Stuart Gitlow, MD, MPH, MBA, DFAPA, was eleven years old when he first realized he wanted to enter the field of addiction medicine. On the night of the realization, he was accompanying his father, a past president of the American Society of Addiction Medicine (ASAM), to Salt Lake City for a conference and tagging along at a dinner for colleagues. While listening to his father’s peers speak about addiction, he began to develop his own voice. Dr. Gitlow explains,
What I remember was that they never mentioned the drugs. They never mentioned alcohol or pharmacology, they talked about the people and they talked about the need to get to know the individual and that stuck with me . . . that addiction was a disease that involved people and getting to know them as a key component of their treatment. Everything else in medical school I could’ve ignored if I’d just learned that. That was the most important thing. It strikes me that in medical school, we don’t seem to tell people that one point.
Indeed, ASAM was formed with a vision of helping individuals with addictive disorders live rich and fulfilling lives. However, in a field where the disease state is stigmatized and specialized professionals are few and far between, success is no easy feat and the well-being of patients is constantly being challenged.
Health Care Providers
One of the major issues facing the field today, according to Dr. Gitlow, is the lack of standardization regarding the type of care provider best equipped to treat addiction:
My dad, Stanley Gitlow, one of the founders of ASAM, was annoyed because we’d gone from internists who learned all about how to treat addiction to psychiatrists who really didn’t know what they were doing, but were just getting started with the field. All of a sudden we were at a point where mental health was now including addictive disease and there wasn’t parity, so people with addictive disease were getting subpar care from people who didn’t know what they were doing.
The problem that I have now is that here as a psychiatrist, more than halfway through my career, the field has changed again to where it’s not even physicians who are providing the bulk of the care; it’s a group of nonphysicians who have no medical background. So the question becomes: Do they know what they’re doing? I think really the whole field is getting reinvented now for a third time, and we still don’t have any literature or any studies at all that distinguish what it is the counselor does, the social worker does, the nurse does, the psychologist does, the physician does, better than the other members of the team. So I don’t know, when a patient comes in, should I send that patient to the nurse practitioner? The PA? The counselor? The psychologist? The addiction medicine specialist physician? I don’t know, because we have no data on what differentiates each of them from each other. So the worst part of the system is the patient will come in, be approved for level 2.1 intensive outpatient care based on the ASAM criteria, but care from whom? Does a doctor have to be involved at all and if so, does it have to be an addiction-trained doctor?
Elizabeth Howell, MD, stresses that especially in light of the opioid crisis, all clinicians should be prepared to handle addiction:
Our main issue now is how we’re going to educate primary care physicians in their role because I don’t care how many fellowships we have or how many specialists we have, we’ll never have enough. We’re at a unique point because there are a lot more primary care physicians interested in addiction related to more than just nicotine. We’re all face-to-face with this right now, especially because of the opioid epidemic.
Lawrence S. Brown, Jr., MD, MPH, FASAM, adds that the multifaceted nature of addiction makes identifying appropriate clinical outcomes a difficult task for all caregivers:
You don’t have the same level of specificity as you do with, say, diabetes treatment. I think that sometimes we in general medicine sort of fool ourselves into specificity, thinking that’s all that needs to be on the level of concern.
I think choosing an appropriate health care provider is always going to be a topic for conversation because science doesn’t stop, training is going to parallel some of that science, and the ability to say whether or not people who had core competencies in the past are qualified to deliver care in the present needs to be addressed. So I think we’re going to always have that, but we don’t always have enough information to say, “Okay, what types of things matter other than the title of the position?”
I’ve come to appreciate that there are differences among generations, and it’s really a good thing that we’re getting more people in addiction medicine because I think that will improve the value of care, though I do think that there will be a lot of hiccups and a lot of pain as the adjustment occurs.
I also think it’s important for people to understand that “addiction medicine” and “addiction treatment” aren’t the same. There are differences in the ways that they approach things, and sometimes in our field we get the people with a medical school degree and the people without a medical school degree say, “Hey docs, you think you know everything, but you really don’t know a darn thing. There are certain things that you don’t talk to the patients about, so we’re the ones who know whether or not they’ll be able to follow your instructions.”
There needs to be a sufficient populace that knows how to provide integrated care, and in the worst case how to refer to specialized care, and I don't think there’s enough of that. Everyone needs to stay on top of their game and you also see on the other side of things, don’t be starting things that you can’t prove have value because all that does is increase cost. SAMHSA came up with these different stages of counselors based on their experience—I still want to know what it is about the stages that makes a difference. I understand theoretically why we have different levels in SAMHSA, but what’s the evidence that this actually does improve quality of care?
In New York, many of the counselors who have the credentials are not even working in addiction treatment, so that’s to show you that there’s a disconnect here. We provide this training for each individual and unfortunately many providers are here for the season, not for the reason. So they came because it’s a job they happen to fit in at the time, but if you ask them what training they had to get the job, they can’t answer.
I don’t mean to say that all is bad, though, because I think there’s an opportunity to really assess these things. I always say that we have to put resources in the assessments at the same time that we have this deployment of different interventions. We tend to forget about the assessment of treatment techniques and I think we have to understand the assessment isn’t going to be a short-term thing because it’s a long-term disease, so why would you expect to use a short-term analysis?
Physician Health Programs
Louis E. Baxter, MD, FASAM, recognizes the need for specificity and analysis as well, especially when it comes to caring for caretakers:
In my field in particular, taking care of health care professionals, it became very critical that we were able to establish some benchmarks and some guidelines in the field. For example, some individuals thought that everybody needed to be in addiction treatment for it at least six months, if not a year. Then there were others that felt that people could be safely returned to the practice of medicine after three months. There were a lot of unanswered questions and we pretty much got involved with taking care of these individuals based on what ASAM was saying and what AA was saying. It was very fortunate for us when we started to develop the ASAM Patient Placement frontier, because that then gave us some sort of a framework. Before that time it was actually anecdotal and we did what some of the early pioneers did. Dr. Talbot, of course, was the earliest, and then we had some others like Dr. David Catavan, who’s credited as being the godfather of physician’s health programs (PHPs). So we had various opinions in terms of how to actually treat health care professionals with impairing conditions, but the most important thing that happened for us was the development of the ASAM criteria.
So we had the dimensions and we could say, “Okay, this guy needs residential, this guy needs long-term,” and at some point we were able to come to a determination about whether or not it was safe for someone to return to the practice of medicine. As my time went on in ASAM we did a big study of all the PHPs and we were able to gather some common components that seemed to work well across the board, so we were able to start to develop some guidelines about treatment. Once again, it was based on the ASAM criteria, but there was still a prevailing thought that if you were a physician you needed longer care rather than shorter and today that’s not true. I’ve found that sticking with the ASAM criteria works very well and we have fewer physicians now that actually go into residential treatment than we did back in the 1980s.
Another concern in the addiction field, as Dr. Brown points out, is the isolated, safe environment that inpatient treatment facilities provide. As he explains,
You’re taking someone out of their setting and once you transition them back into that setting, we often see an increase in the behaviors that led to needing inpatient in the first place. The social dislocation is especially problematic in adolescents who are still developing their social network.
Dr. Gitlow agrees that the issue of environmental change should be studied, and questions whether or not it is absolutely related to relapse rates:
It’s questionable whether a person can go back to doing what they were doing, go back to the environment they were in that may have been in some ways a trigger or responsible for their drug use. But it’s interesting, in the airplane industry—where we have roughly an 80 percent or better long-term recovery rate—they’re all going back to their job after a short period of time and doing quite well, suggesting that the environment may not be related. This brings me back to the question that disability folks have always asked: If you have a bartender who’s alcoholic, can he return to work in recovery as a bartender? Well if that answer is yes, then clearly you can go back to playing football or being a doctor or flying a plane, but we don’t know the answer to that question. No one’s ever studied to see if bartenders can go back to work and be right in the presence of alcohol. I think it’s those sort of basic questions that we don’t have answers for, and I think answering them is essential.
Urine Drug Testing
Another essential aspect of addiction medicine that needs to be studied and standardized is the utility of urine drug testing. Dr. Gitlow remembers discussing drug testing with his father and the staggering difference in opinion between professionals of the past and present:
So the world’s changed, but my dad’s position was very clear. He was opposed to urine drug testing because it was used primarily as a tool for punishment and he didn’t want to see individuals punished, particularly on a false positive or because they were caught doing something as opposed to being diagnosed with something. That’s still important to consider today, though in some ways times have changed in that we have data in the impaired physician program, and also in the FAA for pilots, that demonstrate that long-term urine drug testing is an important variable in people’s ability to maintain their sobriety. So from a perspective of, the person has already been diagnosed, should we use it going forward? Yes, absolutely.
There’s also the question of screening. We test every fifteen-year-old in the country for their blood pressure, even though they’re rather unlikely to be hypertensive or diabetes, but the one disease they’re most likely to have and that we’re most likely able to catch, we don’t test for. Urine drug testing is one of the most basic screening tools we could use that would help identify these individuals, although of course a positive screen doesn’t necessarily mean a person has an addictive disease. So I think we’re in a situation where, yes there are some people overusing the tests, yes the tests can be used for misguided purposes such as for punishment, but I think we really need to look at it as a tool that we can use diagnostically.
Dr. Baxter agrees that misconceptions play a large role in the care of individuals with addiction, both in terms of urine drug screening and the general application of treatment practices:
That’s a problem even today that half of our colleagues still don’t fully grasp, that this is a chronic medical illness as opposed to if you do a urine drug screen on a fifteen-year-old you’re accusing them of something or you’re saying that they have bad behavior or what have you. Until we can get past that misconception—that it’s all behavior and not a real medical illness—we’ll never be able to fully treat it, prevent it, and talk about it like we do with other chronic medical illnesses. We had a discussion along the way, since I’ve been in ASAM, about which type of treatment works best. What we’ve been able to find was that any intervention that’s applied will work while it’s applied, and so you really don’t have much in terms of benefits when you look at intensive outpatient versus residential. What really seems to make the difference is the length of time that the intervention is applied.
Education and Future Challenges
One factor that seems to make a difference in addiction medicine across the board is continuing education and a willingness to adapt to a changing field. Dr. Brown points out,
I often find that whether it’s physicians or nonphysicians, sometimes in our field there seems to be a halt in maintaining one’s core competency. That is, in academic settings, in order to maintain your appointment, you have to do some things, including continuing medical education. In addiction treatment, particularly outside of the academic setting, you don’t have that external incentive. A lot of people involved in addiction medicine never come to an ASAM meeting and I think we need to realize that a lot of these are part-time, fly-by-night doctors that are there as glorified signatories and really don’t know much about the medical and scientific aspects of it. So you can see how a nonphysician might have less respect for them because you really aren’t demonstrating the tenants of being a physician by learning, teaching, and sharing that information with other professionals and even with your patients, so that also becomes an issue.
I sometimes find that the addiction treatment fails because there are certain things that aren’t present there that stimulate continuing learning and benefit patients. For example, when you have many methadone programs and you say, “Well, what proportion of your patients are on buprenorphine?” people are pausing because they’ve never even offered the opportunity to the patients to consider that possibility. The same goes for Vivitrol. However, if you’re an academic center and you stayed at the same class of medication for the treatment of a disease, you would be shooed out and you wouldn’t be able to continue that. I think you always need some kind of external stimulation to make sure that you’re on top of your game, that you stay current and make sure that patients benefit.
As Dr. Gitlow points out, part of continuing education is updating the language used to describe different terms within the addiction field:
For instance, how often in the field do you hear the term “aftercare?” Well you can’t have “aftercare” for a chronic disease. You can have “ongoing care” and “continuing care,” but not “aftercare.” We also have “medication-assisted treatment” (MAT) instead of just “treatment” that includes pharmacotherapy, like it does in so many other places. How many times do you hear people talking about a “buprenorphine clinic”? I don’t have a “sertraline clinic” or a “statin clinic,” so why would I have a “buprenorphine clinic”? It doesn’t make sense!
Addiction and Pain
Language is not the only confusing aspect of recovery; there is also plenty of controversy and misunderstanding surrounding the relationship between pain and addiction. Dr. Baxter takes a cautious, evaluative approach to treating pain and delivers personalized care to each of his patients, as he describes:
There are some basic things that I think we always have to remember when we’re evaluating situations involving pain and addiction. First, opiates don’t cause addiction. If they did, everyone who took them would become addicted. We must always remember that having an addictive disorder is something that has genetic factors and environmental influences, but ultimately it’s a primary disease. It’s not a disease as a result of something, like too much alcohol or too many opiates. We always tell our patients that when they do get into recovery or sustained abstinence from psychoactive substances that they should avoid unauthorized use of medications that have psychoactive properties, including benzodiazepines as well as pain medicines. But they’re not in recovery to suffer.
I remember early on when I got into the field, one of the instructions was that under no circumstances should patients take psychoactive substances, benzodiazepines or pain medicines. If you were still anxious, then you weren’t grateful enough. If you were depressed, you weren’t grateful enough. You should just become John Wayne and bite the bullet if you have pain. Fortunately, we know that those things aren’t true today. People who are in recovery who have acute pain conditions can get benefit from nonnarcotic medications because acute pain is usually three, four days at the max and when we use maximum dosages of NSAIDS and other nonnarcotics, many people, not only people in recovery, can get their pain alleviated.
However, there are some circumstances in which people in recovery do require narcotics or analgesics and I think that under those circumstances, not giving them a ninety-day prescription, giving them a medication to take as directed, not on a PRN basis (because that sets up the addiction cycle), but rather a monitored distribution by family member or sponsor, prescribed for a short period of time, is okay. If the pain continues in a person who is in recovery, that pain needs to be reevaluated because most acute pain, as we know, is acute. So we’ve learned a lot over our time since the late 1980s, and I think that it’s doing our patients a disservice when people say that because they’re in recovery they can’t benefit from using those kinds of medications.
Dr. Gitlow agrees, but also points out that overprescribing of opiates is one of the major causes of the current opioid crisis:
There’s the misunderstanding that opiates represent a personalized treatment for noncancer chronic pain and there’s never been any research demonstrating the value of that. There’s also a misunderstanding that benzodiazepines are a valid way to treatment someone who has anxiety longer than eight weeks, even though they were never tested for longer than eight weeks, even though the PDR says beyond eight weeks you’re on your own. They’re still seen as first-line, so half of what I’m treating, if not more, is the result of misguided prescribing.
Mike Miller, MD, suggests that the ASAM organization has the ability to play an important role in combatting the opioid crisis.
ASAM should highlight that the goal of addiction treatment is to help individuals recover and engage in a life of ongoing recovery; the goal isn’t simply cessation of use of highly rewarding substances. The emphasis on pharmacological treatment is appropriate, but it shouldn’t be in the absence of emphasis on psychosocial interventions and assuring access to and payment for psychosocial services.
Dr. Brown suggests that another trend prominently featured in the addiction field is a continuing pattern of discrimination against patients. He elaborates,
Because of the history of many people having discriminated against our patients, we put into place systems that only further enhance defragmentation. I’m certainly very sensitive to the fact that sometimes people in medicine will be just as discriminatory as people outside, but I do still have a hard time accepting the premise that it’s okay to segregate information so that a physician wouldn’t know the full scope of the care and needs of the patient. Now, I do understand it’s a patient’s right to decide to disclose or not, but I think systems that don’t even offer to have that conversation only perpetuate harm and act as further disincentives for integration of care.
In New York, for example, in our prescription drug-monitoring program—probably one of the more stringent in the United States because of the federal regulations—doctors can’t see patients enrolled in MAT. I really have a hard time knowing that we don’t think that’s going to cause some harm to our patients. I believe the way to do this is to hold the people, doctors included, responsible for discriminating against patients.
In health care you need to know what the left hand and right hand are doing, and if you don’t know that, your patients can suffer. So I understand that there’s been some movement, though I’m not sure that I’m comfortable that the movement is enough to make sure all care is integrated, because it makes it seem that you can only talk about integrated care when it has nothing to do with addiction.
Elizabeth Howell, MD, wholeheartedly agrees that discrimination is a prominent theme in the addiction field, particularly in regards to race:
When less-advantaged, African American men were shooting heroin, nobody cared. That was just a criminal issue. Now it’s made it to the suburbs and all of a sudden it’s considered a “disease,” an “epidemic,” and we need to be really careful to make sure we don’t miss that part of the stigma. I hear a lot more about that now from black professionals and people in the advocacy field and I think we need to keep that front and center. This is an epidemic for everybody. A lot of addiction medicine grew out of the Civil Rights Movement and I think we need to remember that.
Look at the sub Oxone ads too; who are the people in those? They’re all white, middle-class folks. They’re not showing people in jail or people who are black. It’s like now it’s “okay” to be concerned about the opioid epidemic because the affected populations are “good people.”
David Smith, MD, concurs that discrimination has reared its ugly head since the very beginning of addiction medicine’s formation.
During the “Summer of Love,” people were saying they didn’t want hippies in San Francisco, so they denied them health care. If you don’t like a particular population, one of the most political acts you can do is deny them health care. We were fighting against that.
Mark Krause, MD, has personal experience fighting discrimination in the field as well.
Discrimination is the story of addiction. We fought about that in Connecticut. If you’re a powder cocaine kid in the burbs, you get a slap on the wrist and are told not to do it again. If you’re a kid smoking crack, you’re going to go to jail for fifteen years. What about marijuana? When you look at the jails in Connecticut, a white state, the jails are full of black and brown kids serving fifteen years for smoking pot! We’re whole-selling people’s lives. As professionals, we need to be the advocates. We don’t just take care of one kind of patient; we take care of people.
Looking towards the future, Dr. Gitlow remains positive and stresses the utility of private practice addiction:
Private practice addiction remains, to this day, an extraordinarily viable practice modality. It’s something I tell students all the time, that if they’re interested in opening up their own office and seeing patients with addictive disease day-in and day-out and running it as a traditional medical practice, there’s been no part of the country where I’ve worked where I haven’t been able to do that. I was full within a few weeks and never had to advertise, because the patients bring their friends and family and everybody else, and that fills up the practice. So to have a practice that gives me the freedom to set my hours, to work as many or as few weeks as I like, to see the patients I want to see, to have the office look how I want, to go get the CME where I want . . . that’s all still very possible and I don’t think our students know or recognize that.
Dr. Brown is also optimistic about the future and notes that ASAM has already made some tremendous strides:
I’m very proud and encouraged that ASAM has developed the associate membership because now at least we are engaging those other stakeholders in addiction treatment who are providing treatment. By being under our umbrella, they are learning the types of things we’d like them to know and I think that helps with coordination of addiction care.
Dr. Miller agrees that the support of small groups of stakeholders is critical for the future of addiction medicine:
I believe we need more support of ASAM state chapters in order to engage new members in societal activities and to identify emerging leaders. We also need to devote time to the future participants in ASAM; for example, the members of the PIT Committee and Ruth Fox Scholars. We should do all we can to get to know the physicians completing an accredited fellowship in addiction medicine.
We should also be aware of the work done by those on whose shoulders we stand. It’s important to praise everyone for the great things they’re doing to bring about success in the field. The most important lifeblood for the future of our field is fellowship training, so relationships forged with these individuals must be healthy and genuine.
Dr. Howell is a strong proponent of supporting the younger generations in their pursuit of entering the addiction medicine field:
We need to recruit more people who are young in their profession. It’s exciting to see how excellent the young people are nowadays. I think it’s going to make the field stronger and larger. ASAM is now spreading to focus across the country and even across the world, so I hope we keep going in that direction.
Dr. Kraus stresses the importance of advocacy for the future as well:
Advocacy has to be a significant role now. We have to be a loud voice, a united voice, because we really are the champions for our patients. The stigma is there and we have to advocate for all patients. I don’t care who you are, addiction disrupts every aspect of your life and we really need to get to the politicians and bring them onboard. What’s sad is that our policymakers are so uninformed—ASAM needs to inform them and become a huge advocate. If the Trump government does what they want and the block grants get reduced, I can tell you as a provider and as an CMO of 2,500 patients we have in our OTPs, I’m going to have to lay off a ton of people and I don’t know how I’m going to do that without cutting services. We need to let doctors choose how to treat patients, not politicians.
The addiction field may be fairly young, but it is full of promise, just like the hundreds of young physicians training to become a part of it. Above all, as Dr. Gitlow’s father pointed out many years ago, it is of vital importance that the field remain patient-centered and personalized. As long as clinicians are working with the best interests of the patients in mind, clinicians in the addiction field should be able to defeat their challenges and enjoy a bright, prosperous future.