I work at a residential drug and alcohol rehabilitation facility. Two separate occurrences prompted me to ponder the nature of addiction and relapse.
The first took place during my psychiatry rotation as a student. One of my patients, “Matt,” was a 27-year-old man who was heroin-dependent and using intravenously. Matt loved to play the guitar and cook. He had some recurring medical problems that caused him chronic pain which had, unfortunately, led him to the illegal use of opioids. He was well-liked in the residential community and encouraging to his fellow patients. One night he developed severe flank pain and hematuria. He was transferred to a nearby emergency department for evaluation and spent the night in the hospital passing a kidney stone. I saw him the next day in a follow-up and asked him about the experience. Matt replied, “They looked at me and treated me like I was a junkie.”
The second occurrence is a question I am often asked. Now that working with those with addiction is my profession, people often ask, “Isn't it discouraging when so many of your patients relapse?” The idea that my work must discourage me seems to be common, so I want to offer a more accurate and forgiving view of addiction and relapse.
Clinicians practicing in virtually every field of medicine encounter the addicted and/or alcoholic patient. A stigma surrounds substance abuse in our society, and this stigma can negatively affect our treatment of these patients. In my view, a person fighting addiction deserves just as much compassion and respect as one who is fighting diabetes or cancer.
Addiction is a chronic disease. Matt will always have addictive tendencies, but the disease can be managed. This is similar in many ways to a disease such as type 2 diabetes, the onset of which is often preceded by poor dietary choices and inactivity. The onset of addiction is often preceded by poor coping skills and self-medication. Both conditions involve genetic predispositions as well as environmental influences. No cure is available for either illness, but much can be done to counteract them.
Let me introduce you to a second patient, “Amy.” She suffers from type 2 diabetes. When her disease was first diagnosed, Amy received education about diet and lifestyle changes. She was told that she could reverse the course of her disease by exercising and losing weight. When Matt's addiction first came to light, he received education about coping skills and lifestyle changes. He was taught that he could reverse the course of his disease through abstinence, attending Narcotics Anonymous (NA) meetings, and finding a sponsor through NA who would support him in the new life of recovery. Amy was placed on metformin, given a handout on nutrition, and scheduled for a follow-up appointment. Matt was referred to counseling, placed in outpatient substance abuse treatment as a first step, and scheduled for a follow-up appointment.
The first follow-up appointment went well for both Amy and Matt. Amy attacked her diabetes through experimentation with vegetables, she began attending a zumba class, and her hemoglobin A1C dropped a little bit as a result. Matt fought his addiction through rather painful counseling, began weight lifting as an alternative means of dealing with stress, and achieved 30 days of sobriety.
The second follow-up visit has a different flavor. Amy demoted grocery shopping on her priority list, and the drive-through at McDonald's was unfortunately quite convenient. Zumba sounded like a nice idea, but after her long day at work, the couch was more inviting. Her hemoglobin A1C has increased. Matt was not prepared for the hard work and length of counseling. The pain and anxiety were still present, so he decided that counseling was not helping and stopped attending. As the weeks went on, his motivation and energy to lift weights were lost. Matt has relapsed.
I am not saying that diabetes and addiction are completely congruent. They are not. Diabetes diminishes the physical health of our society, while addiction has multiple adverse societal effects. Substance abuse is associated with many negative behaviors, which can sometimes be tragic; however, when these actions are dissected, they are simply symptoms of the addiction. The beauty of the situation is seen in recovery.
The goal of practicing medicine is to help and heal the sick. Many medical conditions have no cure, but that does not mean clinicians cannot help patients move toward substantial healing. People who are fighting addiction should not be seen in a different light by their healthcare providers. Addiction is not a moral problem, and relapse is not a moral failure. Treating addiction is not a hopeless pursuit but rather the opposite. There is hope in the midst of relapse. This is the pattern of life; we strive for better, we fall, and then we get back up and try again.