Addiction and the Stages of Healing, Part 4: WHAT SHOULD IMPROVE, AND WHEN?

Consider these indicators:

  • Total lung capacity?
  • Inspiratory and expiratory volume (breath)?
  • Dopamine production and function?
  • Cognition and neurocognitive impairments?
  • Abscesses and skin?
  • Return of taste and smell?
  • Gait, balance, strength?
  • Anxiety, sleep, pain, wellbeing?
  • Hope and self-efficacy.

Are patients served by addiction professionals getting better, or not? 

I have been speaking rather frequently and thoroughly with someone about this basic idea. This person works in respiratory therapy and has also completed a graduate degree in public health. While discussing these ideas with that individual, they raised the issue of smoking cigarettes and tobacco use disorder.4

Consider COPD

Of course, when such patients present in the hospital they present as a COPD patient, for example, and if so, their tobacco use disorder is treated with nicotine replacement therapy and a little bit of education and encouragement around smoking cessation.

That is the typical extent of the services pertaining to addiction treatment and long- term healing and recovery from their tobacco use disorder. But what does get loads of attention in the hospital is their lung function.

Hearing the person describe this in terms of a typical clinical course, the patient undergoes an aggressive or thorough initial assessment battery around lung function and the other indicators pertaining to their COPD. What is striking, however, is that those patients return time and again to the hospital with acute exacerbations of that COPD, while their addiction illness (the disease driving their clinical presentation) is relatively ignored or underserved when viewed from the perspective of an addiction professional. What is also interesting to hear and consider is that some of these very same patients might also have alcohol use disorder. 

When that same patient profile discussed above presents in an average addiction treatment setting, of the kind I am familiar with, we:

  • readily identify and diagnose the alcohol use disorder,
  • might identify and diagnose the tobacco use disorder, but
  • would certainly not bring in and add any of the physical measures that were being used yesterday in the hospital, with the very same person.

Further, in an average addiction treatment setting, the one typical measure we might use would be a urine toxicology screening.

I say that by way of example to illuminate this whole issue of broad, normative measures that are comprehensive, being underutilized in addiction care and ongoing support. Thus, total lung capacity as a metric is unheard of in addiction treatment settings, as are inspiratory and expiratory volume – even for a patient with co-occurring alcohol use disorder, tobacco use disorder, and resulting COPD.  Or for one merely smoking methamphetamine.

The point is that the addiction treatment patient should be getting completely well, and total healing should be in view of the clinician – rather than the problem areas, diagnoses, clinical targets and outcomes merely being defined and confined, brought on-board and taken off-board, simply according to the procedural traditions of the clinician’s workplace (e.g. addiction treatment setting vs. hospital).

Consider Parkinson’s Disease

To further illustrate this, consider that those clinicians working with Parkinson’s patients understand assessment of dopamine production and function.

Such assessment would be completely unheard of in an addiction treatment setting – even for those people that are a Parkinson’s patient and eventually present in an addiction treatment program. The lack of assessment of dopamine production and function in addiction treatment settings is potentially relevant for those people with cocaine use disorder and no movement disorder, as well as those addiction patients that arrive for care of any SUD other than cocaine use, but who also have prolonged cocaine use patterns that do not rise above a cocaine use disorder diagnostic threshold.

Consider neurocognitive impairment

Another example of the lack of use of measures in addiction services is in the general area of cognition and neurocognitive impairments.  The simple question is: “Are those providing addiction services obtaining baseline neurocognitive measures and subsequent on-going measures, over the many years of the patient’s response to care, as needed?”

Consider other improvements

If you have spent many years working in residential addiction treatment settings you will know that there are results of care, and that some of the results are very direct.  You would also know that other results seem much more indirect – but these results happen, nonetheless. And that many of these indirect results are changes for which the patient is fantastically happy. 

At such times it is not unusual to have the patient come bounding down the hall to the clinician’s office, knock on the door to come in, and say they are very happy for the improvement in the color of their skin, or the healing of an abscess at an injection site, or other similar improvements.  For example, the patient might notice a return of the sense of smell or taste, and report, “I can taste my food again!”  These are improvements that happen all the time, right in front of us, in our patients, and the patient is delighted.

  • Are these improvements documented? 
  • Are they a point of clinical attention and focus?
  • Do clinicians in addiction treatment settings notice when these improvements are lagging? Is it important to know if improvement in these indicators is lagging?

Gait and balance are similar; when these are improving the patient is delighted.

So, are people getting better or not?

I would like to point out that some of those listed measures and indicators above have question marks after them because in addiction treatment programs they are relatively unheard of, not considered, and are frankly unknown. But “Hope and self-efficacy” has no question mark after it.  Why?  The question mark is lacking because the addiction treatment clinician is likely to bring these up directly, the patient may address them indirectly or directly, and they are very likely to get some attention.

The family practice physician I mentioned previously looked at that array of indicators with the question marks after them and added “anxiety, sleep, pain, and wellbeing”.

Generally speaking, addiction treatment is flying blind.

4Coon, A.  (2017).  Personal communication.

In case you missed it, Part 3: A CLEAR IMAGE is here.


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