The spiritual side of recovery is a critical side without which patients in recovery are often described as being a “dry drunk.” Yes, they’re sober, but they won’t be for long. But what about the medical side? Indeed, what is the medical side? What in fact does the term “medical” mean when it comes to addictive disease?

For many years, clinicians fought to educate the public and one another as to addiction’s incorporation into the disease rubric. Substance use disorders have since been accepted as disease processes, sitting on the podium next to diabetes, hypertension, and cancer. Each such disease has a usual course, a usual pattern of signs and symptoms, and a usual pattern of outcomes. Intervention, properly carried out, results in a potential change in disease course and outcome. The intervention can take a variety of forms, as it can with nearly all other diseases.

So what is a medical intervention? We are speaking of a disease process. Is not any intervention that results in an altered disease course and outcome a medical intervention, no matter who carries out that intervention? Or is the medical intervention defined not by content but by delivery agent such that if I intervene, it is a medical intervention no matter what I do, and if a counselor intervenes, it is not a medical intervention?

Is this entire point purely semantic? I’ve recently come from an effort in which there were marked disagreements with respect to such terminology. I would indicate, for example, that an alcoholic patient coming to our clinic would be treated using a medical model. The medical model is a biopsychosocial one, of course, and incorporates spiritual interventions just as it does pharmacologic. Some found the term offensive, however, and felt that I was being exclusionary. There are two social workers in my private medical practice; I’ve always felt that we use a medical model there, and that they and I are instruments of that model. But there the topic has never come up.

I used the term clinic alongside medical a few sentences ago. There too, some were offended by that term, feeling that it presents a medical feeling. Instead of a warm spiritual place, they visualized doctors handing out pills. Clinic is often defined as a facility in which professionals of differing educational backgrounds work together. My private practice is therefore defined as a clinic, I suppose. As I began to explore medical terms with respect to substance use disorders, I discovered that a great many facilities go to extremes to avoid the medical disease terminology that we’ve worked so hard to achieve.

Keeping “medical” out of treatment
Sierra Tucson, on their website, starts out by saying that “...pain is met with compassion, fear is met with reassurance, and anger is met with understanding.” How about “addicts are met by a medical team skilled in a rapid evaluation, diagnostic work-up, and individualized intervention.” The facility refers to itself as “more than a drug treatment center,” and they are. I’ve toured the facility; it’s a hospital. But you wouldn’t know that from the site’s home page. Betty Ford welcomes you to her program’s website by speaking of alcoholism and drug addiction, of intervention, of disease, and of her Center as a place which offers “hope and a special place of healing.” Hazelden’s front page offers a thought for the day as well as mission, vision, and values statements. There is nothing distinctly medical here. The Caron Foundation provides, according to their home page, “an enlightened, caring treatment community.”

And what about the images: Hazelden shows sugar maples in the fall; Betty Ford shows only a picture of Mrs. Ford; and Sierra Tucson shows the Catalina mountains, an adobe building, and some people sitting on floor mats. I don’t see any doctors walking around with stethoscopes. I don’t see anyone dressed professionally. A quick glance might leave one thinking that the patients are roaming the campus on their own. Caron has a few close-ups of people, an early black and white of Chit-Chat Farms, and a photo of, I suppose, one of their current buildings.

The term “medical” is scary, I suppose. It reflects upon our own potential for sickness and ultimate mortality. I’m sensitive to its use among patients: if I have a patient newly diagnosed with cancer, I don’t say, “You need immediate medical treatment.” On the other hand, given a patient newly diagnosed with a substance use disorder and alternatives of “You need to participate in a drug treatment program” and “Medical treatment can be very helpful here,” I’ve always felt that the latter is better received. It therefore intrigues me that our own websites where we describe our treatment for substance use disorders go to extreme lengths to avoid implying any medical involvement.

Since so many of those working in this field, and a majority of those reading this column, are not physicians, does that make our overall treatment of this disease less medical? I think all of you provide medical care. Do you agree? When you read that, is your reaction one of annoyance that I would imply such a horrible thing, one of distress that you’re associated with a medical intervention, one of gratitude that I recognize the importance of your efforts, or one of embarrassment for my foolishness at saying such a thing? Or is the real problem with the vast majority of physicians and other clinicians who don’t recognize the importance of spirituality and other similar modalities and intervention forms? Are they causing problems for me and my desire to have "medical" be an all encompassing term for that which treats and addresses addictive disease?

Dr. Gitlow is on the Board of the American Society of Addiction Medicine and serves as Chair of the American Medical Association’s Task Force on Alcohol. His views here are his individually held opinion and do not necessarily reflect the views of the AMA or of ASAM.

This article is published in Counselor,The Magazine for Addiction Professionals, December 2005, v.6, n.6, pp.32-33.

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