Rethinking the Characterization of Addiction as a “Relapsing Condition” (Bill White and Paula Davies Scimeca)

ShameDefining addiction as a “chronically relapsing” condition, in spite of its advocacy by leading organizations in the addictions field (see here and here), has generated unintended but harmful consequences. Such language should be abandoned and replaced with words that more accurately depict the variable course of substance use disorders (SUDs) and that are more personally and professional empowering. 

Our hearts go out in compassion, respect, support, and admiration for people who share their struggles with cancer, heart disease, diabetes, and other medical conditions that require prolonged if not lifelong monitoring and active management. Because a personally positive attitude and family and social support can play crucial roles in bolstering recovery, health professionals do everything in their power to provide optimal hope and encouragement for recovery from these medical conditions.  Even when it is statistically unlikely that a patient will be able to survive or return to previous levels of health and functioning, she or he is given words and images of hope. Less than fifty years ago, a diagnosis of cancer was so threatening that those six letters were left unspoken in many households and were socially taboo. Today, society has begun to automatically pair the word “cancer” with “cancer survivor.” It is now commonplace for people to live, and live well, transcending diagnoses of cancer, heart disease, diabetes, asthma, and numerous other complex and life-threatening health conditions. The expectation of surviving and thriving in the face of such conditions has blossomed into a something of a cultural phenomenon.

Unfortunately, when the medical illness is a substance use disorder (SUD), affected individuals and families are often not afforded such optimistic language and images of hope. Until the recent rise of a new addiction recovery advocacy movement, the public faces and voices of “addiction survivors” were rare in the United States, due primarily to the social and moral stigma attached to addiction. The language that accompanied a SUD diagnosis often conveyed the overwhelming expectation–inferred, and often voiced–that recovery from addiction was the rare exception to the rule. Nowhere is such pessimism more evident than in the characterization of addiction as a “chronically relapsing” condition. We offer the following objections to such language.

The lapse/relapse language within this phrase is historically rooted in morality and religion, not health and medicine, and comes with considerable historical baggage (See related blog). The lapse/relapse language in the alcohol and drug problems arena emerged during the temperance movement and was linked in the public mind to lying, deceit, and low moral character—a product of sin rather than sickness. The application of the lapse/relapse language to other medical conditions once linked to personal culpability, such as tuberculosis, cancer, epilepsy, and schizophrenia dissipated as more objective and morally neutral language (e.g., recurrence) was embraced and the etiology and course of these disorders became more clearly understood.  Hopefully, the same will be true with SUDs.

The phrase “chronically relapsing” applied to SUDs misrepresents the natural course of SUDS by misapplying findings from clinical research populations and clinical experience with the most severe, complex, and chronic SUDS to the larger pool of SUDs found in the community. Recovery, not prolonged disability and death, is the norm for the long-term course of most substance use disorders. (See here for a review of more than 400 scientific studies confirming that conclusion.)  More than 23 million Americans have achieved remission from substance use disorders, and surveys of people in recovery reveal dramatically improved health, functioning, and quality of life.  Such findings are cause for personal, public, and professional optimism—not the pessimism conveyed by the “chronically relapsing” language.  Recognizing that vulnerability for recurrence is a common dimension of substance use disorders marked by high severity, complexity, and chronicity does not mean that such conditions warrant hope-suffocating language. Such individuals can and do achieve long-term recovery without further episodes of recurrence or with only a few brief episodes of such recurrence.

The characterization of all SUDs as “chronically relapsing,” by inadvertently portraying a SUD as a hopeless condition, is personally disempowering, serves to lower personal expectations of sustainable recovery, and fails to convey how an individual’s daily decisions and lifestyle management can lower the risk of future SUD recurrence. Our concern is that the christening of a SUD as “chronically relapsing” and categorizing individuals as “chronic relapsers” by medical authorities becomes, not an inherent condition of a SUD, but a self-fulfilling prophecy when embraced by professional provider and patient.   As with many other health conditions, recovery from a SUD requires assertive and continued management, and resources to support such long-term recovery management are increasingly available.  It is time the definitional language of “chronic relapsing disease/condition” was abandoned and replaced with language that conveyed the reality of recovery without repeated activation of addiction, and that there are personal actions that dramatically reduce the risk of recurrence.  It is time those in recovery from addiction joined the family of other “survivors” recovering from health conditions that positively respond to assertive and ongoing recovery management.    

The “chronically relapsing” characterization of SUDs obscures the large population of individuals who achieve remission from such disorders with no experience of repeated reactivation of the disorder. (Sustained monitoring programs for airline pilots, physicians, and nurses often find 80%+ of them initiating and sustaining recovery from addiction without continued episodes of alcohol or drug use and its consequences.) The “chronically relapsing” language also obscures the high levels of social functioning and social contribution achieved by individuals in long-term recovery. It instead conveys, at best, the image of people in SUD recovery as inherently fragile, “white knuckling” their way through life, on the brink of resumed alcohol and drug use at every moment. Such a caricature may find some truth for those in the earliest days of SUD recovery, but is challenged by the majority of people who live quite comfortably in long-term SUD recovery, many achieving productive and purposeful lives of social contribution.

The characterization of SUDs as “chronically relapsing” contributes to social stigma, discrimination, and the social abandonment of people experiencing such disorders. If the commonly expected outcome of a SUD is not recovery, but repeated and prolonged acute episodes, then persons with a SUD become less viable candidates as intimate partners, parents, friends, employees, college applicants, loan applicants, renters, applicants for health and life insurance, or recipients of government benefits. Characterizing individuals with a SUD as “chronically relapsing”—socially interpreted to mean biologically or psychologically inferior/damaged, provides justification for addiction-related social stigma, sequestration of persons with a SUD from community life, and, at the historical extreme, campaigns of extermination, e.g., inclusion in mandatory sterilization laws, prolonged incarceration, or campaigns of genocide against people with SUDs (as occurred in Nazi Germany).  

The “chronically relapsing” language fuels therapeutic pessimism among providers of SUD treatment and serves as a smokescreen for ineffective and financially exploitive approaches to addiction treatment. Professionalized addiction treatment has become disconnected from the larger and more enduring process of addiction recovery, disconnected from indigenous recovery community organizations, and disconnected from regular contact with legions of individuals and affected family members in long-term recovery. With an ever-briefer model of addiction treatment, such professionals are prone to see a core of individuals with histories of multiple treatments as a norm confirming the “chronically relapsing” declaration. Addiction treatment organizations whose owners view persons with SUDs as a crop to be harvested for financial profit can provide inert, ineffective, and even harmful treatments multiple times to the same individuals while masking their ineffectiveness and profiteering behind the “chronically relapsing” depiction of the disorder. Under such circumstances, people with severe and complex SUDs and little recovery capital can repeatedly undergo treatments that have little evidence of producing sustainable recovery while being personally blamed for such outcomes (i.e., “not working the program correctly”). The “chronically relapsing” and “chronic relapser” monikers perpetuate ineffective and exploitive treatment by miscasting flaws in treatment philosophy, design, and execution (system failures) as problems stemming from the condition (“It’s the disease, not our treatment approach.”), and problems of patient compliance (personal failures).

The “chronic relapsing” portrayal of SUDs also exerts its effects on policy and public resource allocation. Why would politicians or the public allocate their limited resources to people perceived as having so little hope of achieving recovery? People experiencing and recovering from SUDs and their families will never be a political constituency of consequence as long as they are pictured as permanent burdens on community resources rather than as people who can and do achieve stable health, work productively, pay taxes, vote, and voluntarily serve the communities that have supported them.  The addiction treatment advancements made to date have flowed from Mrs. Mary Mann’s declarations in 1944 that people with such health conditions can be helped and are worthy of help—a portrayal far different than that conveyed by the “chronic relapsing”/”chronic relapser” labels.    

The recognitions that severe substance use disorders mimic characteristics of other chronic health conditions and could benefit from sustained recovery management rather than serial episodes of acute stabilization have been critical milestones in the advancement of modern history of addiction treatment. But such sustained care and support is at its best when it is hope-infused and stripped of language that adds to the burden of stigma facing individuals and families in recovery.  While care must be taken in the characterization of SUDs as a potentially “chronic” condition for some persons (for some of the same above reasons–see such concerns expressed here, here, and here), it is time “relapsing condition” and such pejorative, objectifying labels as “chronic relapser” were forever deleted from the lexicon of addiction medicine and addiction treatment.