I’ve seen this segment from the PBS News Hour get some attention recently.
Segment Summary
The focus of the segment is the use, more specifically the lack of use, of naltrexone for alcohol problems.
It rightly points out that the scale and toll of alcohol problems dwarf most other drugs.
- Deaths attributed to heavy drinking have reached 178,000 per year.
- This is a 29% increase since 2016.
- It’s estimated that 29 million Americans have an Alcohol Use Disorder (AUD).
They noted that less than 2% of people with AUD are treated with medication.
Experts discuss barriers to wider use of medication for AUD:
- Lack of knowledge about the medications.
- Beliefs that they don’t know how to treat AUD or have the right credentials.
- That abstinence is the only way.
- That they can/should just refer to a 12 step group and leave addiction alone.
Background
Frustration with prescribing rates are longstanding with respect to Opioid Use Disorder. Medication advocates hoped that eliminating education requirements for buprenorphine would increase prescribing rates, anecdotal reports and a recently published study suggest it hasn’t had the desired impact. This suggests that the other factors are more important. Some point to factors like stigma and reimbursement. I suspect, in most cases, it has more to do with prescribers believing that they are in over their heads and don’t have the resources or networks needed to effectively treat substance use problems.
Advocates and public health officials have responded by trying to convince prescribers that they are capable, they can, and they should prescribe these medications.
They don’t seem to consider the possibility that prescribers may be right about their capacities.
Another way?
The segment actually highlights a potential middle path.
The segment highlights two patients benefitting from medication for alcohol problems.
The first patient is Cindy. She decided she wanted to drink less. No one else had noticed but she felt she drank a little too much, and had not been able to limit herself to one or two. She enrolled in a naltrexone study she heard about on the radio. Once she started the medication she immediately knew it was helpful. She only wanted to have one or two and stopped. She wasn’t “white-knuckling” it, because she wasn’t even thinking about whether to have another drink. She said a monkey on her back is gone. She still drinks occasionally without problems.
The second patient is Stephen. He was a heavy drinker for 50 years, often 40-45 drinks a day. He tried to stop and had sought help through therapy and AA, but was never successful in resolving the problem. His wife left, he describes losing everything important to him, and he aborted a suicide attempt. He eventually went to an addiction clinic that included counseling and extended-release naltrexone and found it to be helpful in resolving his problem and achieving sobriety.
Cindy and Stephen represent two very different types of problems.
Cindy appears to experience little, if any, functional impairment. While she does describe preoccupation and impaired control. Her motivation appears to be entirely internal and driven by a desire to be present in her relationships, be at her best in the morning, and a desire to feel in control. She presents with high hopes and low pain.
Stephen presents with high problem severity, complexity, and chronicity. 50 years of heavy drinking with severe consequences, severe impairment in control, multiple treatment attempts, multiple mutual aid attempts, and an aborted high-lethality suicide attempt. His treatment-seeking is associated with external motivators, pain, and crisis. He presents with high pain and low hope.
Cindy reports improved quality of life with moderate drinking,
Stephen doesn’t provide details but says he’s been sober for 4 years and is committed to ongoing sobriety.
Cindy describes receiving the medication and nothing else.
Stephen describes going to a specialty addiction program that includes medication from an addiction psychiatrist and counseling.
It’s easy to imagine Cindy doing well with a prescription from a primary care physician. It’s hard to imagine Stephen benefitting. Further, the stakes are very high for Stephen. He presents with some very real safety issues.
They both have the same diagnosis of Alcohol Use Disorder, but their problems are very different, and the single diagnostic category of Alcohol Use Disorder (AUD) for both of them obscures this. AUD/SUD does have specifiers of mild, moderate, and severe, but this implies mild cases are just in earlier stages of progression. This is not true. Most people meeting criteria for an SUD fall into the mild to moderate range, are not chronic, and will never progress into severe.
These should be thought of as different types of problems rather than different severity of the same problem. (Previously explored here and here.) I believe this conflation is a significant barrier to developing protocols and models of care that can meet the needs of patients and engage these prescribers.
The segment also brings up the matter of endpoints for FDA approval — that current guidelines don’t recognize reductions in drinking that remain above heavy drinking thresholds. (These issues are often framed as moderation vs. abstinence, but they are actually heavy drinking vs. moderation.)
This post won’t get into whether the FDA ought to recognize heavy drinking as an acceptable endpoint for drug approval, but I do have a couple of thoughts about the segment’s comments on treatment and abstinence. The segment suggested an overwhelming bias towards abstinence for alcohol and other drug problems. I think it’s important to distinguish between specialty addiction treatment settings and more generalist medical and behavioral health settings. I believe moderation is the default in most generalist settings, with education and encouragement to moderate. I don’t have empirical information, but I believe specialty addiction treatment settings do have an abstinence bias. (Though an abstinence orientation doesn’t mean zero tolerance or that there’s no room for treatment plans focused on reduced use, particularly during the assessment and engagement process.) Why might that be?
Moderation or abstinence? The right endpoint for the right patient
In these discussions it’s frequently mentioned that “spontaneous remission” or “natural recovery” are common and these pathways often involve moderation. The Sobells’ research on reduced drinking is sometimes mentioned. What’s much less frequently mentioned is that the Sobells established decades ago that resolutions of severe alcohol problems predominately required abstinence and resolution of mild/moderate alcohol problems generally involved reduced drinking.
What we need is typologies for these different kinds of problems that provide models for understanding the course, guide the assessment process, provide the right endpoints for the type of problem, and provide clear first, second, and third line treatment plans for each type.
Might we get more engagement from prescribers if there was clear guidance:
- to assess and distinguish people who can be well-served in generalist settings vs. who needs specialty care;
- on who can be expected to flourish with reduced drinking and who will only flourish with an abstinence endpoint;
- on first, second, and third line plans of care, so providers aren’t guessing and feeling like they’re doing the same thing over and over again and hoping for different results;
- on when non-medical treatments are indicated and easy access to those services; and
- on when specialty care is indicated and an easy referral process to that care.
Back to the future
As a category, AUD/SUD is about as helpful as pulmonary disease. It tells you something about the likely symptoms, but it could be acute, it could be chronic, it could be mild, it could be severe, it could be secondary, it could be primary, it could be a minor inconvenience, or it could be disabling and something that shapes the person’s identity.
It tells us nothing about the nature of the problem, the cause, the course, the severity, whether it requires treatment, the kind of treatment indicated, what problem resolution (recovery) looks like, or the implications for the patient, their loved ones, and the community.
Of course, this isn’t news and it’s not without consequence.
But, there is a way to differentiate chronic and severe problems from other types of SUDs.
One of the experts in the segment used the term addiction when it was clear they were referring to SUDs.
It would be helpful to establish a definition of addiction to distinguish it from other SUDs. In my opinion, ASAM did a great job in 2011 with the following definition:
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.
Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.
American Society of Addiction Medicine Public Policy Statement: Definition of Addiction (2011)
Conclusion
There’s a lot of talk about breaking free of one-size-fits-all solutions, rightly so. It’s just important that we break free of one-size-fits-all diagnosis. The current diagnostic framework lumps together vastly different problems under the same category, leaving providers and patients without a clear roadmap. By restricting the term ‘addiction’ to describe severe, chronic conditions and distinguishing it from other SUDs, we can pave the way for precision in treatment and provide more options. This clarity could reduce stigma, guide providers, reduce suffering and save lives—transforming the way we think about and treat substance use problems.
If we want generalist providers, like primary care physicians, to treat AUD patients like Cindy, we need to give them the protocols to identify and treat the Cindys. We also need to help them identify the Stephens who need to be referred to specialty care and make sure they’ve got accessible referral pathways.
Recovery Review 