Percy Menzies, M.Pharm.
published at jointogether.org (March 2003)
Addictive disorders are beset by two persistent issues: stigma and poor treatment outcomes. Could the two be related?
Stigma against addictive disorders has persisted for time immemorial. Descriptions of the disease, from “alcoholic” to “drug abusers,” tell it all. The reasons for stigma are numerous, but it is pervasive, affecting every segment of society. Stigma keeps patients from seeking treatment. On moral grounds, society shows no sympathy for the victims. Funding for treatment is chronically scarce.
Punishment is the order of the day for the victims of this disorder. Name changes from “alcoholics” and “addicts” to less loaded words like “alcohol use disorder” or “chemical dependency'” have not helped. Sadly, the stigma appears to be unshakable and society is not ready to change.
Indeed, society’s response is likely to make the problem worse. Responding to the pendulum swinging towards punishment, lawmakers rushed to build more jails and prison, believing that incarceration will solve the drug and alcohol problem.
It is estimated that 40% – 60% of the more than 2 million citizens currently incarcerated had a drug or alcohol problem at the time of arrest. Yet offenders receive little or no treatment for their addictive disorder in prison. Over 600,000 inmates will be released per year from jails and prisons, and most of them are ill prepared to reenter society. Many will go back to prison because of drug or alcohol use. There seems to be no end in sight.
In response to this daunting problem, rather extreme solutions are being offered. Groups backed by wealthy individuals are advocating the legalization of drugs like marijuana, promoting needle exchange programs and suggesting we allow market forces to reduce the lure of illegal drugs. The highly contentious ballot issues on drug legalization will only grow more acrimonious in the coming elections.
The treatment community, on the other hand, has operated on the slogan “treatment works,” and statistics are cited about the return on investment dollars spent on treatment. Yet treatment outcomes have not changed significantly, nor have the treatment approaches. The significant advances in the understanding of the neurobiology of addictions and the newer medications developed remain grossly underutilized.
The treatment community seems to operate on an internal belief that “real counselors do not use medications.” This problem was articulated several years ago by Dr. Alan Leshner in the article Addiction is a Brain Disease, and It Matters (Science. Vol 278. 3 October 1997).
The rejection of medications for relapse prevention has left patients in a permanent cycle of detoxification and relapse: there is no controversy in using medications for detoxification, but when it comes to the critical phase of relapse prevention, medications — however safe and effective — are rejected.
There is a chasm between the medical and treatment community, and the victims are the patients. There are just five drugs available for relapse prevention for alcohol and drug use disorders, and they are not used much. Few people can name all five drugs.
History has shown that the stigma for a disease can only be removed through prevention, treatment or control. Depression once carried quite a stigma. When Senator Tom Eagleton revealed that he was treated for depression, the furor forced him to quit as the vice-presidential candidate. When Governor Lawton Chiles of Florida revealed that he was taking medications for depression, the stigma was gone and it was a non-issue. Housewives to CEOs talk openly about their battle with depression with not a hint of stigma. We are nowhere close to that stage. Anonymous treatment for alcoholism is still the norm.
The future belongs to the newer medications that are radically different than the medications of the past. Medications like naltrexone, acamprosate, ondansetron, nalmefene and selegiline look promising in the treatment of a variety of addictive disorders. Some are already approved, and the others will follow in the next few years. These medications are going to require competencies and skills that do not presently exist.
Integrating these medications with behavioral therapies will significantly improve treatment outcomes. The benefits of integrated therapy are many: medications maximize the effectiveness of counseling; patients and therapists see tangible improvements; more options mean more patients seeking treatments; improved outcomes mean more funds for treatment.
How do we begin? The first step will be for the treatment community to set aside the rejection of — and at times, hostility toward — medications that often stems from personal recovery and experience. Concerted efforts should be made to learn and use evidence-based maintenance medications. As an immediate result, the chasm with the medical community will be bridged.
The fear that medications will lead to loss of control is unfounded. Unlike depression, addictive disorders have a huge behavioral component that can only be addressed through cognitive therapy. Medications, especially non-psychoactive ones, make the role of the counselor even more critical throughout the treatment phase.
The battle against addictive disorders is not going be to be won single-handedly. The concept of disease management makes it imperative to create virtual clinics and enroll the help of physicians, pharmacists, public health nurses with the counselors in a leadership role. This is the future of the brain disease called Addiction. And it matters.