Despite that fact that substance abuse has been defined as a chronic, relapsing disease, we don’t treat it the same as we do other conditions such as diabetes or obesity. And yet the parallels are clear: Imagine for a moment that you are obese. You’ve struggled with it for years, your family and friends give you a hard time about it, your doctor warns you about it. It’s not clear why this is a problem for you— is it genetics? Behavior? Underlying depression? Why is it that other people can eat as much as they want without gaining weight? Physically speaking, you shouldn’t be overweight and yet you are, despite your best efforts otherwise. It’s costing you your health, your happiness, and taking years off your life. Well consider this: how is drug abuse any different? Food addiction is real, just as alcohol addiction and opiate addiction are real.
One of the main differences is that while substance abuse can often be hidden or minimized, it is impossible to hide obesity— it is right there in the open, for all to see. This leads to more judgments and psychological harm, of course; but it also leads to increased visibility in terms of effective, long-term treatments. Imagine if we treated obesity the same way we treat addiction— saying to an overweight person: “Why don’t you go to ‘fat camp’? We’ll send you there for a few weeks and you’ll be fixed. You’ll learn everything you need to know about how to lose weight, eat healthier, exercise and adopt a healthier lifestyle. Then you’ll come home and, bam, you’ll be good.”
People who lose weight and keep it off have adopted a healthier lifestyle. They gradually made better choices and slowly lost the weight. They ate a little better, maybe exercised a little more but it added up. Months later their weight is down. We don’t take obese people who are addicted to food and admit them into 28 day rehab program and expect them to be fixed. We don’t expect them to come out thin. Why do we continue to do this with substance use disorders? We have good evidence that patients with substance abuse disorders show no long-term benefit from completing a residential program compared to an outpatient program. In fact, relapse rates with opiates and alcohol approach 90% within months of leaving such a program.
A chronic disease like obesity can be managed with counseling, education, exercise, accountability, check in’s, peer support, and sometimes medications. I believe drug addiction is no different. The patients who I see doing well are those who have embraced those tools; accountability, education, peer support, drug testing, and have invested in learning the tools of relapse prevention. By no means is this a science-based statement, but of all the patients in the last 6 years who I have treated in the clinic compared to the ones who went to a residential program, the patients who completed an outpatient program and continue to participate in some programming do better by far.
In the same way we don’t think that obese patients can come out of a 28 days residential program and be cured, let’s not think it works for addiction patients. Patients with eating disorders or substance abuse disorders have a lot in common. Patients with serious substance abuse disorders need ongoing treatment. For some, it may begin with a residential program, but for their treatment to continue to be successful it requires ongoing maintenance and accountability.
And with all that said… this doesn’t even get into the moral and legal ramifications of treating substance abuse differently from other chronic medical conditions! Stay tuned as we address this in the next post.
- Finney JW. The effectiveness of inpatient and outpatient treatment for alcohol abuse: the need to focus on mediators and moderators of setting effects. Dec 1996. Addiction. Vol 91, issue 12. Pages 1773-1796.