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Is there a doctor in the house?

December 30, 2013
by Roland Reeves, MD
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Why are doctors often on the periphery—or absent altogether—when the disease being treated is addiction?

“Who needs a doctor anyway?” some might ask. “They just push drugs and make you switch addictions. I got clean without a doctor.”

I have heard such comments from those actively addicted, but sadly I’ve just as often heard them from stalwart pillars of recovery groups and from those entrusted with the treatment of individuals.

Today we study the disease of addiction in detail, we spend billions on it, but in the opinion of many we do not always do a very good job of treating it. It is clear that too often doctors do not have a clearly defined role in the process. Instead, to too great an extent the industry is characterized by “boutique programs with screenings and assessments made by salespeople,” as a commenter on an Addiction Professional article last July wrote.

While there are many fine programs providing high-quality care for this disease, the treatment industry is heavily populated with facilities selling the easier, softer way, with absolutely no evidence-based practices. A perusal of the Internet reveals numerous centers with claims of amazing success rates, leaving one to wonder why addiction even continues to be a problem!

Thomas McLellan, PhD, director of the Treatment Research Institute (TRI), states in the introduction to Anne Fletcher’s book Inside Rehab that “seriously addicted people are getting very limited care at exhaustive costs and with uncertain results.” Consider the success rates of any of the centers described in Fletcher’s book. “Success” in this context can be defined as an arrest of the progression of the disease manifestations that lasts. Apply this standard to the treatment of a loved one for cancer or heart disease. Is that good enough?

The National Center on Addiction and Substance Abuse’s (CASA’s) 573-page report on the gap between what has proven successful in addiction treatment and what is found in many programs is not an indictment of thousands of competent and diligent therapists in this field. Rather, it is an incrimination of the medical field for allowing a disease that last year killed more people than the death toll at the peak of the AIDS epidemic to remain “largely disconnected from mainstream medical practice,” as the report states.

Disease management model

Our medical system makes sure that someone going home after having been admitted to a hospital in a coma and found to have diabetes receives appropriate aftercare. This includes home visits to educate and evaluate, with frequent reports to the doctor. Appropriate medications are given, patients are instructed in continued self-care, and adjustments to treatment are made based on information obtained from patient logs. If a patient does not remain engaged, phone calls and even visits from social services are made to re-engage the patient. Some addiction programs, particularly those required for impaired physicians, involve this same level of vigilance. Now we need the medical community to do the same for non-physicians with addiction.

We must treat one patient at a time in the manner that each deserves. This can mean arranging follow-up with an American Society of Addiction Medicine/American Board of Addiction Medicine-certified physician, or one with experience in addiction, if possible.

We can begin the process of formulating and implementing a chronic disease management plan upon initial encounter with an addict/alcoholic. Know that a Suboxone-certified doctor is educated only about Suboxone, not all the intricacies involved with the treatment of addiction. Doctors at every level must become involved extensively in the disease management process. Such an effort can eventually lead to insurance, policy and medical education changes that are needed on a much grander scale to make a real difference.

A disease of the pancreas called diabetes can lead to abnormal glucose levels, and subsequently alterations in vision, renal function and every system associated with small vessels. All of this must be treated with a multidisciplinary approach. A brain disease called addiction leads to abnormal dopamine levels and a cascade of subsequent chemical alterations resulting in abnormal behaviors and a change in fundamental drives. This too requires a multidisciplinary approach to treat the resulting sickness of mind, body and spirit.

Addressing the spiritual

Capable therapists and psychologists most ably treat the mind. The medical community must up its game in the body portion of treatment. The entire industry must evolve with an insistence on making available the evidence-based treatments that today are available in a minority of treatment centers. Only if that is done can the third, and I believe most important, portion of the disease can be addressed: the spiritual portion.

Chemical processes in the brain lead to consciousness and behavior. They also result in intuition, fairness, love, and ultimately peace. Chemistry contributes to spirituality. We must recognize that this continuum from cellular chemistry through spirituality is a two-way street. Changing one’s spirituality leads to chemistry changes. Medication can change neurochemistry temporarily. Meditation changes dopamine. Acceptance changes serotonin. Doctors, therapists, and self-help groups are all imperative components of the treatment of this complex disease.

Therapists are usually “in the house.” Where are the doctors?