Yesterday the New York Times ran a story called “Rethinking Addiction’s Roots, and Its Treatment,” about how medical schools are starting to establish accredited residencies in addiction medicine. This would allow med students who have completed such residencies to enter the field of addiction medicine right out of med school, rather than go through additional training.
So glad to see the NYT covering addiction issues. Something that needs to continue, in order to bring addiction into the national public health discourse. But:
Lots of complaints in the comments section about how problematic this story is.
Here are a few I found.
Problem 1: The Diabetes Analogy
Man, what a tired analogy. Let’s either get rid of it, or take it all the way. Right now, people only take it up to the point where diabetics inject insulin—implying “real” addiction treatment should be about drugs. Then they miss a critical part: most cases of diabetes these days are Type 2, which indeed has a genetic component but is largely influenced by poor “lifestyle” factors: smoking, drinking, and obesity. These problems are all related to addiction, and they all have underlying psychological drivers about alleviating stress.
Another critical part missed: in the vast majority of cases of diabetes, the pancreas never recovers its function, whereas in the vast majority of cases of opioid addiction, the opioid receptors do recover their normal functioning—if, at some point, when the recovering person is ready, they’re allowed to remain abstinent for a while.
Both addiction and Type 2 diabetes can be considered the result of unfortunate genetics and poor lifestyle choices. As for treatment: insulin doesn’t “cure” diabetes. While no drug or treatment could restore the function of the pancreas to normal, treating the cause of diabetes would address the underlying compulsions—the addictions—so people wouldn’t continue to smoke, drink, and eat compulsively.
The diabetes/insulin analogy drives the ending of the NYT story, where Suboxone comes in to save the day for a 53-year-old patient on bupe maintenance. This sets up Suboxone (and, implicitly, other future Miracle Drugs), as the magic bullet that can “cure” addiction simply by “blocking cravings.”
Problem 2: Unexamined Conflicts of Interest
Is it really news that “the medical establishment is putting its weight behind the physical diagnosis”? The medical establishment, in the U.S. at least, is largely funded by Big Pharma—through government institutions such as NIDA. The most recent study on extended-release buprenorphine, the opioid drug in Suboxone and other preparations, was funded by NIDA to the tune of $7.6 million. The government did not hire the researchers of this study independently; the grant went to Titan Pharmaceuticals, the maker of the proprietary buprenorphine formulation being studied, who then turned around and picked the UCLA researchers—who were already being paid speakers’ fees and research funds from both Titan and Reckitt Benckiser, the makers of Suboxone.
Problem 3: The Split Between Medicine and Psychology in Recovery
It’s important that med schools are starting addiction-medicine residencies—this helps to educate more doctors about addiction. Nora Volkow makes a good point when she says it’s a “very serious problem” that general practitioners lack knowledge about addiction—this is true, and leads to the corollary thought that it might actually be best to spend the money training primary-care physicians in addiction, rather than create more specialists. PCPs are on the front lines; they’re the ones prescribing, for example, the most Oxycontin and Vicodin. They could do with more education about addiction.
And it’s important to think of recovery from addiction as the management of a chronic problem, the way high blood pressure and diabetes are managed. (Addicts have been thinking of the problem this way for a long time. 🙂 )
But why should we automatically think about addiction as EITHER a medical OR a psychological problem? Why can’t its treatment involve both disciplines, as well as others? Most active and recovering addicts and alcoholics are able to articulate the experience that addiction involves not only their physical response to the substance or behavior, but also a psychological component—we use/drink/eat/gamble/have compulsive sex to alleviate “stress.”
“Bringing Respectability to Addiction Medicine”?
In the third graf the writer mentions a guy named David Withers from a rehab called Marworth (a physician? addiction specialist? the writer does not tell us… aha! quick Google search reveals he’s an M.D. and associate medical director at Marworth). Withers says that the establishment of residencies in addiction medicine is “the first step toward bringing . . . respectability and rigor to addiction medicine.” What a slap in the face for the many doctors in America already dedicating their practices to addiction medicine. Be interesting to hear what, for example, Dr. Drew thinks of this (as of this morning he hasn’t yet tweeted on it). I intend to call my local, renowned rehab and speak to the well-known medical director about this statement.