Addiction has historically been viewed not as an illness, but instead as either the personal choice to engage in bad behavior or a lack of self-control over intoxicants. But a growing body of research has demonstrated that genetic and neurochemical factors play large roles in substance dependence.
Increased understanding of the science of addiction has led to a new way to thinking and speaking about substance dependence, for example the phrase ‘disease theory of addiction’ replaced by ‘the disease of addiction.’
Of course there will always be members of society who see addiction as a lack of will power, and I sometimes wonder whether the definition of addiction as a disease by the medical profession is more a matter of lip service than of actual belief. But at least according to ‘medical political correctness,’ addiction has gained standing as an illness that warrants research dollars, rather than a character flaw that warrants public scorn.
I can’t help but think, though, that when it comes to treating addiction, we doctors are a bit late for the party. The medical profession has not shown the same zeal to be the leaders among the various healing professions when it comes to treating the disease of addiction, as seems to be the case for other diseases. Organized medicine clearly wants to be at the top of the food chain for treating cancer and heart disease, with dieticians, nurse practitioners, and holistic practitioners in supporting roles.
And in the world of pain management, the field of medicine looks down a snobbish nose at chiropractors and naturopaths, even fighting, over the years, to block parity for such specialties for payments from health insurers. There has been no such fight by organized medicine to lead the treatment of addiction, almost as if the medical profession has recognized that it has little to offer those people. In defense of the medical profession (I guess), until recently that may have been the case!
The approach for treating addiction has undergone significant change in recent years, both for addiction treatment in general, and for treatment of opioid dependence specifically. Treatment programs have long used clinical judgment and formal algorithms to allocate resources depending on need, with patients placed into different treatment paths depending on their need for initial hospitalization, the severity of their addictions, and the history and nature of prior attempts at sobriety. Treatment paths are also (perhaps even primarily) affected by patients’ financial resources. Residential treatment costs from $5,000 to $50,000 per 30 days of a 90 day program, far beyond the reach of most people with addictions—let alone after the typical financial consequences of opioid dependence!
Residential treatment programs have been the gold standard for addiction treatment, and medical professionals usually have a limited role in such programs. The treatment process can be divided into three stages; detox or detoxification, definitive treatment, and aftercare. Physicians have traditionally been involved only for detox, providing monitoring and medication to prevent the most serious consequences of withdrawal, and in some cases to make withdrawal more bearable.
After patients finish several days of detox, physicians are usually happy to turn patients over to the care of ‘addiction counselors,’ people who often are in recovery themselves, and who, physicians assume, understand the world of addiction much more than physicians would ever care to!
Going forward I’ll describe the traditional approach to treating opioid dependence. Then we’ll discuss the dramatic changes to that approach that have occurred during the past decade.