Relapsing is part of managing a chronic disease

Monday, August 21, 2006 There has been an increase in treatment on an outpatient basis. By SUSAN BRINK LOS ANGELES TIMES Mel Gibson's relapse was a public humiliation. Robin Williams, who "found himself drinking again" after 20 years of sobriety, according to a statement released last week, had a private one. Both are back in treatment as some of their legion of followers "tsk-tsk," shake their heads and conclude that two more stars have failed. But such relapses are fairly common during the lifelong struggle against what science considers the chronic disease of alcoholism. A relapse into renewed drinking, experts say, is no more a treatment failure than is a second heart attack in a cardiovascular disease patient. And alcoholics are no worse — and maybe a bit better — at responding to treatment, and sticking to it, than are patients with other chronic diseases. "It's not like appendicitis, where they have surgery and it's cured," says Dr. Donald Kurth, chief of addiction medicine at Loma Linda University. "It's more like diabetes. You can manage it, but you have to work at it every day." How it's changed The changing treatment model — outpatient, instead of inpatient — further reflects a growing body of science that gives patients and doctors more choices and more hope that abusive drinkers can eventually change. William R. Miller, professor of psychology and psychiatry at the University of New Mexico, has studied addiction for 40 years. He doesn't even like the word relapse. "I think it's a pejorative term," Miller says. "If you think about asthma, we're not surprised if a person who is treated has an asthma attack. With high blood pressure, if it becomes elevated, we adjust treatment. We don't shame them because they've relapsed." Dr. A. Thomas McLellan looked at three conditions medicine shows can be managed, but not cured, and compared treatment outcomes with those for alcohol dependence. The other diseases were high blood pressure, asthma and diabetes. After a review of studies, published in the Oct. 4, 2000, Journal of the American Medical Association, he found after treatment for alcoholism, regardless of treatment type, about 40 percent to 60 percent of problem drinkers remained abstinent for at least a year. Other chronic diseases, including diabetes, asthma and high blood pressure, have similar or worse relapse rates a year after medical treatment. Fewer than 60 percent of asthma and hypertension patients take their medications as they should, McLellan found, and fewer than 40 percent of adult diabetes patients adhere to their medication schedules. When it comes to lifestyle changes, more than 70 percent of patients with asthma, hypertension or diabetes fall off their prescribed diet-and-exercise wagon. Yet doctors continue to treat people whose blood pressure, diabetes or asthma gets out of control. "We wouldn't tell someone they can't get treatment because they continued to eat doughnuts," Kurth says. "We don't scold them, we don't chastise them. We treat them." With alcoholism, a setback isn't a reason, either, to give up. The ever-present threat of those setbacks, after all, is precisely why people in Alcoholics Anonymous call themselves "recovering," not "recovered." What treatment means Treating the disease means treating people through their relapses. The trouble is, while an alcoholic is learning to stop drinking, every slip contributes to the disease's $185 billion annual cost, according to the National Institute on Alcohol Abuse and Alcoholism, in crime, lost productivity and social problems. The personal costs are just as steep. Drinking distorts reason, and lays waste to marriages, friendships and careers. Treatment needs vary, but for the majority of alcoholics, outpatient treatment has become common — and in many cases, preferred. The 28-day inpatient treatment programs, such as those at the Betty Ford Center in Palm Springs, Calif., or Hazelden in Minnesota, were once considered the gold standard of care. For many, they may still be the best choice. But even those programs depend on months of follow-up care, including individual counseling and group programs such as AA. Of the 700,000 people getting treatment for alcohol dependence on any given day in the United States, 13.5 percent are in a hospital or residential treatment center, while 86.5 percent are getting outpatient treatment, the reported choice of Mel Gibson. Effectiveness "That could be more effective, because you learn how to live in your community, rather than being off in some resort-type setting," says Eric Goplerud, director of Ensuring Solutions to Alcohol Problems, a research center at George Washington University. Intensive outpatient treatment generally involves three to four hours of one-on-one and group treatment most days of the week for several weeks. The patient keeps going to work and continues to live at home. "One of the supports that people need for staying sober is holding their job," Goplerud says. "Outpatient treatment allows them to hold their job and work out the system for staying sober in the context of their everyday life." While in treatment, they're still dealing with everyday stresses from a spouse, kids, commuting or the temptation to drive past a favorite bar. A strong predictor of who is going to get better, even after relapsing, Miller says, is that an undeniable message makes its way through even the worst alcohol fog. Maybe the signal comes when a spouse leaves. Or when a drinker ends up in court, or lands in jail. Or when an employer warns that a job is on the line. Or, in the case of a celebrity, the message that alcohol is messing up one's life might arrive when humiliating behavior gets plastered all over newspapers, TV and the Internet.