Guest blog by Angie Hamilton
A response to Marvin Ross and Dr. David Laing Dawson
Thank-you Marvin Ross for this opportunity to respond to your article Addictions and Mental Illness Do Not Belong Together and Part Two of that article by Dr. David Laing Dawson.
In your article you state that addictions are quite separate from mental illness but that, for some inexplicable reason, addiction has been lumped in with mental illness.
However, the reality is that they occur together more often than not. How is it possible to separate addiction and other mental health conditions? Dr. Kim Corace, a psychiatrist at The Royal in Ottawa, recently presented a paper at the Issues of Substance Conference by the Canadian Centre on Substance Use and Addiction (CCSA) entitled “Opioid Use Disorder in Youth: Mental Health Comorbidities and Treatment Outcomes”. It showed that 100% of the youth with opioid use disorder also had depression, 70% had anxiety and many had other co-occurring mental health conditions. In my experience attending support groups for parents of addicted youth for over three years, all of the teenagers had co-occurring mental health conditions (although statistics usually range from 70% to 90%).
Numerous studies point to the overlap between addiction and other mental health conditions and we are not, as yet, able to determine causation. Did self-medication of the other conditions lead to addiction or did addiction cause the other conditions or did something else lead to both?
Your article also states that lumping addiction in with mental illness does a disservice to the mentally ill because addiction, at some point, involved a choice whereas there is no choice involved for schizophrenia, bipolar or depression. It is true that, at some point, addiction involved a choice to use an addictive substance. With respect to alcohol, it is a decision that has been made by 80% of Canadians. When you add in prescribed medications that can lead to addiction it is a decision that maybe all Canadians have made. There are many patients who have become dependent on, or addicted to, painkillers taken as prescribed by their doctors. Rather than vilify people for making a choice that most of us make, it would make more sense to ask “Why do some people who use an addictive substance become addicted and others do not?”
Addiction is a pediatric illness. Early initiation is a major risk factor. Seventy to ninety percent of addiction develops during adolescence. The decision to use or overuse a substance that leads to addiction is usually being made by a teenager. The adolescent brain, in layman’s terms, has been described as all gas and no brakes. Because the pre-frontal cortex (home of executive function) is not fully developed we have all kinds of laws designed to protect minors because we acknowledge that their ability to understand the consequences of their behaviour is not developed.
Other risk factors include genetics (which accounts for 40-60% of the risk), co-occurring mental health conditions, personality traits (risk-taking, impulsivity, anxiety and hopelessness) and environmental factors especially adverse childhood experiences (trauma). Adolescents do not choose their genetic predispositions, personality traits, environments (with the exception of peer groups) or to be traumatized. And they don’t choose to become addicted. It happens without them knowing. By the time they figure it out, it’s too late.
As to where the experts stand with respect to addiction being a choice or a disease, The National Institute on Drug Abuse (NIDA), a U.S. federal government drug use and addiction research institute, defines addiction as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. While most experts and professionals do not dispute the disease model of addiction, it is not without controversy.
You quote Dr. Sally Satel in your article. In her article Addiction and the Brain Disease Fallacy she states:
“First, we do not address the question of whether addiction is a “disease.” With the potential exception of certain organic brain syndromes, the field of psychiatry recognizes “disorders” or syndromes, rather than diseases because the etiologies of mental illness are not yet well understood. So, addiction fits the notion of disorder insofar as persistent craving and/or continued, excessive use leads to dysfunctional behavior. We are more concerned with the very different issue of whether addiction is best construed as a brain disease or brain disorder.”
It is clear that while she takes issue as to whether addiction is a disease or not, she still views it as a disorder. If we are focused on treatment and recovery, does that distinction really matter?
The gist of Dr. Dawson’s article is that people with addiction choose to use and choose to continue to use. Accordingly, they are to blame for their addiction. They are immoral and should be criminalized for any crimes they commit because of their addiction, unlike people with other mental health conditions who are engaged in criminal activities (those deemed not criminally responsible). But many have developed an addiction while trying to self-medicate other mental health conditions.
Disease or not, all experts would agree that addiction creates changes in the brain that result in compulsive drug seeking in spite of adverse consequences. At its core, addiction is about self-harm. It is a slow death (or quick in the case of overdose). At the severe end, people struggling with addiction do not make decisions in their own best interest with respect to all aspects of their lives and they lose everything that matters to them – jobs, family and friends. They lose control over their lives which become chaos. And so yes, they consume substances that could kill them.
It is estimated that eighty percent of overdoses are accidental and twenty percent are deliberate. Which side of that equation is more horrific? Dr. Dawson wants to blame them for their self harming behaviours. I believe Dr. Dawson would say that those without addiction who are depressed and take their lives are not to blame and are innocent victims of their depression. Their decision is not their own, as they are struggling with a serious mental illness or disorder that impairs their ability to make decisions in their own best interest. To which I would say yes, just like addiction.
Prior to 1972 it was illegal in Canada to attempt to kill yourself. We look at that law now and think how irrational it is. Criminal law is meant to punish people who harm other people, not to prevent people from harming themselves. It is time we realized the same for people struggling with addiction.
It appears Dr. Dawson thinks persons with addiction don’t deserve treatment because their harms are self-inflicted (their choice). So we should not treat the obese? Those who smoke? Those who do not wear their seat belts or bike helmets?
Finally, Dr. Dawson does not believe that treatment exists for addiction. He states “I put treatment for addiction here in quotation marks because there is no treatment as such.” Like most primary care physicians and psychiatrists, he does not know that there are very effective evidence-based treatments for addiction, like medication assisted treatment (MAT), cognitive and other behavioural therapies and motivational interviewing.
To quote one of Canada’s most pre-eminent addiction medicine specialists, Dr. Meldon Kahan, Women’s College Hospital, Toronto:
The scandal is that there are evidence-based treatments for substance use disorder which are effective that are not being used. META:PHI presentation, May 24, 2017.
WHY WE NEED TO STICK TOGETHER
Most addictions start during adolescence and the vast majority of adolescents struggling with addiction have other mental health conditions. It is widely accepted that treating these conditions concurrently is most effective. We do not yet know which causes which, or if something else causes both.
Instead of fighting amongst ourselves, we need to stick together to eliminate the discrimination in health care funding and treatment against those with addiction and/or other mental health conditions.
“Stigma in the U.S. health care system contributes to disparities in funding for research and treatment of mental disorders in comparison with physical disorders and to the negative attitudes, beliefs, and behaviors of health care professionals toward people with mental and substance use disorders. Structural stigma is manifested in the health care system in the low quality of care for people with mental and substance use disorders and the limited access to behavioral health treatment and other services (Institute of Medicine, 2006; Schulze, 2007; Schulze and Angermeyer, 2003…”(at p.45-46) Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change published by the National Academies Press.
In Canada we spend just over 7% of our public health budget on mental illness and addiction but the burden of these diseases in Canada in 2013 was between 10% and 11% (Global Burden of Diseases, Injuries, and Risk Factors Study, 2013). By comparison, countries like New Zealand and the UK spend 10%-11% of their public health budget on mental illness and addiction. In 2012, the Mental Health Commission of Canada in Changing Directions, Changing Lives, The Mental Health Strategy for Canada, called for Canada to increase the amount it spends on mental illness and addiction from 7% to 9% over 10 years. This recommendation pre-dates the federal government’s commitment to legalize cannabis, which will generate income for the federal and provincial governments, and the current opioid overdose epidemic which is killing thousands of Canadians annually, many of them our youth and young adults with addiction and mental health conditions.
This sad state of affairs is the result of decades of discrimination in how society, including physicians, continue to view addiction as the moral failing that it is not, instead of the illness that it is. And so it is that doctors have overprescribed opioids, their patients have become dependent or addicted, and yet they do not know how to prescribe suboxone or methadone to treat opioid use disorder. They are also unaware of, and do not know how to prescribe, the medications available for treating alcohol use disorder (Campral and Naltrexone). Addiction medicine is not taught in medical school yet it affects one in seven. No wonder we are in the midst of an opioid overdose epidemic. In the words of another pre-eminent addiction medicine specialist, Dr. Evan Wood, British Columbia Centre on Substance Use (BCCSU):
Oftentimes, I hear people say that the addictions system is broken … Actually, the system isn’t broken, we need to build a functioning addictions system.” CBC Interview, Sept. 16, 2016.
Angie Hamilton is the Executive Director of Families for Addiction Recovery and has lived experience as the parent of a child with substance use disorder.