Rethinking Addiction’s Roots, And Its Treatment
By DOUGLAS QUENQUA
Published: July 10, 2011
There is an age-old debate over alcoholism: is the problem in the sufferer’s head — something that can be overcome through willpower, spirituality or talk therapy, perhaps — or is it a physical disease, one that needs continuing medical treatment in much the same way as, say, diabetes or epilepsy?
Bryce Vickmark for The New York Times
Christine Pace, an addiction specialist, examined Derek Anderson, a former heroin addict, at the Boston University Medical Center.
Increasingly, the medical establishment is putting its weight behind the latter diagnosis. In the latest evidence, 10 medical schools have just introduced the first-ever accredited residency programs in addiction medicine, where doctors who have completed medical school and a primary residency will be able to spend a year studying the relationship between addiction and brain chemistry.
“This is a first step toward bringing recognition, respectability and rigor to addiction medicine,” said David Withers, who oversees the new residency program at the Marworth Alcohol and Chemical Dependency Treatment Center in Waverly, Pa.
The goal of the residency program, which started July 1 with 20 students at the various schools, is to establish addiction medicine as a standard specialty along the lines of pediatrics, oncology or dermatology. The residents will treat patients with a range of addictions — to alcohol, drugs, prescription medicines, nicotine and more — and study the brain chemistry involved as well as the role of heredity.
“In the past, the specialty was very much targeted toward psychiatrists,” said Nora D. Volkow, the neuroscientist in charge of the National Institute on Drug Abuse. “It’s a gap in our training program.” She called the lack of substance-abuse education among general practitioners “a very serious problem.”
Schools offering the one-year residency include St. Luke’s-Roosevelt Hospital in New York, the University of Maryland Medical System, the University at Buffalo School of Medicine and Boston University Medical Center. Some, like Marworth, have been offering programs in addiction medicine for years, simply without accreditation.
The new accreditation comes courtesy of the American Board of Addiction Medicine, or ABAM, which was founded in 2007 to help promote the medical treatment of addiction. The group aims to get the program accredited by the Accreditation Council for Graduate Medical Education, a step that requires, among other things, establishing the program at a minimum of 20 schools. But it would mean that the addictions specialty would qualify as a “primary” residency, one that a newly minted doctor could take right out of school.
Richard Blondell, chairman of the training committee at the ABAM, said the group expected to accredit an additional 10 to 15 schools this year.
The rethinking of addiction as a medical rather than strictly psychological disease began about 15 years ago, when researchers discovered through high-resonance imaging that drug addiction resulted in actual physical changes to the brain.
Armed with that understanding, “the management of folks with addiction becomes very much like the management of other chronic diseases, such as asthma, hypertension or diabetes,” said Dr. Daniel Alford, who oversees the program at Boston University Medical Center. “It’s hard necessarily to cure people, but you can certainly manage the problem to the point where they are able to function” through a combination of pharmaceuticals and therapy.
Central to the understanding of addiction as a physical ailment is the belief that treatment must be continuing in order to avoid relapse. Just as no one expects a diabetes patient to be cured after six weeks of healthy diet and insulin management, Dr. Alford said, it is unrealistic to expect most drug addicts to be cured after 28 days in a detox facility.
“It’s not surprising to us now that when you stop the treatment, people relapse,” he said. “It doesn’t mean that the treatment doesn’t work, it just means that you need to continue treatment.” Those physical changes in the brain could also explain why some smokers will still crave a cigarette 30 years after quitting, Dr. Alford said.
If the idea of addiction as a chronic disease has been slow to take hold in medical circles, it could be because doctors sometime struggle to grasp brain function, Dr. Volkow said. “While it is very simple to understand a disease of the heart — the heart is very simple, it’s just a muscle — it’s much more complex to understand the brain,” she said.
Boosting interest in addiction medicine are a handful of promising new pharmaceuticals, most notably buprenorphine (sold under brand names like Suboxone), which has been proven to ease withdrawal symptoms in heroin addicts and subsequently block cravings, though it causes side effects of its own. Other drugs for treating opioid or alcohol dependence have shown promise as well.
Few addiction medicine specialists advocate a path to recovery that depends solely on pharmacology, however. “The more we learn about the treatment of addiction, the more we realize that one size does not fit all,” said Petros Levounis, who is in charge of the residency at the Addiction Institute of New York at St. Luke’s-Roosevelt Hospital.
Equally maligned is the idea that psychiatry or 12-step programs are adequate for curing a disease with physical roots in the brain. Many people who abuse drugs or alcohol do not have psychiatric problems, Dr. Alford noted, being quick to add, “I think there’s absolutely a role for addiction psychiatrists.”
While each school has developed its own curriculum, the basic competencies each seeks to impart are the same. Residents will learn to recognize and diagnose substance abuse in patients, conduct brief interventions that spell out the treatment options and prescribe medications to help with withdrawal and recovery. The doctors will also be expected to understand the legal and practical implications of substance abuse.
Christine Pace, a 31-year-old graduate of Harvard Medical School, is the first addiction resident at Boston University Medical Center. She got interested in the subject as a teenager, when she volunteered at an AIDS organization and overheard heroin addicts complaining about doctors who could not — or would not — help them.
Earlier this year, when she became the in-house doctor at a methadone clinic in Boston, she was dismayed to find the complaints had not changed. “I saw physicians over and over again pushing it aside, just calling a social-work consult to deal with a patient who is struggling with addiction,” Dr. Pace said.
One of her patients is Derek Anderson, 53, who credits Suboxone — as well as a general practitioner who 6 years ago recognized his signs of addiction — with helping him kick his 35-year heroin habit.
“I used to go to detoxes and go back and forth and back and forth,” he said. But the Suboxone “got me to where I don’t have the dependency every day, consuming you, swallowing you like a fish in water. I’m able to work now, I’m able to take care of my daughter, I’m able to pay rent — all the things I couldn’t do when I was using.”
“The goal of the residency program, which started July 1 with 20 students at the various schools, is to establish addiction medicine as a standard specialty along the lines of pediatrics, oncology or dermatology. The residents will treat patients with a range of addictions — to alcohol, drugs, prescription medicines, nicotine and more — and study the brain chemistry involved as well as the role of heredity.”
What with the vicious destruction caused by the monumental failure known as the War on Drugs (which really translates into the War on the Black Community & the Poor), so many people who should have been given medical treatment to combat this illness were instead sent to prison.
Once upon a time in America’s history, drugs were legal. Yes, cocaine [for flatulence, ulcers and sores] , heroin, an opium derivative [as a cough medicine for children].
Marijuana [for nausea, labor pains, rheumatism], opium/morphine [as an abortifactant], laudanum, now known as Tincture of Opium [an opium-based painkiller], used by nursing mothers to quiet babies, and as an analgesic and cough medicine—all were legal drugs used in many forms, all were consumed by your average Jane Doe, for health reasons, and all were dispensed with their doctor’s approval.***
***Information from the Merck’s Manual, 1899, reprint of the original manual on the 1ooTH Anniversary re-issue in 1999.
Needless to say, there were drug addicts then,
as there are now, all facing the same withdrawals, pain and dependence on the drugs.
Then decades later came the monstrous War on Drugs which has done more harm than good. This started at the beginning of the last century, when the fear of legal drug used was addressed with the following: the Pure Food & Drug Act of 1906 [which created the federal agency now known as the Food & Drug Administration], the Harrison Tax Act of 1914 and the Marijuana Tax Act of 1937. The war escalated when President Richard Milhouse Nixon started his campaign to end drug usage in America. In this year of the 40TH Anniversary of the so-called War on Drugs (a term coined by Nixon in 1973 during his administration, and with the creation of the Drug Enforcement Administration), drug users should be given job-training, substance abuse counseling, job opportunities, and psychiatric counseling. A non-criminal approach to drugs is more proactive than a criminalized draconian beat down on those suffering from drug addiction. The dismal, hateful War on Drugs has been a collossal failure.
America’s government and judicial systems will have to come to terms on the following linchpin: legalizing and regulating drugs; there is no more shoving the head into the sand over this issue. Then again, which drugs should be legalized? Which drugs should not? How will they be classified–and how will they be dispensed pharmaceutically? And at what level under the 1970 Controlled Substances Act(aka, Comprehensive Drug Abuse Prevention and Control Act of 1970)?
If drugs are legalized, what effect would this have on the illegal sellers of drugs? What effect on law enforcement, especially the so-called drug task forces which depend on federal funds allocated to them? Money spent on so-called drug task forces (which are nothing but stormtroopers in Black communities) and addict incarceration that would be better spent on treatment for addicts–how would that money be funded to treatment programs to help the addicted? Fewer funds on the pathetic War on Drugs, and more money to help addicts would be more proactive.
Also, what about the uninsured addicted? How will they receive treatment when many do not have insurance, often the first thing that is asked of the patient, by staff, nurses, physicians, and hospitals? How will they be insured by insurance companies, especially with the stigma placed on drug addicts? Since physicians’ financial payment comes mostly from insurance, how many addicts will be turned away from treatment because they do not have insurance? How will this affect the big pharmaceutical companies that manufacture drugs that are the bread-and-butter lifeline of their financial gains?
People who have succumbed to the addiction of drugs need what they were receiving in this country, at the beginning of the last century up to the 1970s and 1980s with drug treatment programs. Putting people in prison for drug usage when their crime was using drugs in a non-violent act, fills up the prisons with people who need medical treatment for their drug addictions.
The prisons are too full now with the sentencing of drug users.
Free up that space for those who really should be in prison. . . .
rapists, child abusers, murderers, kidnappers. . . .
With so many non-violent drug users in prison, there is very little room left to incarcerate those who are guilty of the latter crimes.
And those who have become addicted to drugs should not be imprisoned for their use of drugs.