As a physician reviewing the article by Lee Tannenbaum, MD, in the July/August 2011 issue of Addiction Professional (“ASAM's split personality”), I believe the essay has grossly undermined and inappropriately maligned the supporting non-medical treatments that are essential to high-quality care and evidence-based treatment of the patient with the disease of chemical dependency.
As Dr. Tannenbaum stated in his own article, this disease is heavily influenced by an individual's environment and behavioral choices. The graph included here with this article illustrates the epigenetics of addiction. Today, we do understand addiction as a chronic disease of the brain, and for the past 10 years we have been investigating the processes and factors that add to changing gene environments and contribute to heritable traits. The regulation of the expression of genes through non-coding RNAs is presently being investigated as having a major part in the complex genetic disorder of addiction.
Unlike the genome, the epigenome can be changed by factors and influences in the environment. If you consider that the factors and influences on the gene include stress, toxins, nutrition, behavior and stochasticity, then you also would recognize the importance of nutrition and the close-knit community of 12-Step recovery programs in clinical therapy.
We as physicians would of course continue to administer medical protocols, yet we enhance chances for recovery by employing evidence-based clinical treatment modalities such as 12-Step facilitation,1 cognitive-behavioral therapy (CBT)1 and relapse prevention.2,3,4 Herein lies the importance of clinical therapeutic techniques that Dr. Tannenbaum dismisses.
Given that the epigenetics of addiction is now recognized as playing a major role in the initial achievement and subsequent maintenance of recovery, would it not be prudent to provide an environment conducive to contributing to recovery-related changes that are inherent in such evidence-based clinical interventions as the 12 Steps, CBT, relapse prevention and spirituality?
These are the stress-reducing and behavioral techniques that are being found to play a major role in the silencing or over-expression of noncoding RNAs, which can contribute to or detract from the recovery process.
The National Institute on Drug Abuse (NIDA) has endorsed a two-tiered approach for treating addiction: opioid replacement therapy and abstinence. Dr. Tannenbaum has offered only physician-initiated and -monitored therapy for substance use disorders. Sometimes withdrawal symptoms are best treated with either a cautious attenuation of the chemical aiming toward abstinence or opioid replacement therapy and/or off-label uses of antipsychotics and/or antidepressants temporarily to ease the discomfort of patients in withdrawal.
I do realize that there are clinical and political urgencies to questions about treatment effectiveness. Findings from the Drug Abuse Treatment Outcome Studies (DATOS) have reported that treatment effectiveness is related to patient motivation, problem severity, therapeutic engagement and intensity of services, as well as linkages to community-based social support.5
Addiction is a chronic disease, and its course is influenced by environmental and behavioral factors. What Dr. Tannenbaum's article does not include are the genetic factors of addiction, the comorbidity of addiction, and the epigenetic factors and drug phenotyping that influence addiction.
All of this requires complex chronic disease management-real doctors treating the real disease of addiction. And real doctors do require the collaboration of other real professionals. In recent decades, physicians have made significant strides in developing multidisciplinary approaches to treat many health issues, including addiction.
We do not want to set the world of addiction medicine back about 50 years by ascribing to a very narrowly focused non-academic point of view. We as physicians have a duty to our patients to provide them with the best available care. We need to incorporate the state-of-the-art, evidence-based approaches that the research in this field has provided us.
Barbara Krantz, DO, FASAM, MS, is CEO and Medical Director at Hanley Center in West Palm Beach, Florida. A fellow of the American Society of Addiction Medicine (ASAM), she wrote this article in her leadership role with the National Association of Addiction Treatment Providers (NAATP). Her e-mail address is firstname.lastname@example.org.