In an attempt to address a significant—and unmet—need in contemporary health care, the American Board of Addiction Medicine (ABAM) has accredited ten new residency programs in “addiction medicine.” Details can be found in this article in the July 10 New York Times. This new initiative will permit young doctors who have completed medical school and an initial internship year to spend an additional year learning about the management of addictive disease.
To be sure, there’s a definite need for trained addiction specialists. Nora Volkow, director of the National Institute on Drug Abuse (NIDA), says that the lack of knowledge about substance abuse among physicians is “a very serious problem,” and I have certainly found this to be true. Addictions to drugs and alcohol are devastating (and often life-threatening) conditions that many doctors are ill-prepared to understand—much less treat—and such disorders frequently complicate the management of many medical and psychiatric conditions.
Having worked in the addiction field, however (and having had my own personal experiences in the recovery process), I’m concerned about the precedent that these programs might set for future generations of physicians treating addictive illness.
As much as I respect addiction scientists and agree that the neurochemical basis of addiction deserves greater study, I disagree (in part) with the countless experts who have pronounced for the last 10-20 years that addiction is “a brain disease.” In my opinion, addiction is a brain disease in the same way that “love” is a rush of dopamine or “anxiety” is a limbic system abnormality. In other words: yes, addiction clearly does involve the brain, but overcoming one’s addiction (which means different things to different people) is a process that transcends the process of simply taking a pill, correcting one’s biochemistry, or fixing a mutant gene. In some cases it requires hard work and immense will power; in other cases, a grim recognition of one’s circumstances (“hitting bottom”) and a desire to change; and in still other cases, a “spiritual awakening.” None of these can be prescribed by a doctor.
In fact, the best argument against the idea of addiction as a biological illness is simple experience. Each of us has heard of the alcoholic who got sober by going to meetings; or the heroin addict who successfully quit “cold turkey”; or the hard-core cocaine user who stopped after a serious financial setback or the threat of losing his job, marriage, or both. In fact, these stories are actually quite common. By comparison, no one overcomes diabetes after experiencing “one too many episodes of ketoacidosis,” and no one resolves their hypertension by establishing a relationship with a Higher Power.
That’s not to say that pharmacological remedies have no place in the treatment of addiction. Methadone and buprenorphine (Suboxone) are legal, prescription substitutes for heroin and other opioids, and they have allowed addicts to live respectable, “functional” lives. Drugs like naltrexone or Topamax might curb craving for alcohol in at least some alcoholic patients (of course, when you’re talking about the difference between 18 beers/day and 13 beers/day, you might correctly ask, “what’s the point?”), and other pharmaceuticals might do the same for such nasty things as cocaine, nicotine, gambling, or sugar & flour.
But we in medicine tend to overemphasize the pharmacological solution. My own specialty of psychiatry is the best example of this: we have taken extremely rich, complicated, and variable human experiences and phenotypes and distilled them into a bland, clinical lexicon replete with “symptoms” and “disorders,” and prescribe drugs that supposedly treat those disorders—on the basis of studies that rarely resemble the real world—while at the same time frequently ignoring the very real personal struggles that each patient endures. (Okay, time to get off my soapbox.)
A medical specialty focusing on addictions is a fantastic idea and holds tremendous promise for those who suffer from these absolutely catastrophic conditions. But ONLY if it transcends the “medical” mindset and instead sees these conditions as complex psychological, spiritual, motivational, social, (mal)adaptive, life-defining—and, yes, biochemical—phenomena that deserve comprehensive and multifaceted care. As with much in psychiatry, there will be some patients whose symptoms or “brain lesions” are well defined and who respond well to a simple medication approach (a la the “medical model”), but the majority of patients will have vastly more complicated reasons for using, and an equally vast number of potential solutions they can pursue.
Whether this can be taught in a one-year Addiction Medicine residency remains to be seen. Some physicians, for example, call themselves “addiction specialists” simply by completing an 8-hour-long online training course to prescribe Suboxone to heroin and Oxycontin abusers. (By the way, Reckitt Benckiser, the manufacturer of Suboxone, is not a drug company, but is better known by its other major products: Lysol, Mop & Glo, Sani Flush, French’s mustard, and Durex condoms.) Hopefully, an Addiction Medicine residency will be more than a year-long infomercial for the latest substitution and “anti-craving” agents from multi-national conglomerates.
Nevertheless, the idea that new generations of young doctors will be trained specifically in the diagnosis and management of addictive disorders is a very welcome one indeed. The physicians who choose this specialty will probably do so for a very particular reason, perhaps—even though this is by no means essential—due to their own personal experience or the experience of a loved one. I simply hope that their teachers remind them that addiction is incredibly complicated, no two patients become “addicted” for the same reasons, and successful treatment often relies upon ignoring the obvious and digging more deeply into one’s needs, worries, concerns, anxieties, and much, much more. This has certainly been my experience in psychiatry, and I’d hate to think that TWO medical specialties might be corrupted by an aggressive focus on a medication-centric, “one-size-fits-all” approach to the complexity of human nature.
“Addiction is a brain disease in the same way that “love” is a rush of dopamine or “anxiety” is a limbic system abnormality.”
Thanks for the comment. Steal away. Admittedly, I’m a bit weak in the metaphor department…. I may come up with a better comparison in the shower tomorrow morning (it’s where I do my best thinking!) and edit it, so be on the lookout for new analogies.
BTW, I liked your analysis of panic attacks, very similar to what I’ve written here. Brain disease? Not exactly…
If the experience of the chronic pain community is any indication, rather than “The physicians who choose this specialty will probably do so for a very particular reason, perhaps—even though this is by no means essential—due to their own personal experience or the experience of a loved one” many will do so because there is gold in them thar hills. I know I am jaded but pain became a specialty and subspecialty only when it became apparent there was money to be had; insurance covered more, numbers of patients more numerous, and a number of the ‘treatments’ could be done quickly and for good renumeration.
(author A PAINED LIFE, a chronic pain journey
Pain management is a very, very lucrative subspecialty.
Speaking from experience, addiction medicine is not. Most of our patients are quite different from Dr. Drew’s. However, there are certain places in posh locations like Malibu, Newport Beach, Antigua, and Rancho Mirage where a pretty penny can be made. The question is, do their success rates beat those of the Salvation Army or the AA Fellowship down the street?
Nice rant but no matter what you write, the Medical Industrial Complex will pollute the “new specialty” training. Andrew Weil, Oprah, Bill O’reilly, Chris Matthews, Deepak Chopra, Vitamin D3 and tons of Omega 3 Fish Oil combined aren’t powerful enough to deter the impact of Big Pharma and Super-Coding Medical billing Software from misdirecting this movement. It will also, however, deliver a few alternative therapy radical physicians who might quest for a higher truth after their biased training. I have hope for the potential for that higher truth to provide new meaning to addiction therapeutic strategies. Thanks for the stimulus.
“In fact, the best argument against the idea of addiction as a biological illness is simple experience.”
Very true, but psychiatry abandoned human experience long ago.
“…I’d hate to think that TWO medical specialties might be corrupted by an aggressive focus on a medication-centric, “one-size-fits-all” approach to the complexity of human nature.”
The first quote explains why the fear in your second quote will be realized: In order to justify its existence, addiction psychiatry will have to offer explanations that differ from simple experience, even if simple experience better explains the phenomenon. In fact, the more that simple experience explains it, the further away “experts” will venture in order to make a niche for themselves. You do not complete a fellowship to explain the world the way a generalist or a nonprofessional would…or to offer treatments that non-prescribers can…You go to differentiate yourself further. The market value of simple experience is not reimbursable or career enhancing.
“But we in medicine tend to overemphasize the pharmacological solution.”
I think we can say that now, but the psychopharmacology of addiction is still in its infancy (I hope). I certainly am glad that AA is there to help the few people it does, but its track record is abysmal. It will be great when people can beat addiction w/o having to sacrifice a precious hours of their lives in dingy, smoke-filled church basements.
Steve, fragmentation in medicine has been going on for about 125 years. Fragmentation is usually called by its more politically-correct name, “specialization”. When medicine began to fragment, generalists argued with some justice that specialists tended to forget the person attached to the kidney or the heart.
Now that we’ve reached a point of divisio ad absurdum, that argument is more cogent than ever. Thanks for reminding us that there’s a person attached to the neurons.
In my neck of the woods, most docs, who become certified Suboxone prescribers, are merely adding another dimension to their already enterprising practices. I find it interesting that they tend to raise their appointment costs simultaneously. What a racket! But people are willing to pay to break the habit, and sacrifice necessities to do so. Another example of a well intentioned but incompetent government sanctioned program which provided for a highly structured environment for prescribing this previously dirt cheap combo drug, only to result in a profiteering cottage industry for the company that cleverly fooled Uncle Sam and its prescribers, who in my community, gave up practicing real medicine years ago.
As an alternative to this expensive yet often effective program, particularly so in my depressed opiate dependent patients, I have seen excellent results in managing both the depression and addiction, by treating with conservative dosages of Tramadol (100mg/day on average), a very interesting drug with both SSRI and serotonin releasing properties in addition to having mu opioid receptor agonism, and NOT CONTROLLED, at least not in my state.
Incredibly thoughtful article. You are a man after my own heart. You have one.
I was in the penultimate residency class (1990) at Einstein in the Bronx (now defunct) before managed care swept the country and changed the face of residency training. I was trained in the old model in which psychodynamics mattered, hugely. By master practitioners. But have practiced my entire career in a clinical environment controlled by managed care, which refuses to pay psychiatrists to do a combined treatment (therapy and meds) for more than a few sessions, but will pay for medication management a bit less reluctantly.
I fear what you fear, and suspect the predictions of Gary and Pat Jonas will come to pass. Not even psych residents, much less in internal medicine, family practice, ob-gyn and pediatrics (yikes!) are getting the kind of training in psychodynamics necessary for a decent treatment of garden variety psych patients, much less a population as complex and difficult interpersonally as addicts.
That said, I applaud and support all efforts that seek to alleviate human suffering. Including this one.
I’m enjoying browsing your site. You are a total brainiac. Smiles, Daniela
Thank you, Steve, for your willingness to put yourself out there for those of us who need (or will need) help.
The existence of an AA track record–which is a common “fact” thrown around these days–really should be put to rest once and for all. Neither successes nor failures can be tracked without a database and AA and its members do not allow members to be formerly polled. So that leaves only the industry treatment centers with any data, which would provide only one facet of recovery.
No one knows how many AA successes nor how many failures there are. No one. We can only guess. We look around and say, “I haven’t seen so-and-so in a long time; I wonder whatever happened to them?”. But we dont KNOW they are back out there actively using again. We just know we haven’t seen them in a long time. Some people leave and stay sober. Some people just leave.
And some people, like me, stay. And I can say THIS: when I first began AA in 1985, the most “senior” members of my group had 10 years of sobriety–today it is common to see multiple members with 15-30 years sobriety and more, and that number has been growing each year. But length of sobriety is not a good measurement of the quality either.
I am excited that the professionals are taking a serious look at addiction now. But on behalf of drug addicts, alcoholics and their loved ones, please don’t let the medical community tell us that more “medicine” is the Next Great Answer. Drinking and drugging are a symptom of the “disease” (for lack of a better word). While there IS a physical craving, that’s not all there is to it. Ongoing healthy maintenance of the mind, the will, the emotions, and spirit are vital.
I’m curious to know if the Addiction Specialists, or anyone in this field, are required to read the AA Big Book. Is the elusive “failure fact” being used to dismiss AA as a force in healing? Huge mistake. One of the things we learn in AA is that we don’t have all the answers. Maybe attending open AA meetings should be part of the cirriculum.
One more thing: remember the family. The entire family gets sick when active alcoholism/addiction is present. Healing of the patient will improve more rapidly if the whole family is also treated. It will hinder the patient’s healing if the family environment is unhealthy. The patient spends more time with them than their doctor.
Thank you for allowing me to give you my input. I am looking forward to reading more of your thoughts on this subject.
I just walked away from my pdoc after 6 months when I found out he’s an “addiction specialist” in his other life, 4 days a week in the ‘burbs. He’s licensed for Suboxone, and this “discovery” (he wasn’t hiding anything, but I, OTOH, never dreamed to ask questions that specific) pretty much put the last nail in the coffin for me. It explained a lot about his behaviors, reactions, and lines of questioning, all of which were somewhat problematic for me, but not deal-killers.
From what I read on teh Interwebs, Suboxone-ready docs are aggressively monitored by the DEA, and this is mainly why I walked away. I never asked him for so much as a Xanax ‘scrip, but that kind of scrutiny HAS to have an effect on his treatment decisions – I’d say even moreso than everyone’s current favorite boogeyman: docs who take Pharma cash.
Yesterday, while teaching medical students about addiction, I used the analogy of love as mediated by dopamine. I then read this in your Addiction Medicine reflections: I joined your blog.
Now that “chemical imbalance” is an unfashionable phrase, this new fad for “brain disease” and “neuroscience” makes me want to barf. Oh, this is the new psychiatry?
Of course the brain is involved in all of human experience! All perception and behavior is mediated through the brain. Calling it a disease is a purely subjective and highly remunerative social construct to justify invasive treatment modalities such as medications.
I really like your blog.. very nice colors & theme.
Did you create this website yourself or did you hire someone to do it for you?
Plz reply as I’m looking to create my own blog and would like to know where u got
this from. thank you