The New York Times last week announced a new medical approach to addiction taking hold in America's medical schools, where addiction medicine is becoming a recognized specialty. Although the Times welcomes this development (it was inevitable), it is doubtful it will improve America's addictive dispositions.
Here are the top 10 problems that accompany the Times' announcement, starting with its opening paragraphs:
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?Increasingly, the medical establishment is putting its weight behind the physical diagnosis. In the latest evidence, 10 medical institutions have just introduced the first 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.
1. The new approach isn't new. The Times acts as though psychiatry has been psychoanalyzing addicts and alcoholics for the last 50 years. It hasn't. For some time, the dominant assumption in the field has been that alcoholism is a disease, one in large part physiologically dictated. Certainly with drug addiction, the dominant assumption in the 20th century -- one which was invented in its early part -- is that addiction is a specific physiological syndrome. (Does the Times argue that people think heroin addiction was psychosomatic?)
2. We have inexorably been moving away from defining addiction medically. Due to the idea that heroin addiction is a highly-specific medical syndrome, we were slow coming around to recognizing other drug use -- starting with cocaine and nicotine -- as addictive, which only occurred in the 1980s. Recent decades are actually all about how addiction is being refocused -- even redefined -- in ways that don't stem from biochemistry. It is not because we know more about how nicotine operates that the Department of Health and Human Services decided it was addictive in 1988, after the Surgeon General's Report specifically rejected that idea in 1964.
3. Point to the brain and repeat after me: "It's a disease." The most distressing sentence in the Times article is: "researchers discovered through high-resonance imaging that drug addiction resulted in actual physical changes to the brain." What exactly does addiction look like in the brain -- can we diagnose it that way? Answer: No, we can't. If the idea is that drugs produce significant changes in the brain, how does that distinguish them from, say, sex, eating and other primary activities? That things affect the brain does not make them addictions or diseases -- or determine whether they are healthy or unhealthy.
4. Addiction is no longer about drugs. According to the Times, addiction medicine is about "alcohol, drugs, prescription medicines, nicotine and more -- and [the need to] study the brain chemistry involved, as well as the role of heredity." It is first notable that some of the things on the list -- like the aforementioned nicotine -- have only recently been added. But, more importantly, what goes in that "and more" category? Is the Times aware the DSM-V has added gambling to the list of addictions, while holding in abeyance sex, eating and video games? Is it aware that the leading journal in the addiction field, called Addiction, devoted its last issue to whether food is addictive?
5. The new approach isn't medical. The argument over treating addiction medically as a brain disease isn't with psychiatry, but with the 12 steps. Of course, the 12 steps are anything but medical, but their identification of addiction as a disease has put them so firmly in bed with disease medicine that they will never be extricated. The American Society of Addiction Medicine (ASAM) -- from which the new addiction medical specialty, the American Board of Addiction Medicine (ABAM), grew -- was founded and dominated by 12-step supporters. How remaining 12-step true-believers react to a medicalized, non-spiritual view of the "disease" will be fascinating to watch.
6. The excluded middle. The Times writes as though the world is divided between psychoanalysis and the 12 steps, on the one hand, and brain chemistry, on the other: "Equally maligned is the idea that psychiatry or 12-step programs are adequate for curing a disease with physical roots. Many people who abuse substances do not have psychiatric problems. ..." Anyone out there heard of CBT, motivational interviewing, the community reinforcement approach; of Aaron Beck, Alan Marlatt, and -- ahem -- me (I was selected one of the 10 most influential addiction experts in America)? Considerable research has generated effective non-medical approaches to addiction other than the 12-steps. Will these new medical programs incorporate or ignore them? (The article does note, "Few addiction medicine specialists advocate a path to recovery that depends solely on pharmacology, however.")
7. Pharmaceutical treatments have problems. Although the Times greets new pharmacological treatments as being great breakthroughs, it also has to note some drawbacks, to wit: "Increasing interest in addiction medicine is a handful of promising new pharmaceuticals, most notably buprenorphine (sold under names like Suboxone), which has proved to ease withdrawal symptoms in heroin addicts and subsequently block cravings, though it causes side effects of its own" (emphasis added). The Times adds, "Other drugs for treating opioid or alcohol dependence have shown promise as well." But there is a history of pharmacological treatments appearing, being greeted as remarkable new cures, and then -- disillusionment. This is now the case with the once-highly-touted use of naltrexone in the treatment of opiate addiction, about which an authoritative review of research found: "the general run of opiate-addicted patients do almost as well given no active medication as when prescribed the opiate-blocking drug naltrexone."
And, of course, it is prescription medications to which Americans are increasingly becoming addicted. The subhead of the Times' idolatrous interview with Nora Volkow, the biggest proponent of addiction medicine, read, "An addiction expert faces a formidable foe: Prescription drugs."
8. The medical approach derails self-cure. As the Times conceives the issue:
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 ... "It's not surprising to us now that when you stop the treatment, people relapse," Dr. Alford 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.
So what do we do with the fact that the government's own research has determined that the large majority of alcoholics cure themselves without treatment? Think about smokers in this regard. Forty million American smokers quit on their own through the 1980s, but the idea that they can do so without pharmacological assistance dwindles with each passing year.
9. Those stupid doctors. The fundamental assumption of the article -- and the addiction medicine movement -- is that doctors are fools:
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.
Of course, alternatively, maybe many doctors have seen people quit smoking and cut back their drinking on their own? The single most empirically validated form of alcoholism treatment is brief intervention, which comprises minimalistic interactions between health care workers and alcoholics where medical personnel point out excessive drinking, set goals and discuss methods to cut back with patients, and then track their progress -- usually meaning reduced drinking. Will addiction medicine throw that baby out with the bath water?
10. And what about policy? The Times doesn't juxtapose the massive discussion currently ongoing about drug policy with the addiction medicine movement. But they are deeply entwined. If addiction is a disease caused by drugs (what was that you said about gambling?) it simply makes no sense to loosen penalties and restrictions on drug use, since people will inevitably become hooked when drugs are more readily available. In a fundamental way, the formalized addiction medicine approach challenges efforts to rethink how, as a society, we deal with drugs. Would we willingly loosen carcinogens on our society and our children? So, given the addiction medicine perspective, how can we accept that people voluntarily take drugs (leaving aside prescription medicines, that is, which are now the fastest growing drugs of abuse)?
The new addiction medicine specialty won't result in clear-cut benefits and progress, to say the least. It won't eliminate the disease of concern as the discovery of germ theory led to the elimination of major infectious diseases. Nobody believes it will, or can.
But that it will make the addiction landscape worse -- that is an idea to grapple with.
Stanton Peele: On the Future of Addiction
Kristen Houghton: Addicted to Food? It's a Complicated Relationship
Adi Jaffe, Ph.D.: Drug Rehab Treatment: America's Broken System
Dr. Andrew Lange: What an Addict or Alcoholic Really Needs
Rethinking Addiction's Roots, and Its Treatment ... - New York Times
Drug Abuse and Addiction Causes, Effects, Symptoms, Prevention ...
While you have made valid criticisms over the years about how the "disease concept" is often articulated, I am dismayed that you continue to ignore clear indications that addictions are diseases. The medical definition of disease is broad. See, for example, http://www.nlm.nih.gov/medlineplus/mplusdictionary.html. Addictions fit this definition.
Debates about "disease," though, can be counterproductive. In our work, we refer to addictions as lifestyle-related health problems, like most forms of heart "disease." In brief, lifestyle-related health problems occur by our choices interacting with our level of biological risk. Genetics sets the level of risk, but high-risk behaviors are the triggering agent. Once the body is altered enough, the health problem is present. Genetics and social factors and psychological factors affect the likelihood of engaging in these behaviors. Genetics also affects how much is needed to cause addiction (animal research is as conclusive about this as any research is conclusive about anything).
Medications like naltrexone has been shown to reduce craving in some people. Genetics appears to affect whether a medication is beneficial for a given person. Nevertheless, while addiction is referred to by many researchers as a "brain disease," this does not mean that a variety of forms of treatment are not beneficial. Thoughts, spirituality, diet, exercise, and social connections all affect brain functioning. Many people with addictions do not need addiction professionals or organized support groups to get better, but some do. There are degrees of severity.
While your article is compelling and critical, you have offered no meaningful alternatives for treating addiction.
It's very easy to critique something new, but unless you offer up your expertise into alternatives other than pharmacological agents, I find this to be far too one-sided.
If not, at the very least, Google someone's name before telling them what they haven't produced.
http://www.huffingtonpost.com/stanton-peele/charlie-sheens-addiction-_b_817665.html
I think addition of these alternatives would add very nicely to this current article (Why Medication for Addiction Will Make Our Problems Worse). This is merely a constructive criticism for this Medication for Addiction article as I felt a thorough critique should involve mention of alternatives (to pharmacological addiction drugs).
Here's why it makes sense to loosen penalties and restrictions for drug use:
It's a free country. No one restricts a citizen from working in a coal mine, fiber glass plant or a nuclear power plant. Yes, these facilities are regulate for safety to a point, but workers aren't treated as criminals because they choose to expose themselves to health hazards. So your analogy of releasing carcinogens on our children (it's always the children) is bogus; we already do that with food additives, industrial pollution and contaminated water.
We spend billions annually on law enforcement and corrections dealing with the so called war on drugs. The assumption that we'd spend more on treatment if drugs were legal is unfounded.
The level of violence in the illicit drug industry is increasing at an astounding rate. Profits are of such magnitude as to erode the values of common people and government officials alike on both sides of our borders. The costs to our communities brought on by the trade in terms of lives and treasure far outweigh the costs of treating addiction.
There's no evidence that the repeal of prohibition created a surge in the incidence of alcoholism in this country. "People will inevitably get hooked" on drugs regardless of their legality.
He was saying that if you take the stance the medical establishment has - that addiction is a disease - which he doesn't agree with - it only makes sense to keep drugs illegal, as we do with other substances that cause diseases.
I can't help feeling that we'd see numbers similar to those reported by NIAAA on addiction, especially as many of the addicts who "cured" themselves were self-medicating to deal with those very problems.
Now that 1 in 66 Americans are diagnosed as psychotic, that might be a worthwhile study to undertake.
I guess we are just taking another step in the direction of the relinquishing more responsibility for our health, our state of mind, and the expanding dependence on others to solve our problems.
A recent story in Al Jazeera by James Ridgeway of Mother Jones illuminates the efforts by major pharmaceutical companies to get doctors prescribing medicines like Zyprexa, Seroquel, and Abilify to patients for whom the drugs were never intended.
Read more: http://www.businessinsider.com/zyprexa-antipsycotics-top-selling-drugs-in-us-2011-7#ixzz1Sfq7KCiI
America is truly a weak-minded, pathetic, obese part of the human race- and we are killing ourselves off little by little through our ignorance and the handing over of our lives to corporate interests.
good luck to us all.
Diagnosing criteria has become so vague as each disorder could be applied to almost anyone.
What I find equally disturbing, is that doctors get kick backs for describing these drugs-and how a person is treated depends on what type of doctor you go to.
We are over prescribed and over drugged in this country.
Is it just me, or does the "addiction is a disease" assertion confuse cause and effect? In other words, it is not difficult for me to believe (based on brain science that I've read) that over time, addiction to drugs--or to particular behaviors, performed impulsively and repetitively--might well cause changes to the brain, but it seems ridiculous to then argue that it's a "brain disease." It's an effect like, say, bulemics and bad teeth--throw up enough, and your teeth rot.
I can only compare it to my experience with eating issues and diabetes. Gastric surgery did a lot to mitigate the effects of a life of eating issues, but it did absolutely NOTHING to stop the actual behavior. Ditto with diabetes: the medications lower the blood sugar but do nothing to either stop the progression of the physical disease or (and perhaps most importantly) change the behaviors which exacerbate the condition. Those issues have ONLY improved through the use of psychological and intellectual tools like personal therapy and cognitive behavioral therapy to help me understand why I may be doing things and develop behaviors in other, more healthy, directions. I would think that, if anything, the medical model would interfere with that process of taking responsibility for one's behaviors. A lot of people confuse it with moral issues. I just see it as doing what works.
Huge studies have shown that 80% of addictive people are bipolar. This being said, the bipolar or other medical issues should be addressed by the medical community and the rest, as Wendy said, behavioral therapy. The most proven behavioral therapy has been in a 12 step program because everyone else there has been 'where you are' and truly understands.
It has survived, unchanged, for the better part of a century because it is ideology (religion) not science. Would you trust your doctor to treat you with the same cancer cure as they used 100 years ago? Why would you trust a "counselor" to treat your addiction with something from the same tired old century?
if you are given pills for addictions are you supposed to take them for the rest of your life? as Dr Drew says once an addict always an addict -- some doctors are stupid, and they are often the loudest. Sounds like big money for pharma.