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.