What do We Mean When We Say Treatment?

Every summer my church offers a lecture series. Until this year, I had never offered to be a speaker.  Then came the endless headlines about the opioid epidemic and I realized it was a timely subject and I could share some of what I have learned. So I volunteered to give a talk on addiction. That was back in March.  Summer seemed a long way aways so I immediately put it on the back burner.  Time went by and every once in a while I would tell myself I needed to start thinking about my talk.  When I finally had to get serious, I felt a bit overwhelmed.  I knew I needed to narrow my focus.  I found myself vacillating from one topic to the next.  Should I talk about the biology, the legal consequences, the drugs themselves, the different types of treatment, etc.?  There seemed no end.  I wandered around in circles.  Finally I sat down and thought about what it is that interests me most when I think about addiction.  Two things came to mind. The first is the broad and somewhat blurry definition of treatment itself and the general absence of studies that consistently measure outcomes.  And the second topic that interests me is how addicts are treated when they are in treatment or in need of treatment or in recovery. Today I’m going to about the first topic.

Several years ago I read the Pulitzer Prize winning book, The Emperor of All Maladies, by the oncologist Siddhartha Mukherjee.  It was a book about the history of cancer and cancer treatment.  As I read it, I realized that all the cancer patients I had taken care of in the 1970s and 80s were receiving care based on what was known or theorized at the time. Makes sense. But the truth is, that what was ‘known’ was mostly wrong. There was no knowledge of the influence of genetics or immunology, or anything else that we now know relates to cancer. Lesson; just because a ‘treatment’ is established or consistently used, it doesn’t mean that it is valid or useful. We can be consistently and persistently wrong and we often are.  Remember that there was a time when  cocaine was used to treat morphine addiction and morphine was used to treat alcoholism.   Wrong, wrong and wrong again.

Unfortunately, care providers get attached to the treatments they know and often insist that these treatments work despite empirical data indicating otherwise. Professional care providers can actually ostracize anyone who dares to bring up an alternative or contradicting theory regarding the cause or the cure of a disease. We want to believe in the treatments we offer and we don’t appreciate outsiders telling us that our current treatment is useless or, even worse, actually harmful. Change is not only painstaking but it can be met with serious resistance and even hostility.

In my talk, I began, as I often do, by looking at the history of drug abuse and was surprised at what I found. Alcoholism was first identified as a disease in the 1700s.  Yes!  Dr. Benjamin Rush, a physician and one of our founding fathers, wrote that chronic drunkenness was a disease that should be treated by physicians. I’m certain he would have felt the same about drug addiction. The questions is, how would a physician have treated alcoholism or drug addiction at that time?  It is surprising to learn about some of the insights they had back then; insights that we assume are very modern.  In 1750 Native American Tribes created Sobriety Circles (take that AA).  In 1891, the Keeley League announced, “The law must recognize a leading fact: medical not penal treatment reforms the drunkard.”

It’s also interesting to note the conflicting behaviors and attitudes of society towards the use of addictive substances and towards persons who become addicted.  A network of asylums and sober homes were established to ‘treat’ people with addiction but at the same time, drug companies were selling and boldly advertising morphine laced potions to middle and upper middle class women for whatever might ail them. At the turn of the century, the American Medical Association approved heroin for general use rather than morphine because morphine was addictive.  It’s really quite amazing.  Many people entered sanatoriums for whatever addictions they were suffering and generally received alternative addicting substances such as cocaine to relieve them of their withdrawal symptoms.  When the hypodermic needle was introduced it was touted as a way to avoid addiction because it was thought that injected morphine would not be addictive. Who knows where that idea came from.

So what have I learned?  First and foremost that a lot of unproven ideas have led to inappropriate and sometimes harmful treatment. If you are in the field of healthcare, as I am, you know that treatment is classified in a variety of ways.

Symptomatic treatment is a treatment or therapy that targets the symptoms of a disease but not the cause of the disease. A symptomatic treatment could be something like a medication that you take for nausea.  It helps the nausea to subside but the cause of the nausea is not addressed by the medication. Causal treatment targets the cause of the disease. For example, if the cause of congestive heart failure (CHF) was a leaky heart valve, then surgery to replace the valve would target the cause of the CHF. Of course it is essential to know what the cause is and that can be tricky.  And even if you do know the cause, it doesn’t mean that a treatment exists that will actually address the cause.  Then there is palliative treatment that focuses on relief of pain and discomfort without addressing the disease itself.

I could go on but I think this will suffice. Because what I want to ask is what kind of treatment is addiction treatment?  Are drugs that help with cravings considered symptomatic treatment or palliative treatment? If we wanted to treat their discomfort, we might consider giving them a maintenance dose of their drug. Are we attempting to discover a causal treatment? In the came of addiction, a causal treatment would likely focus on prevention; finding out who is at risk and helping them avoid experimenting with drugs or alcohol. I think many people associate treatment with a cure. Families get their loved ones into treatment because they want them to be cured.  They want them to be discharged from their Rehab program free of addiction.  They fantasize that they will all return to ‘normal.’ But, of course, that isn’t what happens.

So my question is, what do we mean when we, the families, healthcare providers, law enforcement, the media, the justice system call for more treatment?  There is a bit of hysteria right now with claims that only 10% of people with substance abuse issues will ever receive treatment.  Large sums of money are going to be flung at the states to address the opioid crisis but no where does it say how that money should be spent.  It is a set up for fraud, abuse and disappointment especially since there is little oversight for addiction treatment facilities. Add to that a frightening shortage of licensed and credentialed persons trained to provide treatment; a dearth of scientific studies to validate what does and doesn’t work; powerful drug companies chomping at the bit to capture the market for drugs that reduce cravings, sober living homes happy to bill insurance companies for services not provided and a legal system eager to court-order people into treatment.

My take?  The first thing we need to do is step back and take a deep breath. And then we need to sit down and quietly ask the question, what is treatment?

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