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Addiction Medicine: A New Specialty Or More Of The Same?

July 14, 2011

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.

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