Disease Model: Looking Forward

Here is the final installment of a four-pronged approach to nailing down some of the key concepts and history of disease as it relates to drinking and addiction:

1. Disease Model: Basics
2. Disease Model: Chronology
3. Disease Model: Debates
4. Disease Model: Looking Forward - (this page)

OK, if you’ve been following me through the previous three pages, I’ve become a broken record singing the praises of Bill White.

Once again, he’s put out some intriguing thoughts related to the disease concept of alcoholism, this time synthesizing its history with the current state of the world in order to envision what might come next. He does that in a 2001 article in Counselor Magazine, where he writes a column for his fellow professionals in the addiction and recovery field. A Disease Concept for the 21^st Century (26K PDF) lays out the following blueprint for a disease model which could better represent science and accumulated experience:

• The Tower of Babel: The new disease concept will forge consensus on a language that can be used to differentiate types and intensities of alcohol- and other drug-related problems.
• Alcoholism to addiction: The new disease concept will shift from an alcoholism model to a more encompassing addiction model.
• Boundary integrity: The new disease concept will carefully map its conceptual boundaries, defining the conditions and circumstances to which it should and should not be applied.
• Addictions versus problems: The new disease concept will place alcoholism/addiction within a larger umbrella of alcohol- and other drug-related problems.
• Disease variability: The new disease concept will portray addiction as a cluster of disorders that spring from multiple, interacting etiological influences and that vary considerably in their onset, course and outcome.
• Comorbidity: The new disease concept will define the complex inter-relationships between addiction and other acute and chronic disorders and champion integrated models of care for the multiple problem client/family.
• Role of human will: The new disease concept of alcoholism/addiction will define the role human will and personal responsibility play in the onset, course and outcome of AOD problems and of alcoholism/addiction.
• The variety of recovery experiences: The new disease concept will celebrate the variety of styles and pathways of long- term recovery management.
• Recovery management: The new disease concept will view addiction as a chronic rather than acute disorder and incorporate the principles of chronic disease management that are being used to understand and manage other chronic disorders.

It probably just proves that I’m geeky about alcohol issues, but that’s pretty exciting stuff to me.

If I were writing it, I’d juice up the “variety of recovery experiences” portion of this, specifying that ethical health care includes fully informing folks about available evidence, support, and treatment options. If I’m getting my heart checked out by a doc who tells me all about angioplasty but nothing about using healthy diet to prevent or manage a heart problem, I won’t be getting good care. In the same vein, if I’m talking to my doc about my drinking patterns, and he identifies a problem, I’m not getting good care if I leave his office believing that only one treatment option exists.

I hope the future brings a broader scientific and popular understanding of the shades of gray lying between the white light of abstinence and the dark fury of addiction. In general, folks seem to “get it” when someone says that being able to abstain or moderate effortlessly — on autopilot — is a good thing, as well as when somebody else talks about losing control over, or escalating quantity or frequency of, heavy drinking being a bad thing.

When somebody whose drinking falls somewhere between the extremes of safe/easy moderation and obvious addiction asks:

“Where is the line between sensible and unhealthy drinking?”

One common professional non-answer is:

“Well, just scale your drinking back — dramatically, instantly, & permanently — and everything will be fine!”

But, of course, the stages of change model tells us that change usually doesn’t happen that way, so the non-answer leans toward being a prescription for failure. The guy may hesitate to challenge the dramatic/instant change idea because doing so could earn him a merit badge for denial. He walks away from the conversation without viable alternatives, and even if he looks up moderate drinking, the diversity of definitions may be more confusing than helpful. Bottom line, he’s likely to continue living in murky gray territory, wondering and/or worrying about having a problem.

I can’t put words in the experts’ mouths on this, except to say: As a health care consumer, I expect better than the status quo. I’m looking for straight, simple answers to questions like “Where are the thresholds?” and “What are the risks in some of the different gray areas?” and “Help me identify solutions that fit my values and my life.”