A Doctor’s Most Dreaded Patient: The Addict (Repost)

This is a repost by Dr. David Sack from Psychology Today.

It is an unfortunate reality that most doctors don’t like treating addiction, and they don’t like addicts. They’ll treat the consequences of the disease but they won’t always confront the underlying issues, discuss treatment options or provide referrals to an addiction specialist or even a self-help support group like AA. What’s behind this institutional bias against addicts?

A Health Care System in Denial

Denial keeps addicts stuck in their disease. It’s also keeping our health care system sick. An estimated six million addicts receive health care in hospitals, emergency rooms and primary care clinics each year. This kind of access puts doctors in an ideal position to recognize and treat addiction, yet they receive very little training on how to do so. During medical school, there’s no required course in addiction and only a few states require continuing education in the use of narcotic medications and the management of chronic pain.

In surveys by Columbia University’s National Center on Addiction and Substance Abuse, 80 percent of doctors felt they were qualified to identify drug abuse and addiction, yet only 1 percent correctly identified substance abuse as a possible diagnosis when presented with the case history of an addict. Only 55 percent said they learned how to prescribe controlled drugs during medical school.

This lack of training denies recognition to one of America’s leading public health problems and graduates physicians who are not competent to treat an illness that affects 23 million people. The fact that doctors tend to focus on the illnesses they can treat isn’t entirely bad – it means they understand their own limitations and treat patients they feel they can truly help. The broader issue is how we train our nation’s health care providers.

Fortunately, as knowledge spreads that addiction is a chronic brain disease, not a moral failing or lack of willpower, efforts are underway to educate more doctors about addiction. Although some institutes have offered programs in addiction medicine for years (without accreditation), the American Board of Addiction Medicine has begun training doctors in the first accredited residency programs in addiction medicine.

The goal of these programs is to establish addiction medicine as a recognized and respected specialty similar to pediatrics or dermatology. A new doctor can now specialize in addiction as a primary residency, where they will learn how to recognize and diagnose addiction, prescribe medications appropriately, and guide patients through their treatment options.

A Shared Prejudice

Even when doctors have the knowledge needed to treat addicts, they don’t always want to. Doctors share the prejudices of the societies they live in and we have a very strong bias in our country against people with addictions. Many blame addicts for being immoral, unmotivated or weak and don’t believe they deserve to get better. Inexperience and lack of education advance a view of addicts as criminals rather than sick patients.

Indeed, addicts can be tough patients. Even if they can admit to a drug problem, not every addict is ready to get help. A physician who confronts the issue may be met with denial and anger rather than gratitude. During treatment, the problems aren’t limited to what the doctor sees in the office as addicts also struggle with legal, financial and family problems.

Treating the disease of addiction can be extremely challenging. Addiction is a chronic brain disease for which there is no cure or quick fix. Since it has both biological and behavioral components, treatment can’t be limited to a single intervention – say, medication. While a number of medications, such as naloxone and Suboxone, have proven useful in treating addiction, lasting recovery requires learning a new way of life.

Treatment typically requires a blend of medication, therapy and self-help support groups, and is most effective when delivered by a multidisciplinary team of professionals. To fully understand the illness, the doctor must learn about the patient’s entire profile, including their family history, lifestyle, home environment and any psychiatric conditions. When addiction is complicated by co-occurring mental health disorders like depression or anxiety, patients need specialized, integrated care. Because every individual has different needs, a one-size-fits-all approach is ineffective. There is no “take two of these and call me in the morning” for addiction.

High Stakes, High Rewards

These complexities, combined with a high relapse rate, can make addicts a frustrating bunch to treat. In few other fields are the stakes so high. Substance abuse disorders are a leading cause of death in the U.S., and successful treatment requires a long-term commitment.

What makes addiction complex is also what makes it interesting to treat. Doctors are in a position to do a lot of good – in every field, but especially addiction. They have a unique opportunity to destigmatize an illness just as the profession has done with cancer and other misunderstood diseases. It’s a chance to break the mold – to treat addicts like human beings, to approach addiction as a medical problem and to help patients not only get well but completely change the course of their lives.

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