One of the things that we take for granted as a foundation of addiction medicine is the idea of chronic disease management. This idea is actually kind of strange when we examine it; it’s the insistence that a problem can be managed but never resolved. It shifts the entire focus of care from a single goal, an endpoint — a “cure” — to an ongoing, day-to-day process without any end in sight, and often without any clear landmarks. In chronic disease management, the journey becomes the only destination.
There are people who see “disease management” as useless, or even opposed to what medicine should be. When it contradicts deep-rooted optimism, as it does in addiction, proponents of chronic disease management can be regarded as cynics, or as realists. Profound optimism is actually one of the most valuable aspects I see in counseling and faith-based programs, but there does come a point where optimism and a set definition for “success” — which of course implies equally definite failure — can do more harm than good.
In the end, everything in medicine comes down to harm reduction. Sometimes harm can be reduced to zero, or near-zero, and then we have a cure. Sometimes, harm reductin must be constant, neverending. For instance, I see lots of patients on a monthly basis who have been doing very well for several years. They keep all their appointments, never have any complaints, take their medicine on a daily basis, have exact medication dose counts and have negative urine drug screens. Their visits are very brief, and it sometimes gets to the point that it seems silly for them to be seeing me so often. They are doing great. By all measurements, they appear to have been cured. But if I try to extend the time between their visits, even by a little bit, some of them suddenly take a turn for the worse. They begin to stretch their medications, take unneccesary risks, and sometimes end up relapsing — in other words, their disease creeps back and begins causing them harm again.
Another way to think of it has to do with balance points. For every patient, there is a point of least harm, least distress, least disease. Of course, it is different for every patient; for some patients, their “best” might not look like what others would consider healthy; others might have a great deal of difficulty finding the right combinations of therapy and timing and life situation that result in their best health. Some of them might never find it. The goal in every case, though, is for the physician and patient to work together to bring the patient to the point of highest functioning possible. In an acute disease, once the patient has reached that highest-functioning point, they will stay there until something else moves them away from it. In a chronic disease, the patient will fall away from the point of highest functioning unless there is work being done, constantly, to keep them there. That work can be in the form of medications, therapy, or anything else, but it must be ongoing. The fact that addiction falls into the “chronic management” category is self-evident to me, and I hope it is apparent to others as well. The sudden, shocking relapses that come over even the “best-behaved” patients when treatment is removed have left me completely convinced on that point.
Of course, it is impossible to predict each patient’s tolerance and reaction to treatment; some people can stand a small reduction in treatment, say a longer period between office visits, and some cannot.. At some point, for each person, there is a breaking point where the disease is no longer in control. Since we don’t know where this breaking point is for anyone, chronic disease management involves delivering treatment to a lot of people, with the intent of erring on the side of too much rather than too little treatment. The idea is to initially cast a very wide net, then narrow it gradually, by degrees, until we find the minimum treatment required to keep any one patient at the point of highest functioning. When this narrowing process is working, it can make treatment seem unnecessary — why insist on so many office vists? The patient is doing great! They should be rewarded!
This is how the relapse cycle I described above gets started. Properly managed chronic disease management is like wearing a seatbelt; its primary purpose is to prevent disasters, so when you are using it properly, disasters don’t occur. People can think that, since there are never any disasters, the seatbelt isn’t necessary, but that confusion of cause and effect usually ends up making things much worse.
It can seem almost silly to see my stable patients on a regular monthly basis when there is little obviously going on to indicate the need for these ongoing interventions. But it is important to recognize history, understand probability and understand risk reduction. Just because we are not seeing disasters doesn’t mean we shouldn’t still be working to prevent them.