It’s not medical. It's not psychiatric. What is it?
1. Most clinicians who treat addicted patients are counselors, not physicians; thus they cannot prescribe medication and they generally don’t “believe” in the use of medication for addictive disorders.
2. Most patients have medical insurance that excludes or severely limits treatment of addictive disorders, so payment for service is not good. This situation may change in the near future with the advent of healthcare reform in the United States.
So writes Dr. Charles O’Brien of the University of Pennyslvania Perelman School of Medicine, in a recent article for The Dana Foundation’s website. In his article—“If Addictions Can Be Treated, Why Aren’t They?”—Dr. O’Brien asks a basic question: “Why are most patients not even given a trial of medication in most respected treatment programs?”
Even though pharmaceutical companies have throttled back on their interest in anti-craving drugs in recent years, there are, in fact, a few medications recognized by the FDA, primarily for use in the treatment of alcoholism. But they are not much in favor, and O’Brien believes he knows why:
The answer seems to be that there is a bias among treatment professionals, perhaps passed down from past generations when addictions were not understood to be a disease. Medically trained personnel are minimally involved in the addiction treatment system and most medical schools teach very little about addiction so most physicians are unaware of effective medications or how to use them.
What is on offer at most addiction treatment facilities is not actual rehabilitation, but rather short-term detoxification. And what we’ve learned from neuroscience is that taking away the drug is only stage one. The addiction remains, the reward and memory systems still operating erratically. We understand some of this circuitry better than at any time in history, but the concrete effects of these insights at the level of the community treatment clinic have been small to nonexistent. Money, of course, is part of it, since addiction has only recently, and sporadically, gotten the attention of funding agencies in the public health community.
Health journalist Maia Szalavitz, writing at Time Healthland concurs: “Unlike most known diseases, the treatment of addiction is not based on scientific evidence nor is it required to be provided by people with any medical education—let alone actual physicians—according to a new report.” The report in question, from Columbia University’s National Center on Addiction and Substance Abuse (CASA), notes that most people are shoehorned into a standardized approach built around the 12 Step model of Alcoholics Anonymous. “The dominance of the 12-step approach,” writes Szalavitz, “also leads to a widespread opposition to change based on medical evidence, particularly the use of medications like methadone or buprenorphine to treat opioid addictions—maintenance treatments that data have show to be most effective.”
Szalavitz also believes she knows why, and her thinking is similar to O’Brien’s. “Other medications that are known to treat alcohol and drug addiction, such as naltrexone, are also underutilized,” she writes, “while philosophical opposition to the medicalization of care slows uptake.”
There is a straightforward reason for considering the use of medication in the treatment of addiction: strong suggestions of recognizable genetic differences between those who respond to a given medication, and those who don’t. As O’Brien explains, a prospective study now in progress will be looking to see if alcoholics with a specific opioid receptor variant show a better outcome on naltrexone than those with the standard gene for that opioid receptor. And if they do, the FDA may allow a labeling change “stating that alcoholics with this genotype can be expected to have a superior response to naltrexone.”
But that won’t be happening tomorrow. In the meantime, we are stuck with the addiction treatment industry as it is. “The [CASA] report notes that only 10% of people with substance-use problems seek help for them,” Szalavitz concludes. “Given its findings about the shortcomings of the treatment system, that’s hardly surprising.”
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