Friday, 24.03.2017

Comment (Peter R. Martin)

Paul Devenyi succinctly explains why he believes that “addictions are not treatable diseases”, simultaneously calling into question whether addictive disorders are in the medical domain and also whether they are treatable disorders.  He claims that addictions are instead “the results of foolish human behavior, nourished by individual or social-cultural facilitating circumstances” that only as a result of their complications “may reach disease proportions”. Of course, many illnesses physicians face in developed countries can be conceptualized in much the same way as Devenyi understands addictions.  Most chronic diseases, the major challenge or modern medicine, require thoughtful management over a lifetime of exacerbations and remissions. “Cures” as can be obtained with antibiotic treatment of acute infections or surgical removal of pathologic tissue are simply not the goal for chronic diseases.  A classic example of another disorder that closely resembles Devenyi’s description of addiction is over-eating. While over-eating can progress to type 2 diabetes mellitus and diverse end-organ damage eventually, what then is the primary problem, the over-eating that causes obesity or the resulting insulin resistance? According to Devenyi, insulin resistance and its complications are the disease and over-eating is beyond the scope of medicine. Fortunately, this viewpoint is starting to change in modern medicine.

Devenyi clearly enumerates in his essay five supporting points upon which his contentions are based and I will address each in turn:

First, “Addictions are not diseases but disorders of choice.”  This simply implies that “choice” is a black box, the interior of which is a mystery and hence immutable.  In fact, loss of control of choice, not the complications of repeated alcohol/drug use, is the primary symptom of addiction.  Many addicts seeking help are incapable of stopping their self-destructive behaviors and are highly sensitive to relapse-triggers within the environment.  In fact, the neurobiological underpinnings of the choices people make are currently the focus of active investigation.  Elucidation of the neural pathways that mediate reward and decision making, as well as the molecular biology of learning and memory haveled to better appreciation of the pathophysiology of addiction and should result in therapeutic advances. Hence, the out-of-control behaviors that are self-destructive (addiction) may be modified throughout a patient’s life using pharmacological as well as social and behavioral strategies.In fact, most of psychiatry deals with emotions, sensory phenomena, cognitions, and other aspects of behavior that are not characterized by laboratory abnormalities, are not readily observed via radiologic studies, nor easily examined under the microscope. Neither can most psychiatric disorders be removed like an inflamed appendix. They, nevertheless, can be reliably diagnosed and managedby appropriate (non-curative) clinical interventions, a characteristic they share with a plethora of chronic medical diseases.

Second, “Some addictions become diseases by virtue of their complications.”  In fact, the more we understand brain reward mechanisms, the more apparent it has become that these neural pathways are highly sensitive to repetitive out-of-control drug use. Thus, in addition to the clinically apparent complications of various organ systems resulting from drug use, to which Devenyi refers, the reward pathways that actually initiate and perpetuate drug use are allostatically modified during the life-course of addiction and thus may profoundly influence the “choices” the addicted individual ultimately makes.  Moreover, much current research deals with personality and cognitive styles that predispose young people to impaired decision-making and subsequent drug use disorders prior to their first use of alcohol/drugs and such premorbid characteristics might rightfully be viewed as predisposition to, rather than consequences of addiction.  Research findings are also accumulating concerning genetic factors that contribute to development of addiction, as well as environmental factors such as exposure to drugs in utero or early life events that occur prior to emergence of addictions. Choice is not a “black box”, but rather a difficult to unravel phenomenonwith its own neurobiological underpinnings that should not be discounted. Some choices may ultimately lead to overt pathologies, but such choices can, nevertheless, be considered as pathologic even before the consequences are visible in tissue damage.  Much as in cancer, early identification may lead to better outcomes using appropriate interventions.  It is just the fact that wrapping one’s mind around choice is so very difficult that makes some believe that the complications of addictions are the only part of this process that merit the term “disease.”

Third, “There has been no progress in ‘treatment’ in the last 50 years.” There have certainly been no addiction “cures” in the past 50 years, and frankly, I doubt whether there will ever be. In fact, the greatest advance in addiction treatment has been to stop viewing the addiction treatment process in inappropriate surgical or infectious disease terms, but rather as a chronic disease such as hypertension, diabetes, etc.  If treatment of hypertension or diabetes is successfully managed with lifestyle changes and medications administered throughout the patient’s lifetime, it reduces the probability of complications. Ultimately, management of addiction is also minimizing the emergence of the complications which Devenyi views as the only “real disease” component of addictions. There are, however, significant advances in cognitive behavioral and motivational approaches, as well as pharmacological strategies derived from our understanding of neurobiology, that alter the natural course of addiction.  In fact, approaches to addiction treatment have served to shed light on a significant component of all medical diseases, namely health behaviors, so-called choices the patient alone can make, that are beyond the control of the physician, but  nonetheless can enhance response to treatments offered by the medical profession. Consider recovery post-myocardial infarction (not to mention prevention of heart disease per se) or control of blood glucose in diabetes (if not prevention of the type 2 diabetes in the first place), among many other examples.

Fourth, “There is spontaneous recovery in a minority of addicts, but that is independent of the intensity of "treatment".”  A wise pediatrician told me while I was in medical training that most acute otitis media resolves without antimicrobial treatment; this does not negate the value of antibiotics, nor indicate that antibiotics might not help some cases of otitis media.  Addiction likewise can resolve without treatment.  That says little about the value of the treatment, but rather suggests that not all individuals who are diagnosed as having addiction are identical.  Nor would we expect them to be the same, as we really do not fully understand the etiopathogenesis of any psychiatric disorder, not just drug use disorders.

Finally, “To solve the problem of addictions is not a matter of individual therapy, but social engineering, such as law enforcement and education.” These environmental interventions can certainly influence the prevalence of alcohol/drug use disorders, but if an alcoholic is placed on an island where there is no alcohol, will he/she be cured, or will other behaviors emerge that replace the alcohol?”  I ask this question to be thought provoking rather than because I know the answer.  However, the more we investigate drug use disorders, the more we recognize that the problem(s) do(es) not only lie in the availability of the agent of abuse, but rather in individual differences in experiencing the world and coping with its challenges, and many of these pathological differences pre-date actual initiation of alcohol/drug use.  Many of the psychoactive substances that people use in an out-of-control manner do not cause, but rather, they contribute to the suffering experienced by the addicted individual.  Fortunately, in the last half century significant improvements have occurred in how we view and approach our patients afflicted with these disorders without deluding ourselves that we can cure their disease (Martin, Weinberg and. Bealer 2007).

Reference

Martin PR, Weinberg BA, Bealer BK. Healing Addiction. An Integrated Pharmacopsychosocial Approach to Treatment. Hoboken (New Jersey): John Wiley & Sons; 2007.

Peter R. Martin
September 12, 2013