The Roots of Recovery Management
One of the milestones in the modern treatment of addiction has been the reconceptualization of addiction as a chronic disorder on par with other chronic health problems. This seemingly fresh perspective suggested that approaches found to be effective in the management of diabetes, cancer, heart disease, asthma, and other chronic disorders might be effectively adapted to increase long-term addiction recovery outcomes. Criticism of the concept of addiction as a chronic disorder have focused on its potential to increase addiction-related stigma (Brown, 1998) and misrepresent the more typical trajectory of alcohol and other drug problems (Cunningham & McCambridge, 2012). Such criticisms underscore the need for refinement of the addiction as chronic disorder messaging (White and McLellan, 2008) that has become a central tenet of calls to shift addiction treatment from models of acute care to models of sustained recovery management nested within larger recovery-oriented systems of care. Recovery management is a philosophy of organizing addiction treatment and recovery support services to enhance precovery engagement, recovery initiation and stabilization, recovery maintenance, quality of personal/family life in long-term recovery, and efforts to break intergenerational cycles of addiction and related problems.
In recounting the modern history of the addictions field, I have suggested that the “tipping point” in this understanding of addiction chronicity was the publication of a seminal article by Tom McLellan, David Lewis, Charles O’Brien, and Herbert Kleber in 2000 in the Journal of the American Medical Association. Today’s blog, for the history geeks among us, identifies some of the earlier milestones in this understanding of addiction as a chronic disorder.
1828: “Chronic diseases require chronic cures” (p. 295). Kain, J.H. (1828). On intemperance considered as a disease and susceptible of cure. American Journal of Medical Science, 2:291-295.
1879: “The permanent cure of inebriates under treatment in asylums will compare favorably in numbers with that of any other disease of the nervous system which is more or less chronic before the treatment is commenced.” Crothers, T.D. (1879). Editorial: Practical value of inebriate asylums. Journal of Inebriety, 3(4), 249
1892: “The same principles apply in the treatment of this disease (alcoholism) that apply in all chronic nervous diseases” (p. 288). Enfield, A. (1892). Alcoholism: A disease. Journal of the American Medical Association 18, 287-289.
1913: “Chronic alcoholism is not only a disease itself, but in many instances it springs from other diseases and it is certain that other diseases grow out of it” (p. 435). Pettey, George E. (MD) (1913). Narcotic drug diseases and allied ailments. Philadelphia: F.A. Davis Company.
1938: “An alcoholic should be regarded as a sick person, just as one who is suffering from tuberculosis, cancer, heart disease, or other serious chronic disorder” (p. 244). Report of the Scientific Committee of the Research Council on Problems of Alcohol, cited in Johnson, B. (1973). The alcoholism movement in America: A study in cultural innovation. Urbana, Illinois: University of Illinois Ph.D. Dissertation.
1947: “…it [alcoholism] is a chronic affair; chronic conditions must be approached on a long range basis” (p. 11). Duncan, R.E. (1947). Alcohol as a medical problem. Kansas City Medical Journal, 23(6), 9-12.
1951: Alcoholism must be approached “as much a disease as diabetes or tuberculosis” Charles Franco, quoted in: Duncan, S.C. (1951). Chronic alcoholism as a medical problem in industry.Industrial Medicine & Surgery, 20(12), 47-50.
1959: “The appellative ‘chronic,’ [attached to alcoholism] however, constitutes a redundancy, as pointed out by Dittmer (1932); the suffix ‘ism’ in itself indicates a persistent state” (p. 230). Marconi, J. (1959). The concept of alcoholism. Quarterly Journal of Studies on Alcohol, 20(2), 216-235.
1983: “First, since alcoholism is a chronic relapsing disease, follow-up must be prolonged–at least 5-15 years” (p. 148). “Once it develops, alcoholism is a chronic disorder. Insidious, fulminating, and intermittent courses are all common; so is recovery” (p. 309). Vaillant, G. (1983). The natural history of alcoholism: Causes, patterns, and paths to recovery. Cambridge, Massachusetts: Harvard University Press.
1986: “Without question, alcoholism is a chronic condition; it is disabling; it is unpredictable; there is no possibility of cure; the illness determines one’s lifestyle; the causes and symptoms are ambiguous and unpredictable; there is shame and guilt; there is obvious loss of control; and certainly most alcoholics and family members feel like they are bearing the unbearable” (p. 28).
“The fundamental goal in alcoholism treatment is to help the patient and significant others learn to make certain necessary, and sometimes major, lifestyle changes which will help them live with an incurable chronic illness” (p. 27). “It is my impression that, for some people at least, chronic illness can be a transforming experience, even a new pathway to wholeness and health.” p. 30 Anderson, D. (1986). Living with a chronic illness. Center City, MN: Hazelden Foundation.
1990: “Alcoholism is a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations.” American Society of Addiction Medicine & National Council on Alcoholism and Drug Dependence. (1990). Disease Definition of Alcoholism Revised. Joint News Release, April 26.
1996: “Although addictions are chronic disorders, there is a tendency for most physicians and for the general public to perceive them as being acute conditions such as a broken leg or pneumococcal pneumonia” (p. 237). In comparing addiction to adult-onset diabetes, asthma and hypertension, “All are multiply determined, and no single gene, personality variable, or environmental factor can fully account for the onset of any of these disorders. Behavioral choices seem to be implicated in the initiation of each of them, and behavioral control continues to be a factor in determining their course and severity. There are no ‘cures’ for any of them, yet there have been major advances in the development of effective medications and behavioral change regimens to reduce or eliminate primary symptoms. Because these conditions are chronic, it is acknowledged…that maintenance treatments will be needed to ensure that symptoms remission continues” (p. 239). “Treatment of addiction is about as successful as treatment of disorders such as hypertension, diabetes, and asthma…” (p. 239). “Is it not time that we judged the ‘worth’ of treatment for chronic addiction with the same standards that we use for treatments of other chronic diseases?” (p. 240). O’Brien, C.P. & McLellan, A.T. (1996). Myths about the treatment of Addiction. Lancet, 347:237-240.
1997: “…addiction is a chronic, relapsing disorder, rather than simply a series of discreet, short-term drug-using episodes” (p. 691). Leshner, A.I. (1997). Drug abuse and addiction treatment research: The next generation. Archives of General Psychiatry, 54, 691-694
2000: “In terms of vulnerability, onset, and course, drug dependence is similar to other chronic illnesses, such as type 2 diabetes, hypertension, and asthma” (p. 1693). “…it is essential that practitioners adapt the care and medical monitoring strategies currently used in the treatment of other chronic illnesses to the treatment of drug dependence” (p. 1694). McLellan, A.T., Lewis, D.C., O’Brien, C.P., and Kleber, H. (2000). Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation. Journal of the American Medical Association, 284(13), 1689-1695.
For my own views on how the most severe, complex and prolonged patterns of addiction would be treated if they were fully understood as a chronic disorder, see my monograph, Recovery Management and Recovery-Oriented Systems of Care: Scientific Rationale and Promising Practices.