Tuesday, 27.10.2020

Peter R. Martin: Historical Vocabulary of Addiction

Recovery

 

        According to the current electronic version of Oxford English Dictionary (OED), the noun recovery is derived from Anglo-Norman recoverie, referring to the “action of regaining as a result of a legal process or judgement, legal remedy” and Middle French recouvré “making good a loss, help,” also recovree “remedy, making good, action of regaining or recovering.”  The primary meaning of the noun recovery according to OED is: “Senses relating to gaining or regaining possession, especially of something lost or taken away (primarily immaterial things).” This is essentially a legal concept: “A fine, charge, etc., recovered at law.”  The term has been used thus since 1422 as noted (Smith and Smith 1870): “[To pay fines, etc.] recovered in the seide Maires Court, vnto the seide Maire and to such personeȝ as the seide recovrees belongeth to of right.”  Nevertheless, some of the definitions of recovery in OED are compatible with current usage in addiction psychiatry.  However, the breadth of meanings, which swings as a pendulum between medical and psychosocial/spiritual/philosophical, does suggest a lack of certainty about the term.

        The first OED definition of recovery that fits in the context of addiction is: “The restoration of a person (or more rarely, a thing) to a healthy or normal condition, or to consciousness.”  This meaning was first used in the English language in a 1517 translation by Fox of The Rule of Saint Benedict, a book of precepts originally written in 516 by Benedict of Nursia (circa, 480-550).  The following appears in the section of the book addressing the care of the sick, the old and the young: “Eatynge of fleshe, may be graunted all way, to suche as be seeke and feble, for their more spedy recouery” (Collett 2016).  Another example of this meaning of recovery is: “The greatest and most important Strokes for the Recovery of the Patient, must be made at the time of the Invasion, or first State of this Disease” (Arbuthnot 1732). In these quotes, recovery signifies useful and specific instructions to healthcare providers about how to best help an ill patient to attain wholeness of body and spirit. 

        The second definition in OED is: “The regaining or restoration of one's health or a mental state.”  This meaning indicates what an individual must do in order to regain vigor and health: “It is wyckednes, to ieste uppon holye thinges, ...euen as a man shulde sprinkle durte in a medicine, adorned for recouerie of helthe” (Vives, Morison R, Paynell et al. 1550). This use represents the challenge the sufferer faces in order to accomplish the task of self-healing, as clearly exemplified in the following: “I made the recovery of my health my chief care” (Nugent 1771). 

        The third of the compatible definitions in OED refers to the bipartite task of addiction treatment, namely the balance between self-help and having one’s illness healed by an outside agent: “Restoration or return to a higher or better (esp. spiritual) state.”  This third meaning of recovery conveys the concept that treatment of addiction often requires medical intervention to complement the self-help process, including a spiritual element (Martin 2020).  This use first dates to 1542 (Erasmus and Udall 1877): “A manne wylfully beeyng as a bonde seruaunt to pleasures of the bodye... In suche persons..there was nomaner hope of recouerie.” This quotation exemplifies the essential element of the addiction syndrome, namely out-of-control use and/or pathological behaviors, which need to be overcome as the major goal of recovery.   This theme continues to encompass the uncertainty of the recovery process and the need to accept a (higher) power beyond oneself to facilitate the process (Wilson 1939), e.g., “It shall be lawfull sometime to determine, whether he that falleth, fall desperately, or whether there be any place for recouery” (Bedford 1621).

        The fourth definition of recovery in OED that is compatible with our understanding of addiction also seems consistent with the view that a drug use disorder is, in fact, a medical disorder: “Restoration or return to health from illness, an injury, etc.; an instance of this. Also used with respect to an injury: restoration to a healthy state.” The first example of this meaning dates to 1513 when the German scholar Ulrich von Hutten (1488-1523) wrote of symptoms he experienced suffering from syphilis of which he died: “My body semed to droppe awaye in fylthy matter, to my great peyne and sorowe, and no hope at all of recouerye (Hutten and Turner 1730).”  This quotation succinctly describes the antithesis of recovery, namely, the experience of hopelessness and powerlessness when one realizes that suffering will continue and there is no possibility of return to health.  (Oftentimes, description of the opposite may be the best way to define a concept like recovery.)  The feelings described in Hutten’s quotation share characteristics of the beginnings of a new life of recovery from addiction, which can well be a terminal disease if the individual does not purposefully engage in an alternate pathway (Wilson 1939).  Another quotation sheds light on this last definition: “Recovery is generally rapid under suitable treatment” (Bristowe 1878). This quotation suggests that recovery viewed from the medical perspective may have a tendency to simplify a complex and ephemeral concept, as recovery from addiction is thought to be.  Viewing addiction as “simply” a medical illness excludes some characteristics of recovery:  “We are much more likely to be able to look beyond the mere disappearance of symptoms and signs for indication of true recovery…in those illnesses that easily become ‘latent’” (Malan, Bacal, Heath and Balfour 1968). Hence, reconciliation of a possibly simplified pathophysiological view and that of the more intricate biopsychosocial perspective (Engel 1977) is not easy because recovery is so much more than disappearance of the symptoms, signs and laboratory findings of the illness and resolution of complications.

        So, one must merge these two perspectives — disappearance of signs and symptoms versus restoration of health and fullness of life — in explaining the meaning of recovery within the context of addiction.  Adding to the difficulty of defining the elements of recovery is, in part, the challenge of specifying what addiction per se really is (Martin 2016).  Surely, addiction is not simply the medical complications that ensue with continued use but also comprises what occurred before out-of-control substance use first manifested in the vulnerable person in a biopsychosocial conceptualization.  Stated otherwise, “Is an alcoholic on a desert island without available alcohol still an alcoholic?”  Is the goal of recovery stopping use or making the person whole or both?  Is the sine quoi non of recovery the cessation of out-of-control use, or is reduction of use a meaningful alternative?  Does recovery require treatment, or can it happen spontaneously?  These are useful questions to try to answer and each provides a perspective that is part of the explanation.

        To address the first issue, much effort has been expended to identify genetic and other interacting risk factors for developing alcohol and drug use disorders (Kendler, Ohlsson, Sundquist and Sundquist 2019).  Prior to the era of massive genome wide screening studies, many of the investigated hypotheses concerning pathogenesis were derived from identification of phenotypes through clinical observation of chronic alcoholics or those with other drug use disorders.  Eventually, as understanding of pathophysiology evolved, candidate genes were identified and statistical associations between diagnosis, phenotypes, or genes could be examined.  An example of this process was carried out using electrophysiological studies in chronic alcoholics in whom auditory evoked brain potential findings were outside the normal range, presumably a complication of their alcohol use.  Similar findings in sons of alcoholics before they ever started drinking was quite unexpected and suggested that this indicator of brain dysfunction may play a role in pathogenesis of alcoholism and may be a useful phenotype for studying risk for developing alcohol use disorder (Begleiter, Porjesz, Bihari and Kissin 1984; Chen, Manz, Tang et al. 2010).  Analogously, it was well accepted that brain injury in alcoholism was in part caused by insufficient brain concentrations of the water-soluble vitamin thiamine in those who drank heavily (Mardones, Segovia and Onfray 1946; Victor, Adams and Collins 1971).  The observation that the enzyme transketolase had reduced affinity for its cofactor thiamine in young sons of alcoholics prior to any drinking was of considerable interest, suggesting a risk for development of thiamine insufficiency compared to those without this transketolase variant (Mukherjee, Svoronos, Ghazanfari et al. 1987).  Another approach to the question of risk for substance use disorders has been to determine if brain impairments attributed to chronic alcohol/drug use improve with abstinence. Longitudinal studies of individuals subsequent to stopping use of alcohol or other drugs suggest that some, but not all measures of brain impairment attributed to neurotoxicity do improve during prolonged abstinence (Volkow, Chang, Wang et al. 2001; Parks, Dawant, Riddle et al. 2002).  Interestingly, certain of the brain dysfunctions that do not recover may have subserved behavioral characteristics of these individuals prior to any drug abuse (Tarter, Hegedus, Goldstein et al. 1984).  Therefore, recovery in addiction must include adaptation to premorbid brain dysfunctions that may have played a role in why the individual started to abuse alcohol or drugs in the first place, not simply stopping out-of-control use and allowing neurotoxicity and allostatic changes to reverse. This notion does not readily concur with the definitions of recovery discussed above but is understood by those in the field — recovery requires personal growth, not simply returning to a previous state before pathological use began.  When a person develops addiction due to self-medication of a primary psychiatric disorder this point is more easily understood (Martin 2019c).  Even if the person may be able to stop using drugs/alcohol, the primary disorder per se must be addressed as it is associated with impairments that likely will not recover fully with abstinence alone.  Hence, the recovering person must learn to deal with these premorbid impairments in a more constructive manner than self-medication, likely involving a range of plastic brain changes, or learned coping mechanisms.  These may allow the person to participate in life without (or substantially diminished) drug use, overcoming impairments that might have contributed to pathological use in the first place, neurotoxic and allostatic consequences of drug use, as well as impairments due to psychosocial stressors from a variety of causes including secondary psychiatric diagnoses (Starzer, Nordentoft and Hjorthøj 2017).

        A straightforward view of substance use disorder is that the cause of the problem is out-of-control use and recovery is equated with discontinuing use and allowing the plastic brain changes just described to progress with alacrity.  Another perspective, harm reduction, has gained increasing proponents, especially as addiction is becoming accepted as a chronic medical illness (McLellan, Lewis, O’Brien and Kleber 2000) that plays a significant role in spread and progression of co-occurring disorders that are exhausting societal healthcare resources (Drummond, Edwards, Glanz et al. 1987).  The history of harm reduction in treatment of alcoholism has had a checkered past.  While behaviorists proposed that controlled drinking was a viable approach for recovery, others claimed it was irresponsible because the fundamental problem of alcoholism was loss of control and abstinence was essential (Pendery, Maltzman and West 1982; Sobell and Sobell 1984).  Advances in pharmacological treatment for alcoholism beyond the abstinence-focused medication disulfiram (Martin 2019b) have led to a renaissance of the goal to diminish drinking rather than to strive for abstinence (Falk, O’Malley, Witkiewitz et al. 2019).  Medication-assisted treatment (MAT), an approach that is quite consistent with treatment strategies employed for other chronic diseases such as hypertension, diabetes, HIV, kidney transplantation, among others, that are never “cured” but must be managed throughout a lifetime, has become the preferred response to the “opioid epidemic” in the United States (Martin 2019a).  The goal of treatment has become reduction of morbidity and mortality by enhanced compliance with physician recommendations.  Accordingly, quality of life has become an important consideration (Kelly, Greene and Bergman 2018), with recognition that relapse even after treatment is very common (Hunt, Barnett and Branch 1971).  As addiction treatment becomes integrated into the rest of medicine, harm reduction with improved quality of life becomes a compelling way to view treatment outcomes.  In fact, the addiction community recognizes this notion by designating individuals with addiction who are improving their quality of life by attaining repeated periods of sobriety as being in recovery, indicating that recovery is an active journey rather than the destination.

        The last question posed above is whether treatment is necessary to achieve recovery.  Although a significant number of people can achieve remission spontaneously, without the use of clinical treatment or recovery services, those who undergo addiction treatment combined with mutual support groups had approximately twice the chance of discontinuing alcohol/drug use compared to those who did not receive formal treatment (Dawson, Grant, Stinson and Chou 2006; Lopez-Quintero, Hasin, de los Cobos et al. 2011).  Nevertheless, it is well accepted that relapse is a common characteristic of addiction to all substances of abuse (Hunt, Barnett and Branch 1971).  Therefore, if addiction is viewed analogously to other chronic illnesses such as diabetes and hypertension, the goal becomes helping the patient approach the best feasible control of physiological parameters with regular visits to the healthcare provider and ongoing compliance with provider recommendations rather than an intensive episode of treatment without further medical oversight (McLellan, Lewis, O’Brien and Kleber 2000).  Of course, this is where the medical approach to management of chronic diseases can learn a great deal from addiction treatment in which the focus is self-help through mutual support groups and being in recovery becomes a way of living and thinking differently than heretofore.  Although relapse seems to be unavoidable for many individuals, it can be modified resulting in reduced consumption, likely beneficial to health, including less time devoted to out-of-control behaviors, accompanied by enhanced self-esteem and higher quality of life for both the addict and those he loves.  The active nature of the process is exemplified by the goal of being in recovery.  This term suggests that recovery is not an absolute or passive term but potentially an exciting and engaging journey on the road to improvement of one’s life.

 

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February 20, 2020