What Does it Really Mean to Look at Addiction as a Chronic Disease?
By Kevin Doyle, EdD
It seems to me that health care too often treats substance use disorders as “acute” conditions and does not fully conceptualize them as the “chronic” conditions they are. Though well-respected professional organizations such as the American Society of Addiction Medicine (ASAM), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the National Institute on Drug Abuse (NIDA) have included the word “chronic” in their definition of addiction for years, it’s still a challenge to find care that truly embraces the chronic nature of the disease.
For example, it is not unusual to hear phrases that suggest treatment is a discrete/one-time thing such as “he completed treatment,” or “we tried treatment, and it didn’t work.” Even well-meaning terms like “alumni” and “graduates” imply that the individual has now finished treatment and is “good to go.” In reality, the recovery process for a chronic condition is ongoing and may include formal treatment options, such as counseling/therapy and mutual help groups, as well as additional episodes of more intensive treatment, such as residential, outpatient, or partial hospitalization.
Compare this, if you will, to how we think about more commonly accepted examples of chronic conditions, such as heart disease, diabetes and hypertension. Rarely, if ever, would we hear words implying that these conditions have been permanently alleviated or cured. Rather, language reflects that these conditions require lifelong management and vigilance. The same is true for substance use disorders, and our care systems should reflect that.
The disconnect likely stems from stigma, as one might suspect. We really want someone to be better, and the moralizing around “those people” with substance use disorders inherently leads us to seek out a permanent solution, or “cure” to what is really an incurable (that is, chronic) condition.
Perhaps it would be best to borrow language from another chronic condition, cancer, and refer to people in recovery from substance use disorders as “in remission.” In fact, the Diagnostic and Statistical Manual of Psychiatric Disorders (DSM) uses such language in its latest (5th) edition by conceptualizing recovery as in “early remission” (between three months and a year without symptoms) or “sustained remission” (more than a year). While these timeframes are admittedly arbitrary, and have not gained widespread application and influence, they seem more accurate than some of the other terminology noted earlier that is more consistent with an acute-condition model.
An approach which truly adheres to a chronic disease model would include things like recovery check-ups (as the noted recovery advocate and writer William White has suggested) and less judgment when substance use re-occurs or a person returns to treatment.
I am reminded of my earlier career in residential treatment settings, when “relapse” or a return to use while engaged in treatment would lead to an individual being dismissed from treatment or “kicked out.” As David Mee-Lee, noted addiction psychiatrist, has written: such occurrences are not unusual and require a revision to the treatment plan, not dismissal from treatment. Imagine if we kicked people out of treatment for a return of symptoms and behaviors related to diabetes or cancer.
Indeed, we have made good progress — but there is still a long way to go.