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ASAM's split personality

July 15, 2011
by Lee Tannenbaum, MD
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An ASAM member physician wants less of an emphasis on non-medical treatments
Lee Tannenbaum, MD
Lee Tannenbaum, MD

I returned this spring from the American Society of Addiction Medicine's (ASAM's) annual Medical-Scientific Conference in Washington, D.C., and felt compelled to write a commentary regarding what I see as ASAM's split personality.

I vividly recall how I felt 10 years ago when I first attended an ASAM meeting. I had been a family practitioner struggling to deal with the problem of addicted patients in my community, with virtually no knowledge about what I was doing. When I finally stumbled into an ASAM review course because I needed some CME credits, it changed my life. For the first time, I heard about receptors, evidence-based addiction treatment, outcome data, theories of addiction, medication management, and real doctors treating the real disease of addiction. Since that time I have been to almost every CME activity sponsored by ASAM, have become certified by the American Board of Addiction Medicine (ABAM), and have closed my family practice to focus my career on treating patients with addiction.

So here I was at the Medical-Scientific Conference in 2011 and we are still talking and arguing about the role of 12-Step based programs in the treatment of addiction-programs that are neither medical nor scientific.

As the field of addiction medicine moves forward with the development of residency programs and formalized training programs for young physicians, ASAM is poised to be the dominant voice in directing which ways the addiction field should move. We find ourselves on the verge of being recognized as a real medical specialty, and being in a position to influence how precious medical care and research dollars are spent. However, if we are going to have real doctor responsibilities and if we want to be recognized and appreciated as real doctors treating a real disease, we need to start acting the part.

What we know

Addiction is a chronic disease of the brain. At our current level of understanding it is incurable, but very manageable. Its course, and thus its subsequent morbidity and mortality, is heavily influenced by an individual's environment and behavioral choices, and it is often characterized by variable periods of remissions and relapses. The treatment of addicted patients is complex, challenging, frustrating and rewarding, and requires careful management by dedicated and well-trained experts. However, the components of our disease management strategies should no longer be in question.

We as a medical community know how to manage chronic relapsing diseases. We do it all the time. We therefore know how to manage addiction. Addiction treatment requires participation of the patient, medical stabilization of acute withdrawal symptoms when needed (not “detox,” as there are no toxins being eliminated during this period), further stabilization with medication as indicated for as long as necessary, initiation of psychosocial support with an emphasis on behavioral modifications that are needed to modify the course of the disease, and close, attentive follow-up with appropriate monitoring for exacerbation of the disease process.

Although some patients with chronic diseases might find some of the following procedures helpful or desirable, these certainly are not a required part of our standard disease treatment protocol and should not have a role in real addiction treatment as managed by real addiction doctors practicing real medicine proven by real scientific evidence: yoga, relaxation techniques, acupuncture, educational lectures about the nature of the disease, walks in the park, sweating in the sauna, equestrian encounters, watching movies about or hearing stories from people with the same disease, vitamin therapy, biofeedback, or participation in peer support groups.

Similarly, chronic opioid withdrawal symptoms need to be recognized as such and treated with buprenorphine and not called depression, bipolar disorder, PTSD, ADD, restless leg syndrome, chronic back pain, anxiety, or fibromyalgia and subsequently treated with Neurontin, Seroquel, trazodone, SSRI antidepressants, Abilify, and a variety of other magical concoctions designed to avoid the opioid receptor, the actual dysfunctional cog in the wheel.

Conference talk

Perhaps it is just me, but it seems like every comment I heard about any treatment at the Medical-Scientific Conference was quickly followed by a secondary qualifying statement about how of course it was to be coupled with participation in a 12-Step program. If the speaker did not make this qualifying comment quickly enough, someone from the audience was sure to jump in to make sure it was appropriately acknowledged. “I am going to put this patient in the hospital to treat their severe withdrawal symptoms, but of course afterwards I will refer them to a 12-Step program.”

One presenter even discussed placing his patients on buprenorphine to stabilize their disease of opioid dependence for a short period of time while he worked on getting them into what he called “real treatment.” One audience member suggested that he would withhold buprenorphine from a patient, otherwise doing well, unless that patient had proof of 12-Step meeting attendance. That would be like my saying I tried this approach with a diabetic patient, refusing to refill her insulin because she had not gone to her Weight Watchers meeting. The patient died, but other than that I felt pretty good about it because I was really trying to help her get to the underlying cause of her disease and break her dependence on medication.