Why Psychiatrists Don’t Treat Addicts

Of all the conditions that psychiatrists face (almost) daily in their practice, addictive illness is easily among the most common.  There are almost 5 million drug-related emergency room visits per year, and the number of ER visits and hospital admissions for complications of drug use is undoubtedly several times higher.  In psychiatric patients, symptomatic exacerbations are often the direct result of substance (ab)use.

Addictions are captivating, both literally and figuratively.  In fact, addiction has been described by Alan Leshner, former director of the National Institute of Drug Abuse, as the “quintessential biobehavioral disease.”  Addictions arise from disrupted brain chemistry, faulty psychological adaptations, counterproductive behavioral strategies, moral decline, irresponsible social policies, spiritual emptiness, poor role models, or some combination of the above.  For the psychiatrist who professes to treat “the whole person,” who wants to “bridge the gap between mind and brain,” etc, it would seem that addiction is the “perfect” psychiatric disease.  Or, to put it another way, if psychiatric disorders are music, then bipolar disorder, schizophrenia, and ADHD are catchy Top 40 hits, while addiction is a timeless Rachmaninoff concerto.

Unfortunately to most psychiatrists, addiction instead is treated more like background noise.

To be sure, some psychiatrists are very well versed in the treatment of addictions.  Some of the most meaningful contributions to addiction treatment in the 20th century came from psychiatry.  Carl Jung’s treatment of the intractable alcoholic “Rowland H” led to the foundation of Alcoholics Anonymous.  The popular “self-medication” theory of addiction originated in the writings of Edward Khantzian, whose focus on deficient ego strength is informed heavily by psychodynamic theory.  And today, the American Board of Psychiatry and Neurology recognizes “Addiction Psychiatry” as a distinct subspecialty, requiring rigorous training, experience in chemical dependency settings, and deep knowledge of substance abuse and its treatment.

But in most psychiatric settings today, addictions are not actively treated.  In my part-time work in a county mental health department, for instance, patients with chemical dependency (CD) problems are referred out of the psychiatric setting and into programs run by non-psychiatrists.  When we admit inpatients to our psychiatric unit whose presentation was clearly exacerbated (or caused) by ongoing substance abuse, we’ll document it, but often have little (or no) consultation with the patient or the family about the importance of CD treatment.  In my residency training at a private university hospital (which had, at the time, recently closed its CD partial hospitalization program because it reportedly made no money), we frequently blocked dual-diagnosis patients from our psychiatric services, using the argument that “the addiction had to be treated first,” before we could address mental health problems.

Why is this?  Why are we reluctant to treat the one disorder that, in most patients, involves virtually every aspect of the “biopsychosocial” model that we so proudly profess to treat in psychiatry?

Personally, I can think of a number of reasons.  First of all, the definition of “addiction” is unclear to most of us; in fact, the DSM-IV defines “abuse” and “dependence,” but not “addiction.”  Some cases of addiction are obvious to anyone (“you know it when you see it”), but for the vast majority of patients, we just don’t know how to define it, much less diagnose it.  Interestingly enough, most docs do recognize that the concepts of “abuse” and “dependence” insufficiently describe the phenomenon of “addiction,” but the whole concept is amorphous, vague, and confusing—so we don’t go much further than that.

Secondly, treatment is difficult.  Psychiatrists like to have a strategy to use, ideally based on clinical trial evidence or at least a plausible “mechanism” (physiological, psychological, or otherwise) with which we and our patients can understand the disease.  The strategy may be an evidence-based manualized therapy, a standardized treatment approach, or (especially these days) a medication.  Indeed, we do have medications like naltrexone and Suboxone, but these don’t treat the addiction, when given alone (I’ll write more about that in a future post).

Third, I believe our hubris keeps us from treating what we know we cannot.  Psychiatrists know intuitively that addictions are cunning, baffling, and powerful (even if they don’t know the true derivation of that phrase).  Addictions are frighteningly illogical, patients don’t respond to sensible entreaties to stop using (as the old saying goes, insanity is doing the same thing over and over again and expecting different results), and, to make matters worse, some people get better without our help.

Furthermore, the effects of addiction interfere with what we psychiatrists really want to do with our patients.  When a patient uses drugs or drinks, it affects the response to our medications or therapy.  We may conveniently ignore someone’s ongoing drug use, but deep down we know (or at least we should know) that that might explain the patient’s symptoms or complaints more than the condition we’re ostensibly treating.  But we don’t like that.  Over time, our countertransference leads us to despise the patients as much as we despise their disease, until it’s just easier not to see these patients in the first place.

This is a huge shame.  And a huge loss.  In my opinion, addiction is not only the quintessential biobehavioral disease, but also the quintessential human disease.  What makes addiction difficult to treat (the lack of a uniform approach, the multifactorial nature of any successful strategy, the different meaning of the disease to different people), is precisely what makes it interesting.  It’s also what will keep us from ever developing a magic bullet, a one-size-fits-all treatment for addictive disorders.  Unfortunately, with our current emphasis on biological (and quick) “fixes,” I think we’ll continue to come up empty-handed.  We just have to hope that addicts won’t continue to be shunned by those of us who should rise to this unique challenge.

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19 Responses to Why Psychiatrists Don’t Treat Addicts

  1. Dr. Balt,

    Ironically, most psychiatric drugs are addictive.

    Sadly, most people who are on psychiatric drugs (physiologically addicted), and in the case of benzodiazapines,psychologically addicted, are left to sort through the mess created by psychiatry on their own.

    Psychiatry is is NO position to get into “addiction treatment” without first addressing the drug-addicted patients it has created; and to help them slowly and safely taper off mind-altering drugs.

    Duane Sherry, M.S.
    discoverandrecover.wordpress.com

    • Why psychiatrists don’t treat addicts…

      The question that needs to be addressed is: Why do psychiatrists create addicts?

      As far as responding back to others, I choose to sit on my hands, and read what others have to say (a request you made some time back, as I recall)…

      Duane

    • stevebMD says:

      Duane,

      As always, thank you for your comments. While I understand your sentiment, the specific statements illustrate the discrepancy I referred to in my post, namely the fact that “abuse,” “dependence,” and “addiction” are very different things.

      Perhaps I’ll write more about this at some other time. But I think “addiction” arises from some deep subconscious unmet need (call it an “emptiness,” a “helplessness,” a “lack of spirituality,” whatever) which the addict then consciously fills with the addictive substance, act, or behavior. (For more details of a definition with which I fully agree, see Lance Dodes’ site.) Once the unmet need is satisfied, the substance or act in question no longer has such addictive power over the individual.

      With this definition, I would find it difficult to believe that anyone could be “addicted” to a psychiatric drug, being used properly. (OK, OK, I know people can become addicted to benzos or stimulants, but in such cases the drugs are often obtained under false pretenses, or they’re prescribed irresponsibly.) Dependence, of course, is another matter, and I agree we have ignored the fact that we have created many patients “chemically dependent” on us.

      Like I said, I’ll write more at some other time.

      • It’s my understanding from the work of a well-known medical doctor named Prudhomme, who used to run the Schick-Shadel alcohol and drug treatment center here in Fort Worth, Texas… along with others in the field that the definition of physiological addiction (not psychological craving) is two-fold:

        1) Increased tolerance
        2) Measurable (physical) symptoms upon withdrawal.

        Dr. Breggin says that all psychiatric drugs have the “potential” for addiction…. He and many others says that most ARE addictive.

        I wanted to address your comment, because you directly addressed mine. I sit on my hands and listen to any others.

        Thank you for letting me post.

        Duane

    • Iatrogenia says:

      “Addiction” is a medico-legal term. Technically, antidepressants do not meet the criteria for addictiveness, although they may incur physical dependency.

      (Doctors in the UK, however, have a looser definition of “addiction” and sometimes do say antidepressants are addictive.)

      The distinction between addiction and physical dependency is something a lot of doctors don’t even understand. They hear that antidepressants are not addictive, they understand this as meaning they do not cause physical dependency, either, and they deny that withdrawal syndrome exists.

    • Iatrogenia says:

      Duane, I agree with the sense of what you’re saying, but I beg you to stop posting that psychiatric drugs are addictive. It deflects the conversation to discussion about the meaning of “addictive” and your point is lost.

      If you must, please say psychiatric drugs cause physical dependency, as evidenced by the difficulty of withdrawal from them.

  2. doctorz says:

    Duane, I think you’re confused about types of addictions, or addiction in general, for that matter. People with melancholic major depression are no more addicted to antidepressants than people with hypertension are to antihypertensives. I agree that physicians inappropriately medicate conditions that may better respond to other therapies, but making such blanket condemnations is a disservice to many major advances of psychopharmacotherapy. Regarding the issue of benzo prescribing, the real concern is one of physical withdrawal…Since when is a potentially life threatening complication of seizures associated with abrupt withdrawal from this class of drugs considered psychologically based??

  3. compsports says:

    Dr. Z, you said, “”People with melancholic major depression are no more addicted to antidepressants than people with hypertension are to antihypertensives””

    Hmm, that why is it when someone misses a dose of a med that has a short half life like Cymbalta, that people suffer big time. It doesn’t matter what your diagnosis is.

    And please, don’t tell me this isn’t addiction. I agree it isn’t addiction as we normally think of drugs but when you suffer adverse reactions when you miss a drug dose due to the body being dependent on it, it is a form of addiction in my opinion.

    Back to the intention of Steve’s blog entry. Frankly, I found your points surprising because I thought the general trend in psychiatry is to view drugs addicts as having an undiagnosed mental illness. What am I missing?

    • doctorz says:

      compsports, you are entitled to your opinion, certainly. And I agree with your point about Cymbalta, that people will experience withdrawal following abrupt discontinuation, regardless of diagnosis, including no diagnosis. But I don’t think labeling that as addiction is accurate, anymore than concluding that the rebound hypertensive reaction to stopping Clonidine, is the result of it being “addictive”. By the way, that happens even in normotensive individuals treated with Clonidine. And what about the very unpleasant withdrawal associated with stopping corticosteroids, which are quite useful in managing any number of acute and chronic inflammatory conditions. Is that addiction as well?
      Most of these problems can be avoided with gradual tapering of the potentially offending medication. I have done precisely this without untoward adverse effects in hundreds of patients whose symptoms are in sustained remission and are not at high risk for relapse.
      I realize there is no universal agreement on what addiction really is. I don’t use the term casually for that reason. However, when I see someone who is repeatedly engaging in chronic maladaptive behavior (typically substance abuse in my practice) as a means of trying to adapt to situations to overcome problems, then my index of consideration is raised, particularly if further impairment occurs in physical, social, and occupational functioning. I fail to see how anyone can conclude that an individual is addicted to Cymbalta if it allows them to recover from an immobilizing illness. That being said, you won’t get any argument from me that psychotropic medications are often inappropriately prescribed.

  4. compsports says:

    Dr Z, the issue isn’t whether meds should be prescribed or not. It is fully informing patients of the risks in discontinuing a med which of course need to be weighed against the benefits.

    And yes, I would say that anything that is difficult to discontinue would be addictive. By the way, you wouldn’t refer to coffee as having discontinuation syndrome, would you? So why would meds like the ones you mentioned be different?

    Regarding someone being addicted to Cymbalta who is being treated for depression, why do all psychiatrists make sure that patients have enough meds during visits? Of course, you want to make sure people are taking the meds if you feel they need them.

    But you and your colleagues also realize that if people run out of meds, they are going to be most likely hurting big time when CT meds. If that isn’t an addiction issue, I don’t know what is.

    It is true that if people usually are tapered that they don’t have problem. But there is a percentage of people ( and no, it isn’t in the .0001% range) of people who have severe problems in getting off of meds even in spite of tapering slowly.

    For example, I know of someone who was wrongly prescribed an SSRI for depression that was misdiagnosed. He can’t get off the med. Who wants to tell him that isn’t addiction?

    Sorry Steve for getting off topic. Of course, I wasn’t too sorry since I responded to this post:)

  5. Iatrogenia says:

    Dr. Steve, you are such a diplomat. Obviously the easy pickings for psychiatry are in stressed-out working women and menopausal women, who are going to be deferential and grateful. Addicts are too rebellious and high-maintenance.

    Conversely, the psychiatrists who go into addiction medicine have no interest whatsoever in tapering people off prescription drugs that cause dependency but are not technically addictive. The physical dependency issues might be similar, but the addiction medicine clientele is distinguished by societal disapproval.

    You might say addiction medicine specialists are more drawn to those they perceive as sinners, and psychiatrists are drawn to those they perceive as needy.

  6. Rob Lindeman says:

    It’s refreshing to read addiction described in such detail without using terms such as “reward center”, “brain dysfunction”, etc. Solid work, Steve!

  7. Anonymouus says:

    Dr. Steve,
    Psychiatrists do treat addicts, I should hope your readers have heard of “co-morbidity”. I have bipolar disorder (cynics may begin smirking, rolling their eyes, etc., at this diagnosis) and have been in a depressive phase for about two months. I have gone through this before and will, most likely, be here again. It is the nature of the disoder and I try not to complicate it with becoming neurotic about it. Anyway,in my infinite wisdom, I decided to start drinking a few weeks ago. After about a week of drinking I left a message for my doctor at 5am on his answering machine to say I was in trouble.. He called me back around 5:30am and told me to bring my husband and get my butt in his office at 7:00am that morning.. Long story, short, we got right to work on it and he had me touch base with him by phone every day until we both felt I was out of the woods. He is an extremely busy doctor with hospital responsiblities and private practice, but above all, he is a mensch.and goes the extra mile as a healer/doctor.

    And, yes I take psych meds, For those of you who think they are to get high or for recreational use, you are very mis-informed. I would gladly never take another medication if I knew I could remain stable and a productive working member of society.

    We all have our crosses to bear in this life, so please try not to be judgemental and see how compassion for others feels. You will find that it eases your own burdens and adds grace to your life.

    .

  8. Mariam Cohen, MD says:

    Anonymous’s story points out why so many psychiatrists do not treat addictions — it takes time and effort and availability. Can’t be done in a 15 minute med check.

    • doctorz says:

      Another reason even well-intentioned psychiatrists don’t treat addiction is that most of us are not qualified following our general residency training. The interventions that are effective don’t require psychiatrists; e.g., AA, CBT. Further, in the case of alcoholism, we really don’t have anything as far as pharmacotherapy that works better than placebo, with the exception of Antabuse, which has a narrow clinical indication. One might ask…What about Naltrexone and Acamprosate? Aren’t they approved? Sure, if you trust their respective manufacturers’ clinical trials. But a 5 year, non-industry funded, multi-center study called the COMBINE, a “CATIE trial” of sorts, sponsored by the National Institute of Alcohol Abuse and Alcoholism, showed that these drugs are not particularly promising. The study examined the effectiveness of various individual therapies and/or combinations of drugs/cognitive-behavioral interventions (along with “medical management”; i.e., basic vitals checks and wellness screenings) in 1383 alcohol-dependent subjects. The only treatment that separated from placebo was Naltrexone without cognitive/behavioral interventions, but there was only a 3% difference in “good clinical outcomes” between the naltrexone only group and the placebo and cognitive-behavioral intervention group (74 vs 71%). Acamprosate was no more effective than placebo.
      Speaking as one who lives in a severely underserved community in the Louisiana delta, there are far too many other conditions that require my experience and qualifications, and yet my availability is not adequate to satisfy that demand.

  9. wilyliam says:

    compsports – I actually would very readily describe the symptoms that occur in some people going without coffee as “discontinuation syndrome” otherwise known as withdrawals, of course. Lots of chemicals bring about dependency – addiction as an illness also encompasses the social and occupational dysfunction (lost a relationship and/or job because of your drug of choice, etc.)

    It’s interesting that some folks here seem so angry about what happens if you run out of Cymbalta (or any other short half life antidepressant …) it is of course standard of care to explain the risks and benefits of any drug in order to obtain informed consent – to deviate from that is bad practice. Funnily enough, heroin users usually don’t have to be told not to let their heroin run out – but somehow it’s everyone else’s fault if you let your Cymbalta script lapse and just quit without tapering it?

    All medications are poisons – when used properly, they can do more good than harm – that’s why you go to school half your life to learn how to use them!

  10. compsports says:

    HI Wilyliam,

    First of all, Happy Thanksgiving to everyone who celebrates.

    Sorry if my previous points were not clear. The issue we need to focus on in my opinion is that the physical dependency problem is very serious and isn’t taken as seriously by the medical community as it should be. This is particularly true for drugs like Cymbalta that have short half lives even when they are tapered.

    Of course, some people will not have these issues but far too many are having them and this need to be acknowledged.

    No matter what it should technically be called, that is where the focus needs to be.

    Thanks!

  11. Daniela says:

    Excellent post! I couldn’t agree more that “addiction is not only the quintessential biobehavioral disease, but also the quintessential human disease.” And that’s what makes it so daunting. Our culture and economy enables it: addictions are extremely profitable. Then there’s the extremely stable co-dependency dynamic of addicts/enablers, the powerful biology of craving, and the personality and character of the addict. AND physician. And that’s the easy part.

    What makes treatment almost impossible is the scamming and lying that addicts notoriously succumb to (even when they’re not sociopaths). Effective treatment requires the patient to be forthcoming. Clinicians need reliable data to work with, so as make an intelligent recommendation. That makes treatment in the traditional office setting impossible. Mostly because there’s no way to corroborate what the patient is telling you. HIPAA supports them in refusing you access to relevant family members and their helpful feedback. Assuming, of course, that family is reliable.

    And that gets to the heart of the treatment problem. Addiction is also a psychological dynamic, a pathological yin/yan. Either you trend toward addiction or toward enabling, it’s one of those relational complementaries from which there is no escape. Physicians as a group want to be helpful, and that’s a set up to become enablers to addict patients. Especially if there are addicts (of any type, drugs, food, shopping, gaming, debting, whatever) in the physician’s family. And who doesn’t have an addict of some type in the family?

    Addict patients don’t want clinicians to fall for the scamming, that’s why they’re in your office. On the other hand, they scam anyway, because that’s part of the problem.

    Effective treatment requires an uncommon level of maturity, medical and psychological sophistication in the clinician, a deep commitment to recovery in the patient, and an economic and social commitment currently not on the table at the government level.

    Decriminalization, and a single payer, government supported health care system would begin to address the profit driven, economic underpinnings of the problem. You may say that I’m a dreamer, but I know I’m not the only one. Thanks for this post.

  12. [...] psychiatry” is the area of psychiatry devoted to the treatment of these complicated disorders.  Certain trends in addiction psychiatry, however, seem to mirror larger trends in psychiatry as  [...]

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