Tuesday, July 13, 2010

Natural Recovery

Humans are self healing entities. The principal role of medicine is to facilitate the healing process inherent in the organism.

Commonly people forget about the successes especially if they are commonly dealing with the failures. There is invariably a selection bias.

I once asked the nurses in an asylum if schizophrenics were likely to spend considerable time in an asylum. Naturally they felt this to be true because working in the hospital they didn't seen that the majority of schizophrenics lived independently in the community. They were disabled but not so disabled as to require long term hospitalization.

"Spontaneous remission' is a term used for cancer patients. Patients have cancer and despite the poor prognosis or lack of treatment suddenly the patient's cancer begins to remit.

Sometimes these are called miracles and might well be but they're not uncommon.

The same is true for addiction. Stall et al showed in the mid 80's that a significant portion of addicts stopped their behaviour on their own without any formal treatment. This doesn't change the 'disease' character of addiction but includes it with cancer and other diseases that show a 'placebo response' or have 'spontaneous remissions'. Further 'selection bias' causes people to not infrequently 'miss' this important recovery group.

It was well known with cigarette smokers. Physicians are equally well aware of the older alcoholics and addicts who stop their addictive behaviors almost as if they've 'burnt out'. One study of particularly bad prognosis addicts with antisocial personality disorders became if not model citizens at very least 'relatively normal' and all that could be shown was that these 'hard cases' had indeed met a loving motherly woman.

Miracles happen. There are many roads to Recovery however very few have been studied or 'proven' by evidence based or scientific designs to be particularly 'effective'. A wide variety of 'treatments' were shown to assist in treating addiction for six months to one year. This was commonly needed to obtain 'grants'

What was much more difficult to show was that any particular treatment could result in long term recovery. Vaillant noted that 5 years of abstinence was as likely to lead to long term remission as 5 years abstinence from breast cancer.

Untreated cancer may have a 90% mortality rate but treatment may reduce a cancer's mortality rate to less than 10%. Modern medicine has demanded where possible a response rate better than the 30% response rule of thumb for 'placebo' or 'spontaneous remission' at it's best.

Revia, a drug used to assist recovery from alcoholism and drug addiction was shown to reduce the consumption of alcohol by 50% in controlled studies. This 50% is superior to 'placebo' response.

The gold standard for addiction therapy was for many years the "navy pilot program". Here alcoholic navy pilots whose training cost a million dollars who were flying millions of dollars of planes were grounded due to alcoholism.

The program of recovery which was established for this group was a 28 day 12 step associated inpatient treatment program followed by 3 meetings of AA a week and monthly psychiatric evaluation roughly. At the end of 5 years 80% of the pilots were flying.

Group therapy was central to the treatment paradigm, not surprising given that prior to the success of AA in 1935 addiction was considered an untreatable medication condition. Freud and Jung and other medical doctors of the day considered alcoholism as literally untreatable.

The S.M.A.R.T. cognitive behavioural group series led by a phd psychologist was subsequently demonstrated to have equivalent success to AA and became an alternative 'group' to the AA component in the so called 'gold standard' treatment.

CELEBRATE the acronym for the Christian group therapy process was also shown to be highly successful and sometimes considered an alternative in monitored situations.

Today random urine drug screening is established as part of the 'gold standard' monitored therapy process for recovery where 'accountability' is measured.

There are in fact those that argue that the 'randomized drug screening' may be the most important component.

Diversion programs used by the court system which offer 'rehabilitation services' or 'jail' have shown the efficacy of AA. Previously AA was considered only effective if people 'wanted' to change but the follow up success rates of those court ordered to attend were greater than 'placebo' response.

Prognosis for recovery is altered by a variety of factors such as 'stage' of illness. The American Society of Addiction Medicine has developed 'staging' of addiction similiar to the 'staging' systems used for cancer. The potential for 'spontaneous remission' is greatest in early stages of addiction and relates to the 'burden of illness'.

Commonly doctors and especially addiction specialists such as addiction psychiatrists see particularly complicated cases with usually more complicated histories and greater chronicity. The 'cream' of the addiction 'cohort' rarely gets seen by specialists in the same way that midwives and family physicians are usually more likely to assist in healthy normal births than obstetricians. Much of the criticism of alternative or 'preventative' therapies is that they rarely are able to demonstrate need and continue to fail in controlled studies of accountability despite their continued popularity.

Natural recovery therefore may well be as common as 'spontaneous remission' is in cancer or 'placebo response' is in general.

This 'fact' doesn't alter the fact that most people with any disease would rather use those treatments with a proven success rate and established track record rather than simply 'do nothing'. Indeed the concern of practitioners and patients alike is that there are naturally those who would more than gladly tell addicts and alcoholics to 'suck it up' and just get better. The history of medicine is that all diseases have faced this particularly insidious lobby, especially cancer patients.

Why waste good money on sick people anyway.

The reason is that the vast majority of recovered people contribute to society in a major way and the cost of early intervention is far less that the cost of 'late stage' care.

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