, learning interventions for the above problems can be expected to have little to no effect on the major problems that this patient is experiencing.    

All of those problems at any stage of addiction are a loss of normal functioning or a disease state. With addiction the loss of normal functioning is not trivial. It is disabling, severe, and life threatening. Any quality treatment program should be able to address them and not depend solely on a learning environment to assist these patients.


George Dawson, MD, DFAPA

Computational Aspects of the Human Brain

As part of my lectures on the neurobiology of addiction - I digress briefly to discuss the computational aspects of the brain.  A lot of that discussion is focused on on the above graphic showing that overlaps in capacity with a list of the world's ten fastest supercomputers.  At least that is the estimate of the AI Impacts group.  It is basically a computation based on edges and nodes. I include power estimates for a brain from existing hardware to the actual power estimate of the human brain that I would guess every physical chemistry student from my era had to contemplate at one time.  And then I try to stimulate some discussion of supercomputers versus the human brain and it generally falls flat.  My Socratic process goes something like this:

"OK so we know that humans can't really beat computers on straightforward calculations so what advantages do we have?"

"I will give you a hint - why do we all go thorough residency training? Why can't you learn your specialty by reading about it in a book?"

The first lesson is pattern matching.  The human brain is designed not only to match patterns but to be trained to match a lot of them.  Some research article suggest about 88,000, but when  you consider what has to be matched that has be very a very low estimate.  I quote references from 15-20 years ago and a course I used to teach on diagnostics and diagnostic decision making.  Ophthalmologists correctly diagnosing diabetic retinopathy at a much higher rate than nonspecialists.  Dermatologists diagnosing rashes faster and correctly classifying ambiguous rashes with greater precision than nonspecialists. If I am really on a roll I might digress to talk about Infection Disease rounds at the Milwaukee VA sometime during 1982.  I was the medical student on a team of residents and fellows doing a consult for possible subacute bacterial peritonitis.  As the attending listening to the presentation he was also looking at a rash on the patient's shin.  By the time we were done he had also diagnosed a strep infection in addition to the peritonitis.  When you have significant pattern matching capacity, and you have been exposed to relevant patterns you can recognize them quickly and improve the speed and accuracy of the diagnosis.

I move on at that point to illustrate that the computers are catching up.  The simple captcha is less robust in discriminating machines from humans.  Opening an account may take more that checking the "I am not a computer" box. Now you might have to look at 8 pictures and check the one that contains an automobile or a stop sign.  Some of these photos are often difficult for humans to decipher.

At that point I touch on human consciousness - both the unique aspects and computational power it takes to generate.   About a decade ago I started saying that if there are 8 billion people on the planet - there are 8 billion unique conscious states. It makes sense at a number of levels especially when I put up hard numbers on cell types, protein types, the genetic information represented, and the typical stream of consciousness that every person experiences every day.  What is the content and flow of that activity? How does it get biased in psychiatric disorders and addictions?  How much computational power does it take to generate all of this information?

My latest step is what I like to consider The Matrix observation.  If I am standing in front of a room of 15-20 residents - what does it take to generate the physical representation of all of the people and all of the objects in that room? What does it take to make all of those representations unique? There can be a general consensus about what is happening - but just looking around it is clear that there are obvious different experiences.  One person looks very interested and one semi-interested.  One person is more focused on her Smartphone and is indifferent to my presentation.  Some people look sleepy.  Others look irritated.    They also appear to be indifferent to the context.  I know that my job is to try to get this information across and make is semi-interesting.  There is no real expectation on the residents.  It is clear from the questions I ask that they really don't know too much about the brain.  There are parallel streams of information processing that allow us all to evaluate what is occurring on the fly both the information content and emotion.  In some case there are pre-existing heuristics and in other cases associative memories and biases.  All of this represents a tremendous amount of information or computational power depending on how you may want to discuss it.

I have been preoccupied myself with the computational power and estimating it accurately. I used to try to model it in terms of electrical buses and neuronal firing rates - but the numbers I got were far too low.  There really are no good equivalents in the physical world with the possible exception of the Transversed Edges per Second (TEPS) metric used by the AI Impacts group for the above graphic.  You can't really use estimates of typical audio or visual information and concluding that is what is being processed by the brain.  I have never really seen an accurate estimate of all of the sensory information that the brain is handling in real time.

I went to bed last night and waited for sleep reverie or that period of time where you stream of thinking is jumbled and illogical just before you fall asleep.  As a chronic insomniac it is one of the few reliable cues that I am probably getting some sleep.  It happened when I had a sudden image of a baby high up on a brick wall, followed immediately by a person who seemed to be me sitting in a single seat futuristic car.  The salesperson was describing it to me and suddenly the car and everything else was being swept down what appeared to be a very sophisticated hydraulic roadway. The roadway was bright orange and the salesman shifted his pitch to tell me the advantages of this kind of a roadway with this car.  The roadway was moving at about 20 miles per hour.

I shifted briefly and remembered it was 2018 and I was in my bedroom in Minnesota.

And for a minute I thought about being able to estimate the information necessary to generate that brief full color science fiction scene and the three or four more I would encounter that night.


George Dawson, MD, DFAPA


Some additional examples as they happened:


1. Dream of 11/22/2018:  I am back on my old inpatient unit.  The layout is exactly the way it was 20 years ago (the building has since been razed).  I am working with the same staff.  I walk into the examination room to look at the templates for the day.  In those pre-EHR days I had designed a template with all of the relevant features necessary for the billing and coding requirements.  At the time we were all threatened with legal action if we did not comply with these regulations even though they were totally subjective.  In those days I worked with a physicians assistant who prepared the templates ahead of time before we started interviewing patients and completing the subjective aspects of the evaluation and documenting the progress.

The templates were all stacked in two circular patterns - ten templates in each circle.  They appeared to be the exact temples that we used right down to the blurred fonts from being photocopied too many times.  The precise handwriting of my physicians assistant in the diagnostic section was exactly the way he wrote things down.  The placement of the exam table and crash cart were exactly where they were in reality.  The table we used was circular and about 6 feet in diameter with a laminated blonde wood finish and it was also exactly the way it was in that now 20 year old reality.

I looked at the templates and asked myself: "Why are they all face down?  I can't see the patient's name or identifying data.  I will have to go through them all to find the correct template when I start interviewing patients."

I felt somewhat irritated.

And then I woke up. 

2. Dream of 11/23/2018: I am in a large modern, multi-floor medical facility. It is not one that I specifically recognize, but it seem like there are elements of many that I have been in.  I am rushing around on the ground floor. The impression I have is that I am late for a lecture. It doesn't seem to be an explicit CME lecture but everyone else there (including myself) is too old to be a medical student or resident. I run into the elevator just beating the door as it closes.

I make to to the lecture.  It is basically a large room - maybe 50' x 50' and for some reason I burst through the door running at full speed.  Just before the crash into the back wall, a guy standing on the side wall grabs my arm to slow me down and stop me.

I ask myself if that was really necessary because my plan was just to stop myself by reaching out and planting my hand on the back wall.  I notice that there are several people who I assume are physicians that are standing and sitting near the back wall and they seem a little alarmed about something.

Then I am back in the elevator and headed to the ground floor.  I am walking out of the building and realize that I am chewing something metallic.  I realize that is is a collection of machine screws, nuts, and ball bearings. I realize that is purchased them on the ground floor of this building and that they are sold for that purpose.  I also know that I cannot really chew them or I will break my teeth.  I have to cautiously move them around in my mouth.  They remind me of a chap stick product that is applied with a ball bearing device at the end of the dispenser.

I wake up with a metallic taste in my mouth.

3.  Dream of 11/24/2018:  I am back in my home town. The streets and buildings are identical to the way they look in reality.  I am with a friend of mine and we are looking at a 1960s vintage Buick.  It is large and chalky white.  He tells me that his sister recently bought it and she wants to take everyone for a ride.  He thinks I should come along, but just then I remember something that his sister said to me in the last 15 years that would make me not want to go with them. He is talking about the car as though it is a great buy, but as I walk past the tail end of the vehicle, I notice that it has a new paint job and that whoever did it just painted over the decals of the previous dealers.  You can see them faintly through the paint.

I tell my friend that I can't stay around because I have to go grocery shopping. Just then one of his friends comes out and tells me that he has a lot of groceries he can just give me so that I will not have to go to the store.  I decline but he continues to insist. I reluctantly accept free groceries and sling them over my shoulder in a large garbage bag and start to walk home.

The real path home is just 6 blocks - 4 blocks south and 2 blocks east. It is all residential. But in the dream I encounter a large modern baseball park right next to the street. The game is just completed and they are interviewing the winning pitcher. She is in her mid 20s and short and compactly built.  Her uniform and short brown hair are drenched with sweat.  Just then I notice that it is hot. The announcer asks her if the heat was a factor in the game and she says:

"The hot was so hot that when my hot fingers touched the hot ball - I could barely feel it." 

The ballpark looks real.  There are thousands of cheering fans and the announcer and the pitchers statements are amplified over the PA system.  Everything is in color.

I wake up and feel hot and flushed.

The NEJM "Addiction As Learning And Not Disease" Article

The latest installment of what appears to be an endless debate about whether addiction is a disease or not hit this weeks New England Journal of Medicine in an article entitled "Brain Change in Addiction as Learning and Not Disease." I have looked at a few of the previous articles along the same line that purport to show why addiction is not a disease and it is fairly easy to show that disease or not a disease generally depends on the author's definition and pointing out why the other definitions do not seem to fit. It is basically an exercise in rhetoric.  Those approaches invariably end up at quite a distance from opinion polls that illustrate that most of the public and even more medical professionals consider addiction and severe mental illnesses to be diseases.  I will come back to the philosophical underpinnings of those polls at the end of this article.

In this case the author is essentially making three arguments.  Two of the arguments are in side panel graphics and the third argument is in the main text.  The first side panel argument (p. 1552) concerns the Brain Disease Model and Stigma. In it the points out that the disease model can be destigmatizing but it also can be stigmatizing to some people.  Although I do not agree with some of his premises let us accept that his argument is basically a wash and the people who feel stigmatized and recoil from the prospect of the addiction illness perfectly cancel out those that accept the model are are consoled by it. I recognize that a substantial part of the recovery community base their recovery work on the disease concept of addiction although it is not strictly similar to the biomedical disease that is typically described.  This entire panel described a sociocultural model of disease (2).  This concept is basically that different societies and the physicians in that society may have diverse views of diseases that vary from other cultures.  A secondary factor is that medical recognition may change how that disease has come to be viewed by the society at large.  For example, an illness that was once thought be be caused by moral deficiency is seen differently after it is recognized as a process that may be beyond the control of the afflicted person.  Mental illness, alcoholism, and addiction are common examples.  An associated feature of this model is that this concept cannot be used by the medical field that must concentrate on understanding the biological mechanisms that underlie the disease.  That makes this panel irrelevant to a medical disease concept.

The second side panel (p 1553) looks at Learning Models and Empowerment.  It can also be understood as a sociocultural model.  In this panel the author develops a number of arguments to suggest that if people were free of thinking they had a disease they would be more prone to self examination and less dependent on professionals and the need to adhere to what professionals tell them.  He suggests that disease mechanisms would lead to pessimism on the part of the person with the problem that would not exist if they were engaged in any number of learning programs to help them recover.  He uses the familiar quote that most people recover spontaneously without any help from professionals.  This argument depends on a couple of premises that are clearly flawed.  The first is the group that is described as having an addiction.  The convention I use for that is Volkow's definition of being equivalent to severe DSM-5 substance use disorder in any category.  That category has a high level or mortality, comorbidity, and chronicity. In this case the author seems to minimize the interventions used by addiction professionals to "making life-style choices to improve their prognosis."  That minimization serves his purpose to suggest that learning is an entirely novel approach to addiction when it has been used for decades.  Spontaneous recovery is an often quoted argument against a disease model, when it happens all the time in other conditions (obesity, metabolic syndrome, diabetes mellitus Type II, hypertension).  The fact is, spontaneous recovery by any number of conscious interventions does not preclude a disease process.

The bulk of the author's argument in the main text is based on illustrating how learning in addiction and normal learning are similar if not identical processes and therefore disease is a learning problem rather than a disease.  The most logical way to analyze this argument is to examine the conclusions first.  Looking at the conclusion highlights the seriously flawed premises in the author's argument that addiction is not a disease but is just learning.  I did not see any qualifiers that addiction is a special case of learning or not.

The author's believes that he has developed a "balanced model of addiction" that incorporates various learning mechanisms into what he calls and "embodied cognition model" of addiction.  In this model he sees baseline and adaptive biology interacting with the environment to produce the addiction.  It is interesting that the key environmental feature of drug use disorders - exposure to the drug is way down his list of other social, cultural and familial factors.  Some of his examples illustrate this point.

He discusses the socially disadvantaged youth raised in an adverse environment: "These persons tend to find increased meaning in drugs that reduce stress or promote feelings of security and well being especially because these effects can be attained without medication by other people." That does not explain the flood of advantaged white middle class youths who became addicted to heroin and represent a substantial number of overdose deaths.  It also does not explain the difference between two inner city youths who have to walk past 3 drug dealers on their way to school each day and one of them becomes addicted and the other does not.  One of the important lessons of the current  opioid epidemic should be that exposure to a highly addicting drug in biologically predisposed people is one of the central mechanisms of addiction.     

The authors "addiction spiral" is also problematic.  It begins with "early adversity and trauma" as the first step effectively limiting any explanatory power to that population. In step 2, he discusses development changes in the autonomic nervous system that may occur in response to childhood trauma that can lead to hypercortisolemia as an adult. That makes this model appropriate only for adults who have been traumatized as children and even then - only those children with this pathophysiology.  There can be a broad range of factors that lead to behavioral inhibition and anxious temperament (3). In step 3, he discusses early childhood adversity as a cause of epigenetic changes that can predispose to addiction.  He omits the concept that exposure to compounds like nicotine and other addictive substances are much more potent causes of an array of epigenetic changes and correlate highly with addiction. Kandel and Kandel (4) among others have shown that DNA hyperacetylation from nicotine is associated with cocaine use.  Epigenetic changes from drugs of abuse are widespread .  A recent study of the impact of smoking on the human genome concluded that as many as one third of genes in the human genome can be affected (5) by methylation of 18,760 statistically significant cytosine-phosphate-guanine sites. In order to claim a more potent learning effect at least an equivalent neurobiology of learning with equivalent impact that it applies across the entire population of people with addictions should be presented.  I don't think this paper reaches that threshold.   

That brings me to the point of whether it is relevant to use the disease concept at all.  I am sure that students have heard me say from time to time that it is not. That statement is usually accompanied by the statement that it still has to be recognized as a severe problem that is a significant cause of mortality and morbidity.  There is a little used philosophical approach to the disease concept that I have rarely heard about outside of reference 2.  That concept is disease as a departure from normal functioning (p 160).  In this discussion the authors develop the concept that organisms are a special case of programmed systems.  Normal homeostasis in humans is a result of that programming.  Biomedical research is focused on being able to discover that program and how it is coded, uncoded, and expressed as disease.  One of the authors' conclusions is:

"There is reason to believe that as research progresses, more and more biological processes at all levels of organization will come to be understood as programmed processes."

They refer to closed programming that are those resulting from direct decoding of the genome with inborn errors of metabolism being a key example.  Other phenomenon require an interaction with the environment to result in the full development of the programmed process.  They go on to suggest the existence of "open" programming where some form of learning or conditioning is required to complete the process.  Some of the programs may be "closed" at a certain point and not amenable to further decoding.  All of these programs are shaped by the evolutionary process.  Viewing organisms as biologically programmed systems (p 163) takes social values and norms out of the equation and provides a definition of normal functioning and it also defines the acceptable evidence necessary to delineate abnormal functioning.  The authors' straightforward definition of disease is given below:

"Disease is a failure of normal functioning."

Consider the following vignettes to illustrate that definition. None of the subjects noted had any adverse childhood experiences or pre-existing psychiatric disorders.  They all had positive family histories of addiction.

Patient 1: 22 year old woman who received hydrocodone after her wisdom teeth were removed at age 20.  She received a 14 day prescription and continued to take it even when her pain was gone.  At this point she started to acquire opioids from nonmedical sources and eventually switched to heroin for economic reasons and was injecting herself 4-6 times per day.  She went to treatment and was placed on buprenorphine-naloxone 16 mg/day.  On that dose she had no cravings for opioids and no withdrawal symptoms.  Her family has decided to withdrawal support based on considerable expenditures for various therapies that have been ineffective. She goes to a sober house but after a week there learns that there are fentanyl based products available.  She leaves the sober house in search of these products.

Patient 2:  45 year old man who is an IT professional.  His father and grandfather were alcoholics.  His grandfather died of cirrhosis. He decided at an early age that he needed to avoid alcohol in order to avoid alcoholism and did well with that strategy until about age 40.  At that point professional pressures to socialize with clients lead to some drinking that he escalated at home.  He can work from home and his drinking escalated significantly to the point he was drinking a liter a day of vodka that he consumed between 7PM and midnight.  This pattern continued for several years until he started to get episodes of alcoholic pancreatitis that required longer and more complex hospitalizations. He tried to stop drinking on his own.  He tried online courses that used cognitive behavioral therapy.  He went to Rational Recovery and eventually AA. Nothing worked and he knew that every episode of pancreatitis at this point was life threatening.       

Patient 3: 30 year old carpenter with no previous history of substance use. He was working in a new construction area and found one of his coworkers inhaling paint out of a plastic bag.  He tried it and experienced an intense episode of euphoria.  That night he went home and found Internet sites where solvent-inhalant users compare their experiences and give tips on usage. He picked up a popular computer duster product and was soon inhaling many cans a day. He eventually crashed his truck while inhaling the solvents and as the police pulled him out of the vehicle - he was still inhaling the solvent. When he was seen in the emergency department he told the physician there that he could not stop using inhalants because: "It felt like pure dopamine was coursing through my veins!"

The previous examples are not extreme cases in addiction medicine and addiction psychiatry. They illustrate a failure of normal functioning by compulsive use of a substance despite knowing that this use is irrational and repeated failures to stop.  One of the common comments about the majority of people with addiction stopping on their own totally ignores the people being seen in addiction settings.  It is this combination of severity, inability to stop despite severe consequences, and chronicity that leads physicians and lay persons alike to consider addiction as a disease.

What about the evidence of failure?  It can come in various forms.  In a standard medical format there is a signature clinical course or phenomenology of the illness.  Symptoms can be obvious in a physical or mental status exam. Laboratory testing including chemical and microbiological analyses, electrophysiological studies, imaging studies of various regions and tissues can be undertaken.  In all of these determinations the evidence can always be equivocal, false positive, false negative, or truly positive.  It often takes a level of expertise to interpret the evidence and a good example is electrocardiography.   

From a philosophical standpoint the authors in reference 2 point out the initial value of a functional-failure model of disease.  It has obvious implications for basic science research of disease mechanisms.  That research should be focused on discovering the programming errors in the human organism that results in failure of normal functioning with the hope of understanding the underlying pathophysiology and correcting it.  The model clarifies a role for statistics in the disease model specifically the strength of association of certain variables with normal and abnormal functioning as well as ways to analyze tests for those variables.  And finally, the concept makes it very clear that the disease in question is real and exists independently of societal biases.  I don't think for example that any of the above vignettes could be considered anything less than a failure of normal functioning. In the people addiction specialists treat, there is generally a trajectory of progressive isolation, multiple psychosocial losses, loss of relationships, poverty associated with addiction, and in too many cases - premature death due to the direct or indirect results of addiction.

That is the reality and it is captured by disease as a loss of normal functioning.

I am going to bring this post to a close at this point, but look for a more extensive look at the specific types of learning listed in this article compared with the biological impact on plasticity when people are exposed to addictive drugs.  I started out thinking that I was just going to continue my opinion about the disease concept being irrelevant but instead find that I have been invigorated by a view from a book I read over 20 years ago that is still relevant today.  I will end with a communication I received from one of the authors that I hope sums up this post and illustrates why physicians should probably not cloud the disease concept with popular notions like stigma or  empowerment:

"Most people would think epistemology is always irrelevant to ordinary life, but clearly it isn’t."


George Dawson, MD, DFAPA



References:


1: Lewis M. Brain Change in Addiction as Learning, Not Disease. N Engl J Med.2018 Oct 18;379(16):1551-1560. doi: 10.1056/NEJMra1602872. PubMed PMID: 30332573

2:  Albert DA, Munson R, Resnik MD.  Reasoning in Medicine: An Introduction to Clinical Inference.  Baltimore, Maryland: The Johns Hopkins University Press, 1988: 150-180.

3: Fox AS, Kalin NH. A translational neuroscience approach to understanding the development of social anxiety disorder and its pathophysiology. Am J Psychiatry. 2014 Nov 1;171(11):1162-73. doi: 10.1176/appi.ajp.2014.14040449. Review. PubMed PMID: 25157566.

4:  Kandel ER, Kandel DB. A Molecular Basis for Nicotine as a Gateway Drug. The New England journal of medicine. 2014;371(10):932-943. doi:10.1056/NEJMsa1405092.

5: Vaillancourt K, Ernst C, Mash D, Turecki G. DNA Methylation Dynamics and Cocaine in the Brain: Progress and Prospects. Genes (Basel). 2017 May 12;8(5). pii: E138. doi: 10.3390/genes8050138. Review. PubMed PMID: 28498318.

5:  Joehanes R, Just AC, Marioni RE, et al. Epigenetic Signatures of Cigarette Smoking. 2016. Circulation: Cardiovascular Genetics. 2016;9: 436–447. Full text

Supplementary 1:

My thanks to both Ron Munson and Mike Resnik two of the authors of Reasoning in Medicine - reference 2 above.  Further thanks for Ron Munson for the quote at the end of this post and encouragement to explore his ideas about the disease concept.  It means a lot to hear from both of these authors at a point when they could have easily ignored me.  It is a sign that there are many kind and thoughtful scholars out there. 

As I type this at 2AM that thought about scholars gives me a warm feeling.


Supplementary 2:

The quote used for patient 3 is found on the Internet and used for this hypothetical patient.  I have feedback from at least one addiction psychiatrist that the vignettes provided above are realistic and typical of addiction psychiatry practice.


Supplementary 3:

I added this on 12/22/2018 when I encountered an excellent example of Wittgenstein's work in Existential Comics.  In this case consider the parallel argument about disease or non-disease based on the hot dog versus sandwich argument.  What do you think Wittgenstein would say?

Existential Comics: Is a Hotdog a Sandwich? A Definitive Study.  December 2018.

What Do Surgeons and Psychiatrists Have In Common? - Dread

I have had two surgeries this summer that have really impacted my work and daily life.  I only consent to surgery if it is a problem severe enough that I can't function or will kill me and the first one was for that.  I found a highly skilled surgeon who had done more of the procedures than occur in most countries in the world.  The procedure itself seemed to go surprisingly well. He gave me a prescription for oxycodone but the only treatment I needed for post op pain was acetaminophen.

I went in to see him a month later and everything was still going very well. No surgical complications and the target symptoms were in good remission. I did well for another 2 weeks and then got symptomatic again.  I was reexamined and the original surgery had scarred over requiring a second surgery to remove the scar tissue. He explained that is was very rare in his practice for that to happen, but that he did need to fix is as soon as possible.  The second surgery as done and I was functioning as good as new again.  He advised me to come back in 6 months for follow up.

There were post operative complications.  Despite antibiotic prophylaxis given during surgery I developed an infection with a fever and tachycardia.  He prescribed antibiotics but it got worse. I eventually went into the emergency department at midnight and was given intravenous Rocephin and told to continue the oral antibiotics until they were gone.  The infection cleared up in about 5 days.

I did very well and then at the 6 week mark again, I got progressively symptomatic and called the surgeon again:

Me:  "The symptoms are back, at about the same time frame and course of onset as they were in the past. Do I need surgery again?"

Surgeon: "Well probably.  It is highly unusual that it happened the first time and even more unusual if this has happened again.  I will just schedule the OR so we can take care of it early next week.  Can you do it then."

Me: "Well yes - I will do whatever I need to do to take care of this problem. I can't really go on like this."

Surgeon:  "I was just talking with my partner here and we need to alter the procedure to really remove more tissue when we take out the scar tissue this time. We really need to open that area up"

He sounded a little shaken. He is a top surgeon in his field and this is not just one complication but a second complication of the same initial surgery.  He was consulting his colleague and in this group all of the surgeons are very experienced and highly regarded. I wondered if he was concerned about what I was thinking?  He was safe there - even though it is practically an American standard to blame surgeons for sub-optimal outcomes that was never going to happen. I have seen surgeons with less skill than others and I picked him because of his record. There was no way that I was not going to let him do his job or suggest that I was in any way dissatisfied with his work.

I started to think about all of my years in acute care and how common it was to walk in the door in the morning and get blamed for everything by people who I have never seen before.  People who were there because they were in an alcohol or drug induced state and ended up under my care because there were unsafe and needed to be detoxified and in some cases treated for the psychiatric complications of substance use. People who were admitted for severe psychiatric disorders and associated aggressive or suicidal behavior.  Once they learned I was their psychiatrist - it was my fault that they were there - even though it was my job to get them out of there as soon as possible. My failure to do that resulted in a second tier of blame.  This time by hospital administrators who were often quite aggressive in encouraging me to get patients out of the hospital whether I though they were stable or not.  Shortly before I left the job, one of them actually told me that if I did not get the patient out - he would come down and discharge the patient himself.

I smiled to myself at that point and realized it was a very good thing that I was not blaming my surgeon for anything.

And then I thought about being in the same situation. Most people who have not practiced in acute care have not seen some of the problems that have no solutions.  Aggressive behavior that does not respond to medications.  Catatonic behavior that rapidly leads to life threatening dehydration or starvation.  Bipolar patients on dialysis who are delirious for months waiting for kidney transplants.  Patients with multiple medical complications who are agitated and can't sleep.  On some days an endless list of problems that would keep me up all night long trying to figure out solutions.  I would call and email one of three colleagues who I knew I could count on. They had been working acute care as long as me and I always appreciate their input. We only consulted one another in situations where we had no obvious solutions and we also had a sense of dread. Dread in the sense that you start to ask yourself: "Is there really no solution here? What am I missing? Have I lost it? Do I need to take a break and work somewhere else for awhile?"

There were a lot of nights where I would just lay in bed, thinking about the situation - sensing the blood pulsate throughout my body and feeling a light sweat on my skin. I would get out of bed in the morning amped up on adrenaline and feeling like I had slept for 8 hours when it was probably closer to 1 or 2.

Luckily in my case, there was resolution.  It could happen after a couple of sleepless nights. On many of those nights I would have contact with the nursing staff to see if any modifications could be done while I was away.  I would finally get a break and things would be all right for 2-4 weeks before another crisis hit. It would usually be a surprise. I walk into the unit in the morning and hear "Mr/Mrs Smith is up out of bed eating this morning.  They made a big turnaround last night."

Hoping for that break is the only thing that kept me going. You can only tell yourself that you have done everything right for so long. I never got to the point where I expected that break. It always struck me as very lonely and bleak. My senses seem dulled and everything slowed down around that problem. When the break happened - life was finally good again.

I was able to step back from these associations and realize that my surgeon was likely experiencing some of the dread I typically encountered in acute care.  Despite extended and best efforts - things are not going well and you don't really know why. There are no easy or apparent solutions.

Surgeon: "I should probably see you tomorrow before the surgery. I am sorry this happened. Can you be there are 7:30?"

Me: "Thanks. Yeah I can be there at 7:30.  See you then."

I was very calm and I slept well that night.


George Dawson, MD, DFAPA





Image Credit:

1.  Above image as my second preop identification and allergy band.

2.  Image for Twitter post was from Shutterstock per their standard agreement by Francey Scary Foggy Road downloaded on 10/14/2018.