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Trends that are transforming the field

July 1, 2009
by Gary A. Enos, Editor and David Raths
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New information is altering many old assumptions about treatment

In Addiction Professional we have written about everything from treatment's tried-and-true approaches to compelling ideas advanced by little more than one intriguing mouthpiece. We decided it might inspire some dialogue if we reported on some of the trends we see as having a transformative effect on addiction services.

The eight developments analyzed below, listed in no particular order, are among the subjects that are informing treatment or challenging treatment orthodoxy. What are your thoughts on the trends that will alter the way services are delivered in the future? Share your ideas with us by sending a message to us at

Science fiction may be close to fact

The addiction community has come a long way since the days when eggs in a frying pan passed as an accurate visual representation of the disease. But even though it has been 15 to 20 years since the initial publication of brain research that has uncovered many structural and functional clues to addiction, many believe there is much, much more to come.

“The beauty, and our dilemma, is that the brain is the most complex organ system,” says Joe Frascella, PhD, director of the National Institute on Drug Abuse's (NIDA's) Division of Clinical Neuroscience and Behavioral Research. “We're understanding some of the pathways, but are we close to understanding it all? We're in the infancy stage, I'd say.”

These days, the old messages about “your brain on drugs” have been replaced with, well, an actual brain. The image of two flat-screen computer monitors flanking the office desk of NIDA director Nora D. Volkow, MD, depicting images of healthy and drug-affected brains, has become part of the treatment community's collective psyche, with promise of more effective treatments to be generated from the various discoveries in the lab.

The two technological drivers of new discovery have been positron emission tomography (PET) scans, broadening the understanding of the structural changes brought on by specific drugs, and functional magnetic resonance imaging (fMRI), which came along later to allow researchers to monitor in real time how behaviors bring about functional changes in the brain.

Treatment providers are paying attention. “Substance abuse is now being correlated with regional effects on the brain so that, for instance, the amygdala might be more excited and the prefrontal cortex is under-activated and lower-functioning with resultant problems,” says Kevin Wadalavage, who oversees outpatient clinics for the Outreach Project agency in New York City.

“I am hoping that this research leads to several things, including the empowerment of patients with addiction to see why they are addicted and what they can do about it, just as with other disorders that have neurological implications,” Wadalavage adds.

Frascella says there is much reason to believe that technology for exploring brain structure and function will continue to advance, with possible combinations of various technologies' optimal capacities perhaps being the next frontier in research. He says it is critically important for field professionals not to interpret the findings as indicating that medications alone will be the interventions that emerge from the new science.

“We're trying to encourage initiatives that use brain imaging to look at behavioral treatments,” Frascella says. As the field learns more, for instance, about what areas of the brain are associated with craving, it could be nearing a point where individuals could be trained in ways to “turn on and off” parts of their brain during the precarious early stages of recovery.

“This sounds like science fiction, but there are studies out there that are getting interesting results,” Frascella says.

Physicians become a significant influence

As more has been learned about addiction as a brain disease, the mainstream treatment community continues to ask whether physicians want to assume a significant role in treatment or would rather look away from a complicated problem whose sufferers are thought to lack motivation to get well. A physician leader who has been instrumental in major initiatives to involve doctors directly in substance use treatment insists physicians are ready to assume the challenge.

“The medical profession is rising from a prolonged slumber, and is increasingly recognizing that physicians must be adequately trained to prevent, recognize and treat substance use disorders,” says Larry M. Gentilello, MD, professor of surgery at the University of Texas Southwestern Medical Center in Dallas.

With a greater understanding of the extent to which individuals with at least a problem level of drinking or drug use could be assisted in everyday general medical settings, the numbers are becoming too compelling for physicians to ignore. “Nearly one out of four patients seen in health care settings for routine medical problems would screen positive if evaluated for addictive or harmful alcohol use, illicit drug use, or use of prescription drugs for non-medical reasons,” Gentilello says.

Gentilello has been involved in integrating screening and brief intervention (SBI) strategies into emergency medical care settings, where so many of the presenting problems are ultimately found to have a link with substance use. He was also a leading voice in the successful push to develop billing codes for SBI that have ushered in Medicare, Medicaid and private insurance reimbursement for these services.

Also at present, 10 medical residency programs have been funded to provide comprehensive training on substance use issues, indicating that addiction is taking its place in the education of the next generation of doctors.