The Role of Medicine in Addiction Treatment


JAMA Blog PhotoImagine seeking assistance from a health care facility and being told that you have a progressively debilitating and potentially fatal medical disorder (one widely recognized in the research community as a brain disease), but then discovering that no physician or other medical personnel will be involved in the assessment, diagnosis, acute treatment, or continued monitoring of your condition. Imagine that the vast majority of organizations specializing in treatment of your condition have no affiliation with a hospital or other primary healthcare facility. Imagine the existence of FDA-approved medications specifically for treatment of your condition, but that you will not be informed about nor have access to these medications as part of your prescribed treatment. These are precisely the circumstances encountered today by the majority of people entering addiction treatment in the U.S.

There are more than 18,000 facilities in the United States that specialize in the assessment and treatment of substance use disorders. Surveys of these facilities reveal a low complement of physicians on staff, with nearly half having no physician availability. Publicly funded programs that constitute the bulk of addiction treatment services in the U.S. are particularly lacking in physician services and access to pharmacotherapy as a treatment adjunct.

Physicians are critically needed as part of the multidisciplinary teams involved in addiction treatment. Some of the more important functions they perform include:

*Diagnosing the presence, severity, and complexity of substance use disorders, particularly in distinguishing these disorders from other medical and psychiatric conditions which may manifest as, be masked by, or be self-medicated by excessive alcohol and other drug use.

*Diagnosing and treating acute medical and psychiatric conditions that result from or co-occur with substance use disorders--conditions that if left untreated pose a significant burden within the recovery process.

*Assessing and addressing the physical and emotional toll addiction has exacted on family members.

*Participating in, if not leading, development of a personalized plan for acute stabilization and a more comprehensive plan of sustained recovery management for the patient and family.

*Evaluating the role medications could potentially play in detoxification, acute stabilization, and long-term recovery management.

*Providing guidance on the management of chronic primary health care problems and promoting recovery-enhancing wellness activities, e.g., smoking cessation, diet, and exercise.

*Educating patients and families on the addiction and recovery processes.

*Supervising other members of the treatment team.

*Providing regularly scheduled post-treatment recovery check-ups as part of the long-term recovery management plan.

If you or a family member must enter treatment for a substance use disorder in a program that does not have physician services, I recommend the following two steps.

1) Involve your primary care physician (PCP) in the treatment process. Inform your PCP of the following: you are entering addiction treatment, you would like your PCP to be available for consultation regarding that treatment, you will provide your PCP copies of all records related to your treatment, and you would like your recovery status regularly evaluated through all future check-ups. If you do not have a primary care physician, make obtaining a PCP a priority as part of your treatment/recovery plan.

2) Consider engaging a physician trained in addiction medicine to consult in your overall treatment and to provide ongoing guidance following treatment discharge. It is recommended that such a physician be affiliated with the American Society of Addiction Medicine or the American Academy of Addiction Psychiatry. Addiction medicine specialists in your area can be identified by contacting these organizations.

Beyond these two suggestions, it is critical that anyone seeking addiction treatment become an informed consumer. This requires seeking both experiential knowledge and empirical knowledge about addiction and recovery. The former can be obtained by talking to individuals and families who have successfully resolved alcohol and other drug problems. The latter can be obtained by reading the latest research findings about the critical ingredients of addiction treatment and recovery research findings that have recently been translated for public consumption by the Recovery Research Institute, a nonprofit arm of Massachusetts General Hospital and Harvard Medical School.

Each person in recovery must own his or her own recovery process. A wide variety of professional and peer support services may be helpful along this journey, but it is the person in recovery who must direct this process, assembling diverse consultants who can inform and assist this effort. Physicians and psychiatrists knowledgeable about addiction recovery and experienced in offering guidance through the recovery process can be important and even crucial resources within the recovery process. The challenge for America is to expand the number of physicians and psychiatrists who possess such knowledge and expertise. The challenge for organizations that make up the addiction treatment industry is to assure their staffing patterns match their rhetoric of addiction as a treatable medical disorder.