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| What is Recovery? |
| Written by Howard Wetsman | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Monday, 11 August 2008 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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An essay on the subject of “What is Recovery” raises, for me, the question of what is Addiction. Since everyone of us has an idea, our own idea, of what Addiction is, we'll also have our own answer to “What is Recovery?” Since we don’t have agreement in our field on what Addiction is, I doubt that we can come up with an easy agreement on what recovery is. I could just tell you my definition of both but my goal is not for us to have a debate over which we can come to a resolution. My goal is that we all look at ourselves and how we got to this question. It may be, that after examining ourselves, we may choose to change the question we ask.
Perhaps it would be instructive to take a look at two of the definitions of Addiction that are out there and the resulting definitions of Recovery which follow. We will, of course, have some agreements and disagreements with each, and you may not agree with my interpretation of them. I don't propose the following as any kind of universal truth, just my own. The most generally accepted definition of Addiction, at least the definition accepted by most people, does not even bear that name. I refer to the DSM IV criteria for Substance Dependence. While many of us may find fault with it, there are a lot more people outside of our field than in it, and for them it remains the scientifically accepted gold standard. The first problem with DSM’s definition is that it is entirely medical. Another is that it is specific to a certain drug (except in the case of Poly-substance Dependence) and is based entirely on behavior. This leads to a peculiar definition of DSM’s version of Recovery, Sustained Full Remission. It is far from what most of us would consider Recovery, or even, for that matter, abstinence. To be in Sustained Remission we would have to have longer than the first 12 months that characterize Early Remission. To be in Full Remission, we can no longer be suffering from any of the problematic behaviors that can still be there in Partial Remission. No, in fact, in Full Remission our use can’t be causing us to meet any criteria for Substance Dependence at all. Yes, you heard that right. An Alcohol Dependent patient can be in Sustained Full Remission while continuing to drink as long as he has not met any of the criteria for Alcohol Dependence for a full year. Ah, I can hear what you’re thinking (probably because I haven’t taken my Haldol). You’re thinking, “Howard, so what? How likely is it for that alcoholic to continue to drink for a year and not have any criteria for Alcohol Dependence?” And here DSM IV-TR comes to the rescue having added two qualifiers to explain just how someone can still use and not meet criteria: “On Agonist Therapy” and “In a Controlled Environment.” I’m going to come back to them in a bit because they’re probably more common and more important than we generally realize but first I want to take on a major objection with the DSM definition of Recovery that I think most of you will share. The objection is that the definition is completely behavioral and tells us nothing about what is going on inside the recovering person. Yes, the person has stopped using, but we can’t tell why. We can’t tell if they’ve switched drugs or are just dry drunk. For a contrasting view, let’s take a look at another set of definitions, this time from AA. Alcoholics Anonymous has put out a number of “tests” one can take to see if one is likely an alcoholic but for a definitive view we need to turn to a book as authoritative for AA as DSM is for psychiatry,Alcoholics Anonymous . Of course we must note here that consistent with AA’s single purpose their definition is limited to Alcoholism, not Addiction as a whole. In regards to a strict definition of Alcoholism, AA hasn't been very definite. The closest the Big Book comes to a clear definition is given at the beginning of page 44. “If, when you honestly want to, you find you cannot quit entirely, or if when drinking, you have little control over the amount you take, you are probably an alcoholic.” However, AA was broadminded enough to include a medical opinion as well. Dr William Silkworth, while not speaking for AA, is included and writes that alcoholics have one symptom in common, “…they cannot start drinking without developing the phenomenon of craving. This phenomenon, as we have suggested, may be the manifestation of an allergy which differentiates these people, and sets them apart as a distinct entity.” So Alcoholism is an illness which manifests itself in craving after any alcohol whatsoever is taken, but what is AA’s definition of recovery? Also in the beginning of the first paragraph of page 44 of Alcoholics Anonymous we see Alcoholism referred to as “an illness which only a spiritual experience will conquer.” This begs the question of what is a “spiritual experience,” and in an appendix of the Big Book it is referred to as that “personality change sufficient to bring about recovery from alcoholism…,” the essence of which is an “awareness of a Power greater than ourselves.” So we seem to have two diametrically opposed definitions of addiction and recovery. The DSM provides us with a behavioral approach giving no mention to any inner change the patient may have, while AA gives us a version where the behavioral change is secondary and flows from the paramount inner change. But they have one very important thing in common, the focus on one substance only, and this leads us back to one of DSM IV-TR’s new modifiers. Science has discovered more about the brain than was known when either the current DSM definition or Alcoholics Anonymous was written, it has become clear that the external substance used is not as important as the common end result of all substances and behaviors used in the disease of addiction, the elevation of dopamine tone in the brain’s reward center. The DSM term “On Agonist Therapy” specifically refers to a chemical which acts to turn on the receptor where the abused drug acts. Agonist is a very specific term and many other chemicals can perform the same function while not being agonists. For instance, a medication might increase the level of dopamine by blocking an enzyme that would normally break it down or another might change the shape of the GABA receptor so that it responds more readily to the brain’s own GABA. So “On Agonist Therapy” might be more appropriately referred to as “On Replacement Therapy,” where the medication replaces in a tonic sustained way the transitory effect of the abused substance or behavior. Addiction Medicine has used Replacement Therapy for years and I don’t refer only to methadone. As an example I have long used buproprion to raise dopamine levels in the reward center to relieve the restlessness, irritability and discontentedness that some addicts feel when they aren’t using. Another example is a new medication for nicotine addiction, varenicline, which is a partial agonist at its receptor. Now that buprenorphine is available however, people seem to have noticed this phenomenon much more acutely. Perhaps this is because buprenorphine is specifically a partial agonist for its receptor while buproprion merely affects the receptor by raising the level of the brain’s own chemical. Or perhaps no one noticed that buproprion works the same way as cocaine and was essentially replacement therapy for cocaine use because it’s labeled as an anti-depressant. Of course, addicts knew about Replacement Therapy long before doctors did. Partial Replacement Therapy is a tried and true method of stopping or moderating use of a particular drug. Since the brain gets the dopamine from another source, the offending behavior is lessened or stopped. So now the secret is out. There are people in Recovery who are taking medications which affect the very receptor affected by the drug they abused, and we’re going to have to answer a few questions. One of those questions is, “What is Recovery?” I really can’t answer the question for anyone but myself and, rather than convince you of some opinion of my own, I’d like to ask you to examine your own beliefs in the light of new science and develop your own opinion. But as a physician I want to weigh in on something some of my colleagues have said, that medication assisted Recovery is somehow different than recovery itself. I think two points are apropos here. First, that medication assistance need not be directly with a cross tolerant medication to achieve the same final goal of increasing dopamine. The second is that even in the most ardent AA version of Recovery the discovery of a Higher Power does not prejudge the plan of that Higher Power or in any way obligate the Higher Power to follow any quid pro quo. That is, there’s nothing in Recovery that requires that, while saved from a hopeless state of mind and body, the sufferer must now be completely relieved of the illness itself or the need for active treatment. Finally, there are those I've heard say that anyone attempting Recovery in some kind of Replacement Therapy is not capable of finding and accepting such a Power; that is, that such a person could not be in the same kind of regular Recovery as someone not on Replacement Therapy. If you are such a person I’d like to tell you that I think that Chapter Five of the Big Book is perhaps the finest example of spiritual writing that I have ever seen. Thank God no one told Bill he wasn’t in good Recovery unless he didn’t use nicotine as Replacement Therapy. More will always be revealed, and I just treat Addiction. I’m no one to judge the quality or type of someone else’s Recovery. Even a certain level of denial is compatible with Recovery as this final quote from Bill’s 1960 address to the NACC shows. When asked to explain what he meant by “mental obsession” Bill replied, “Well, as I understand it, we are all born with a certain amount of freedom of choice. The degree of this varies from person to person, and from area to area in our lives. In the case of neurotic people, our instincts take on certain patterns and directions, sometimes so compulsive they cannot be broken by any ordinary effort of the will. The alcoholic’s compulsion to drink is like that. As a smoker, for example, I have a deeply ingrained habit – I’m almost an addict. But I do not think this habit is an actual obsession. Doubtless it could be broken by an act of my own will. If badly enough hurt, I could in all probability give up tobacco. Should smoking repeatedly land me in Bellevue Hospital, I doubt if I would make the trip many times before quitting. But with my alcoholism, well that was something else again. No amount of desire to stop, no amount of punishment, could enable me to quit. What was once a habit of drinking became an obsession of drinking – a genuine lunacy.”
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By not identifying onself as an alcoholic or addict leaves oneself open to
Being sober is absolutley a job qualification when working with
