The Anatomy of Addiction (19 page)

T
hese are strange days for practitioners of addiction medicine like myself. We find ourselves living in a kind of twilight between the past and future. We're surrounded by hordes of zombie rehab clinics that offer antiquated remedies for what should be the medical treatment of addiction. Even our own medical brethren too often hear only the siren call of the 12 steps and ignore their Hippocratic Oath to do no harm by discharging their addicted patients into the hands of amateurs.

In short, we live in a culture of disbelief, where medical science about addiction is cast aside.

Dramatic? Perhaps. But I really do believe we're in the midst of an epic struggle for the treatment of addiction. I have been fighting the battle now for fifteen years. I was among the first doctors to begin treating patients with a substance addiction with controlled and scientifically verified medications like Suboxone.
And it's been twenty-five years since the advent of magnetic resonance imaging proved what doctors of addiction medicine had always suspected: The brain of the alcohol and drug addict is structurally different from that of a nonaddict's.

Decades now into the struggle to make evidence-based medicine the default treatment for substance addiction, the other side still seems to be winning. Incredibly, 90 percent of all rehab clinics and treatment centers for alcohol and drug addiction offer no evidence-based medicine. The largely unregulated, $34 billion rehab industry can make more profit by refusing to recognize the science of addiction treatment. The worst of the lot have simply co-opted and commodified the simple 12-step philosophy—meant always to have been a free program as much about sanctuary and camaraderie as about treatment—into a program offered as a cure and run by drug counselors with no medical training. The more sophisticated ones offer psychological counseling staffed by degreed therapists, but most still ignore the irrefutable research that medications are an essential part of a comprehensive treatment. I know from talking to their former patients that many facilities in Los Angeles where I live won't even allow their doctors to talk about medications.

More troubling, we're drowning in new waves of substance addiction. Suburban youth are now the new poster children for the flood of cheap and powerful heroin flooding the streets. Late-middle-aged to senior adults—traditionally the last group you would think of as drug addicts—are hooked on powerful prescription painkillers with the rate of OD deaths for those ages fifty-five to sixty-four soaring 700 percent between 1993 and 2012. (In 2012, Medicare spent zero on powerful tranquilizers such as Xanax and
Valium; one year later, under pressure from the pharmaceutical companies to include their products in Medicare authorized medication, it was spending $377 million on 40 million prescriptions for this class of drugs.)

Hundreds of thousands of veterans are being treated for substance addictions of all kinds. The nation's energy boom has been accompanied by a methamphetamine epidemic among gas and oil workers. One study, reported in the
Wall Street Journal
, found nearly 25 percent of federally mandated energy workers testing positive for amphetamine in 2011, up from 17 percent just two years earlier.

As for alcohol, it now has the dubious distinction of being the third leading preventable cause of death in the United States, surpassed only by smoking and obesity and responsible for nearly 88,000 deaths in 2014. That's more than deaths from firearms, drug abuse, and sexually transmitted diseases combined (alcohol-related deaths surpassed those from car accidents in 2011 and never looked back). Heavy drinking is up more than 17 percent since 2005, with women registering the biggest increases. That is particularly saddening but not surprising since the prevalence of fetal alcohol syndrome has also risen over the last decade from approximately 3 cases per 1,000 to as high as 7 cases per 1,000 (the more broadly defined fetal alcohol spectrum disorder is as high as 50 cases per 1,000).

A complicit judiciary continues to condition people's freedom on attendance to 12-step programs rather than bona fide, evidence-based treatment centers. Quite literally, people are dying every day because of ill-informed, sometimes religiously biased and often politically cynical elected judges who kowtow to constituents who
expect addicts to be demonized as criminals rather than treated as patients.

The death rate from drug overdoses more than doubled from 1999 to 2013. The nation spends nearly $468 billion annually on addiction but only 2¢ goes for prevention or long-term treatment (the rest is squandered on jails, courts, and emergency care at hospitals).

Yet, maddeningly, after all these years the public at large remains confused about addiction and its treatment. Many people do not believe that addiction is a physical disease, but that is only because they don't understand the meaning of disease and the current definition of addiction. Surveys show that the majority of Americans understand that addiction has a biological component—that it's a disease like diabetes, asthma, or bipolar disorder—yet they can't let go of the past. They cling to the notion that addicts could really stop if they wanted to and that willpower and moral fiber are the answers to substance addiction.

The destined-to-fail war on drugs and its sister campaigns DARE and Just Say No are twentieth-century relics, dismissed by anyone under thirty years old with the same derision my generation had for
Reefer Madness
. Yet, politicians continue to pay homage to these failed public health policies.

Hope on the Horizon

Still, I am hopeful about the changing landscape of addiction treatment. There is a new class of warriors who are fighting for science and medicine and the treatment of addiction as the
chronic disease that it is. I know this because I teach med students and residents every semester at the University of Southern California Keck School of Medicine. The school is at the forefront of informing their soon-to-be doctors about the disease of addiction and the evidence-based treatments available. Indeed, every med student at the school, no matter what his or her intended specialty, must take the curriculum that I, along with my staff, created.

We also now have a history of how evidence-based treatment can, and has, worked. Thousands of patients who likely would have been jailed or succumbed to the ravages of substance addiction are now living normal lives. Medications such as Suboxone have been developed to stop the cravings that characterize substance addiction without the danger of a new dependency.

The concept of substance addiction as a chronic disease that must be treated over a lifetime, as is the case with every other chronic disease, has gained a toehold in popular culture. The failure of local and state authorities to use evidence-based treatment has been chronicled recently in investigative news articles in the
Huffington Post
,
Slate
,
The Atlantic
magazine, and the
New York Times
, with the cumulative effect of casting doubt on the invulnerability of the 12-step monolith.

Documentary films such as
The Business of Recovery
directed by Adam Finberg and
Prescription Thugs
by Chris Bell, Josh Alexander, and Craig Young question the motives behind both the rehab industry and big pharma.

Most heartening, the treatment of addiction as a medical condition is becoming institutionalized. The federal Affordable
Care Act (Obamacare), for the first time in national healthcare policy, mandated what health benefits insurance plans must cover, and substance addiction treatment is included. What's more, it bars insurers from denying coverage due to preexisting conditions—including substance abuse.

But perhaps the most important changes emanating from President Obama's landmark healthcare initiative is the expansion of the so-called parity rules.
Parity
means that insurance plans must cover mental health and substance abuse treatment at the same level as regular medical care. Once and for all, after a century of needless criminalization, the Affordable Care Act codifies in federal law that substance abuse is a medical issue—not the result of moral turpitude and not a problem meant for the criminal justice system.

Finally, under the Affordable Care Act, insurance will pay for evidence-based treatment. Already, some of the most famous and egregious proponents of the 12-step abstinence-only model for treatment are quickly changing their tune. Hazelden, the first center to, in effect, co-opt Bill Wilson's AA philosophy and charge money for it, has now incorporated naltrexone into its treatment model. Big health insurers like Cigna and United Healthcare are following the new law and simply refusing to pay for inpatient treatment claims from centers that do not use evidence-based medicine. Soon, AA will return to what its founder always meant it to be—a free service that might help heavy drinkers and even some alcoholics, rather than being enshrined as the foundation for a nationwide for-profit industry that exploits the fears and suffering of addicts and their families.

The irrationality of drug criminalization is being embraced by a younger generation of Americans. States like Colorado and Washington have decriminalized marijuana use, thus opening it to regulation and taxation (just like alcohol). Similarly, voters in California recently passed Proposition 47 that revises the calculus of drug courts. The new law changed several felonies, including drug possession, into misdemeanors, thus expanding the opportunities for potentially hundreds to receive addiction treatment whose crimes previously were deemed too serious.

Next Steps

So, where do we go from here? First, if you're reading this book because you or someone you care about is an addict, be informed! Choose a treatment center wisely. Do not be swayed by marketing campaigns that gloss over a rehab clinic's failure to provide appropriate medical care. Look for evidence-based treatment not only in the detoxification phase of treatment but also in management and maintenance. Avoid centers that promise only a 12-step model, a one-size-fits-all treatment program, and especially a cure for alcoholism or drug addiction.

As a society, we need to catch up with the rest of the Western world and incorporate commonsense healthcare reform, beyond those offered by the Affordable Care Act, including the following:

1. Require all medical schools to offer a mandatory curriculum on evidence-based addiction treatment. Remember that substance addiction is the third leading cause of
preventable deaths in the United States. It's shameful that only a handful of medical schools offer training to their students, much less require it.

2. Use taxes on the legal sale of marijuana and alcohol for a public education program about the facts concerning the chronic disease that we call alcoholism and drug addiction.

3. Develop standardized terms to facilitate treatment. Too often both the public and doctors interchange terms at random, causing confusion. Not all people who drink or take drugs or who drink heavily or take lots of drugs are addicts. Most of those who consume alcohol and drugs will simply stop or moderate that behavior to a safe level. The term
addict
must be reserved for those who have the chronic, largely genetically based brain disease, characterized by a damaged reward system and an uncontrollable, obsessive craving for a substance.

4. Regulate the alcohol and drug rehab industry. New mandates under the Affordable Care Act will go a long way, but a comprehensive federal law should be passed to require treatment centers to be under the supervision of a medical doctor with a certification in addiction medicine and staffed by trained and licensed medical professionals. The days when your only qualification for being an addiction counselor is that you used to be an addict, or still are, must end.

A Universal Problem

Addiction, as with other chronic clinical illnesses, doesn't consider your race, religion, or political affiliation. It doesn't matter if someone is Christian, Jewish, Muslim, Buddhist, Hindu, or atheist. This disease afflicts people from all walks of life, rich and poor, doctors, successful businessmen, clergy, and elected heads of state. The more people know about the disease of addiction, the less stigmatized individuals who suffer from it will be, and more will get the help they need (keep in mind that 90 percent of those who suffer from the disease are not being treated at all).

Every physician and clinical association worldwide recognizes that substance addiction is a clinical illness that is both preventable and treatable. It is to this mission of prevention and treatment that I have dedicated my life and career, and I invite you to join me as an ambassador of the truth about
addiction.