CURRENT PRACTICAL PROBLEMS
Hopefully it is clear by now that there are current practical problems in our field (including the context within our field); I would like to discuss those a bit.
- One major problem is that the length of the disorder is long and most care is short. Various key problems are secondary to this. There is very little in the research literature concerning empirical evaluation of substance use careers, addiction treatment careers, and recovery careers. It might sound strange, but the history of most empirical evaluation in our field is around pre/post treatment outcome studies of single episodes of acute treatment, rather than looking at substance use trajectories, addiction treatment careers, and addiction recovery – over the long term.
- Another problem is that people do not seek addiction care for the purpose of remission, and payers do not pay for recovery. This results in a double bind. What people seek care for is simply getting better, total healing and getting back to being themselves – and even better than before. Not remission. Remission is merely the diminishment of problem indicators. Meanwhile, payers do not pay for recovery. It is stated that one cannot define recovery, one cannot measure recovery, and that recovery is necessarily different for each person with no central characteristic that is universal. And that as a result, recovery has no real relevance, and simply does not matter as an outcome.
- This leads to the next problem: defining and measuring recovery is its own problem. There is a lot of controversy within our own field about who even has the authority to define recovery and to attempt to identify its indicators – to say nothing of the measures related to those indicators. Furthermore, the maintenance stages of recovery, especially after 5 years, have very little empirical evaluation.
- Clinically, related care planning suffers. How so? Typically, clinical care and support are not offered for as long as five years, and certainly not longer. How does this impact long term wellness for those we serve? How does the shortness of our typical time-frame diminish our measurement of targets? Currently, we do not know.
Controversies about care abound in our field. You are probably aware of that. In its simplest sense, evidence-based practice is not a controversial idea. But the controversy quickly shows up when you get two clinicians talking about a current case, making suggestions about what evidence-based practices should be used now. This is a problem seemingly without end. For example:
- Medication assisted treatment and opioid maintenance therapies: there is tug of war around the intent and meaning of the use of medications in addiction treatment, what constitutes best practice, and the time of on-set and off-set of these medication supports.
- Abstinence-oriented treatment is a nice juxtaposition against that first point.
- It is interesting to note that while researchers and clinical professionals get stuck in those quandaries7, nicotine addiction is largely ignored during addiction treatment.
Consequently, we should not be too critical of addiction treatment concerning treatment outcomes. Why should we not be too rough on addiction treatment for its outcomes? The general state of addiction treatment outcomes should be considered within the context that one’s addiction illness is routinely allowed to actively continue during addiction treatment. It is routine that one’s addiction disease is not actually treated in a total sense, nor is the individual moved toward being completely well (full healing). “How so?” one might ask.
- In routine addiction treatment as it is currently practiced, the smoking of cigarettes is essentially overlooked – while the provider talks with the person about their alcohol use disorder (or some other substance class).
- Thus, one is allowed to keep the addictive use of cigarettes active during addiction treatment.
- That is to say, one’s addiction disease is allowed to remain active during addiction treatment. Thus, the real goal of treatment and recovery support services is not even clear in this context.
This is the largest controversy of all: the very meaning and purpose of addiction treatment itself.
How does all of this become practical? I am glad you asked. Once care has begun, clinicians could benefit from access to a comprehensive array of indicators of healing, while aiming at the standard of full recovery five years after our clinical services are concluded.
How so? I will show you three examples.
First example: If we have someone receiving an opioid maintenance therapy medication such as buprenorphine or methadone, the patient will show improvements in known clinical psycho-social markers. But in such a case we do not know really know what brain healing should be expected, and we do not really know what brain healing should be expected when, with discontinued illicit opioid use. We also do not know what brain healing should not be expected.
One might ask what is meant by healing that is not expected. This question is raised because during opioid maintenance therapy we are still providing opioids – so we are left to wonder what we are holding down from healing due to our medication protocol. Currently, with our given state of science and limited individual patient assessment methods, we do not know. And importantly, we also do not know how the individual patient compares to the relevant normed sample on those and many other measures of healing.
Second example: By way of contrast and comparison, we are at a similar level of unawareness with abstinence-oriented approaches, as are typical in residential treatment programs. Someone might, during and following such treatment, be fully engaged in clinical care and recovery support (according to gross judgments derived from simple observation), but in actuality still lag-behind in key indicators of healing. That is, the person might seem to be attaining recovery milestones and seem to fall within normal limits on our limited existing measures – but is the person really healing? In the absence of relevant holistic metrics, we are just not sure.
People do not seek recovery for recovery’s sake. Why does the person come to get an antibiotic for a lung infection? They come for care to get back to being themselves and get back to life8. Or even better than before.9 I think the same is true with most illnesses, and it is certainly true with addiction illness.
Third example: An article10 I wrote that was published in Addiction Professional a few years ago asked something close to this: “If we have an addiction treatment graduate in sustained recovery following treatment, but dying of emphysema due to continued smoking – did we really treat their addiction disease or just an alcohol addiction?” We should pursue whole person healing and the return of related normed measures to normal limits; this as a starting point would force us to naturally encounter the pressure for the person to completely get better (total healing and well-being).
You can see represented as a picture, then, the terrain of individual and normative progress we are unable to see at all in our current systems of care, including over the decades of the person’s life. But the patient is trying to get it done over decades, as they move forward in time, over their life span.
7White, W. L. & Coon, B. F. (2003). Methadone and the Anti-Medication Bias in Addiction Treatment. Counselor. 4(5):58-63.
8Murphy, T. (2001). Personal communication.
9Budnick, C. (2018). Personal communication.
10Coon, B. (2014). An Addiction Treatment Campus Goes Tobacco-Free: Lessons Learned. Addiction Professional. January 30, 2014.
In case you missed it, Part 6: WHOLE PERSON HEALING: THE PERSON, THE SYSTEM & RESEARCH is here.
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