Commentary: Who Should Treat Addiction?

Think about a patient with addiction. He seeks attention for his illness and would like treatment. Should he go to a counselor, a nurse practitioner or a physician? How would his treatment differ in each case? If you’d like to shake things up further, please add psychologists and social workers to the mixture.

If our hypothetical patient is seen by a nurse practitioner in an ambulatory setting yet fails to improve with respect to his addiction, has he failed medical treatment? Would the next step be for the patient to see a physician? Or would it be to enter a more intensive treatment setting?

Our nation is moving quickly toward an environment in which a greater quantity of medical care will be delivered by clinicians who have not attended medical school. Interestingly, we already have that environment in the field of addiction, and have had that scenario for decades. What we do not know, however, is whether this approach is efficacious for the treatment of patients.

Take a simple research study: 200 patients with newly diagnosed addictive disease are divided into two groups matched by age, sex and socioeconomic background, as well as by drug of choice. One group is seen by addiction specialist physicians, the other by addiction specialists who are not physicians, and both are seen with the same frequency and intensity. At 12 months, determine whether there is a difference between the two groups in terms of recovery rate as defined by abstinence and functional improvement.

The study has never been performed.

No one has ever bothered to determine whether social workers are better than physicians at treating addictive illness, or whether physicians are better than psychologists. And though no one has ever bothered to determine if surgical nurses could perform appendectomies successfully, or if counselors can treat life-threatening illnesses like cancer, there has not been a need to answer those questions. So addiction is in an odd place: there is no proof that non-MD/DO care has sufficient quality to be utilized as a replacement for physician-based treatment, yet non-physician treatment already represents the standard in many locations. And of course, there is no proof that non-MD/DO care does not have sufficient quality either.

In the vast majority of patients coming to my practice, prior misdiagnosis or mistreatment reigns high on the problem list on initial intake. Patients treated incorrectly for depressive illness when they have sedative-induced depression, patients treated with combinations of sedatives and stimulants for alleged anxiety accompanying ADHD, patients with known alcoholism prescribed benzodiazepines for mild insomnia or anxiety: the list goes on and on, with physicians in my community being as much to blame as other clinicians.

Addiction is a complex lifelong disease which, if unaddressed, commonly results in death of the patient. Shouldn’t we have some research to determine to whom these patients should be referred?

Stuart Gitlow, MD, MPH, MBA, is Executive Director of the Annenberg Physician Training Program in Addictive Disease and Associate Clinical Professor at the Mount Sinai School of Medicine. He is Acting President of the American Society of Addiction Medicine.

28 Responses to Commentary: Who Should Treat Addiction?

  1. Lisa Frederiksen - | March 30, 2012 at 11:45 am

    I couldn’t agree more! Now that addiction is understood to be a chronic, often relapsing brain disease, and that the three-pronged disease model of treatment is just as necessarily with addiction as it is with other diseases, the research you call for, Dr. Gitlow, would go a long, long way to determining effective treatment protocols. As you said, misdiagnosis and mistreatment reigns high, which leaves the person with the disease believing it’s them, their willpower, their willingness to change that’s at fault (which is also what the family member and society continues to believe, as well). Thank you for the call to action to conduct the kind of research you’ve described.

  2. Linda | March 30, 2012 at 12:29 pm

    I am surprised to read Dr. Gitlow’s opinion. He apparently is not knowledgeable of the vast amount of scientific evidence that exists in identifying greatly effective non-medical treatments for addictions. I am more bothered by the “either/or” proposition, as current research finds a collaborative approach, that which includes multi-disciplinary, integrative, treatment planning, most beneficial.

    • Stuart Gitlow | April 1, 2012 at 1:51 pm

      Linda, you are absolutely right that there is a vast amount of evidence supporting the efficacy of non-pharmacologic treatment, but “medical” treatments include these. The definition of medical treatment includes the gamut of biologic, psychologic, sociologic, and spiritual. Those who would rely on any one of these aspects of treatment are unlikely to achieve success in any domain. However, current research has not found a collaborative approach to be most beneficial; in fact, there has been no research to my knowledge that has compared a team approach to treatment provided by a single addiction specialist, be that person a nurse, physician, or counselor. The team approach is largely politically and economically driven. My suggestion here is that we need real research to justify any approach over any other approach. Thank you for your comments!

      • Lisa | April 4, 2012 at 8:18 pm

        Evidence-based practices abound, yet what seems not well attended to (and would be a worthy aspect for study) are the qualities of the individual practitioners who have the most positive results with their patients/clients.

  3. Michael W. Shore, M.D. | March 30, 2012 at 1:22 pm

    I absolutely agree with Dr. Gitlow that the issue of whom is best trained and equipped to treat addiction has never been adequately studied. I also would address the inadequacy of “waivered” suboxone prescribing physicians who have minimal addiction training or experience. The complexity of patients with chemical dependency requires adequate training and exzperience to achieve the best outcomes. Dr. Michael Shore, M.D. .

  4. Howard Josepher | March 30, 2012 at 1:55 pm

    It would be interesting to learn if a particular form of addiction treatment, or discipline, or clinical training leads to more successful outcomes. Of course a patient’s economic status would have to be factored in because some treatments are beyond a patient’s capabilities. Until then, the more modalities, the better.

  5. joebanana | March 30, 2012 at 2:06 pm

    Clearly addiction is a medical condition. Why don’t we jail people with ADHD, depression, schizophrenia, political aspirations? Is jail the proper treatment for these conditions? Force, and violence in our society is looked upon as a criminal activity, but, it’s how the government handles everything. A guy sitting on his couch in his own home should never be subject to a violent raid by 20 armed police, breaking property, shooting pets, assaulting children and elderly, being assaulted himself, possibly killed, based on a mistaken address in America, EVER. There should NEVER be the slightest chance of this happening, but it does, daily. Law enforcement has become a terrorist organization. When unarmed mentally challenged homeless men are beaten to death by six cops, the problem isn’t drugs.

  6. Jim Sharp | March 30, 2012 at 2:10 pm

    Excellent questions! Current research indicates that addiction is a biopsychosocial chronic illness. It’s very risky to assume that the treatment of addiction may be left to disciplines with the least education and training.

  7. Joyce R. Dickenns PhD | March 30, 2012 at 2:30 pm

    I do agree with this post “Who Should Treat Addiction?’ There is long over due research on this. For Social Workers with no Addiction Certification or training to be treating Addiction Clients because they happen to have great lobbyists is a sham. No one doctor or otherwise should treat Addictions unless then have been trained in Addiction; have passed the Sate Board and hold a Certification in Addiction Counseling. Granted it is going to be much easier for a Medical Doctor to both get the training and pass the State Board-but it should be done or they too may NOT be qualified.

    Dr. Joyce R. Dickens
    PhD – Addiction Psychology
    Brescia University

    • Fawn Brown | March 30, 2012 at 3:41 pm

      I disagree that physicians should be treating addicts. Physicians nationwide have contributed greatly to the epidemic in this country of addicts who have been prescribed pain meds over and beyond what they need as well as prescribing pills to every drug addict that seeks treatment in rehabs. Enough! Your way does not and will not work. The only effective method for drug addiction and alcoholism is a FREE method that been working for over 50 years. Known as Narcotics Anonymous. “The therapeutic value of one addict helping another is without parallel.” The addiction field has become a racket for doctors, social workers, rehabs, etc. who have nothing to offer but more meds. In the end, they always refer addicts to attend meetings of Narcotics Anonymous. I have seen more addicts come into meetings with prescription addictions. I think any doctor prescribing opiates to anyone should undergo an evaluation by the state to guarantee that they are not abusing their licenses and perpetuating the addiction problem that they helped to create.

      Fawn B., recovering addict, 33 years clean

      • donna groat | April 4, 2012 at 9:40 pm

        Amen Sister! As a recovering addict/alcoholic, I spent many, many years in and out of hospitals, detoxes and psychiatrict units only to be told I was bi-polar, while physicians poked anti ‘whatevers’ down my throat. Only until I was totally and completely detoxded off of EVERYTHING, introduced to Alcoholics Anonymous, and above all, talked to another ‘recovering’ alcoholic was I able to even ‘think’ about what recovery was and is…I was labled my entire adult life as having a mental disorder, when low and behold it was ALL drugs and alcohol! It WAS NOT a physician, counselor or psycho’nut’ that helped to my sobriety, it was just like the Big Book says ‘Another Alcoholic”…A program that works! Let the physician do his/her ‘medical job’ and ‘detox’ us and leave the recovery up to the professionals, Alcoholics Anonymous!!

    • Carol | March 31, 2012 at 8:54 am

      Agree. Though we do need research as the author proposed, I question whether we are prepared to measure competence as he described. Regardless of professional identity, who has had adequate training in addiction assessment at all? Mistakes abound in this area for all of the professions, as I see it….

  8. Henry Steinberger, PhD | March 30, 2012 at 4:44 pm

    Who should treat addictions has been studied by William R. Miller and Patricia Brown, and this is covered in an article in The American Psychologist “Why Psychologists Should Know How to Treat Substance Use …” Miller & Brown (1997)though the question was not ‘should it be medical doctors’ which I believe suggests that addiction is always a life long ‘disease’ (a still controversial assertion). Miller and Brown found that never addicted psychologists and recovering counselors did just about as well, but the problem for the recovered helpers is that sometimes they are wed to how they themselves recovered, whereas the professionals (like us psychologists) recognize (or should) that there are many roads to recovery, and one size does not fit all. It would be better if medical professionals also recognized this well supported fact. Having spent over 20 years helping develop SMART Recovery and more years than that in the addiction field I feel confident in what I’m saying here. Perhaps a little Google searching will help the author to also find the study I mentioned here (it came up easily when I tried) and many other studies (see the 1997 paper mentioned for leads)which I have read but won’t bore this audience with a listing.

  9. Billsea | March 30, 2012 at 5:27 pm

    How much addiction training does the average MD get?

  10. Lou | March 30, 2012 at 8:45 pm

    In my experience there are many valid approaches and treatment providers, not one type. Probably most effective are those with experience, training, empathy, and good boundaries.

    I disagree that addictions are “brain diseases”, as some posit. Multi-factorial, instead.

  11. Bill Crane | March 30, 2012 at 10:32 pm

    Interesting article. I am always amazed by people trained in science that are so certain that addiction is solely a brain problem. If a study, as prescibed by Dr. Gitlow, is actually conducted, would it be under a physican-led group? We must remember that to a hammer (a physician) all problems look like nails (physical disorders). Over several hundred years, addicts have recovered using a variety of approaches. Perhaps one size doesn’t fit all? A study would have to include all well-known approaches to recovery, including medical intervention (drugs and drug supported),social supportive (AA and social model recovery homes), psychological interventions, spiritual approaches, and spontaneous recovery without outside help. State certified and licensed practitioners account for only some of the recovery successes.

  12. smackhead | March 31, 2012 at 11:21 am

    maybe this could help or scare some one enough to make them think twice before getting curious about the wrong stuff:

  13. Denny A. | March 31, 2012 at 2:15 pm

    100 patients in each group? And how many specialists working with each group? 3? 10? And, how are these specialists selected? This would not be a representative sample of specialists allowing generalization to an entire specialty. Perhaps a better method would be to follow-up a random sample of 30 patients selected and variable matched from 30 randomly selected and matched specialists from each specialty? Or, we can wait until the insurance actuaries do this when electronic health records are more widely implemented. They will know what specialty and what specialists are effective. Until then, there are more than enough patients to go around. After 37 years in the addiction field, I have found that for every professional who cannot differentiate depression from appropriate situational sadness, there is another that still believes all substance use disorders are best treated with prescription pad or cognitive behavior therapy depending on their licensed scope of practice and hourly rate. Imagine where oncology would be if there were still such arguments and opinions of this either/or nature regarding surgery, chemotherapy and radiation. And, when the biopsy on the patient’s insurance card and wallet are both negative, they may finally actually follow the advice of any good specialist and go to meetings, read the literature, get a sponsor and follow their path. These are still sound suggestions for many regardless of who makes them. And, many will not do so, as long as they can afford to seek an easier, softer way. While not the only way, or perhaps even not the best way for most I have heard in the last decade or so, it is free and will help some. More importantly, some of those will help others. It is humbling to admit, but some of those are much more effective in producing sobriety and improved functioning, with no degrees, licenses, credentials, or certificates. And, it is free. Someday, it may be all our healthcare system will be able and/or willing to afford. Even now, try to find a public detoxification bed without a wait in many areas of the country.

  14. Angel Gonzalez , MD | March 31, 2012 at 6:04 pm

    I would call your attention to the already forgotten excellent resource published by SAMHSA several years ago “Changing the Conversation, The National Treatment Plan Initiative”. I’ve never read a more comprehensive approach to addressing the problems of our field which are mentioned by you guys. Such a waste! It should be updated and put into practice ASAP.

  15. Joe Rosenfeld | April 1, 2012 at 5:33 pm

    Kind of a joke. Could he find a significant number of physicians willing to spend fity minutes with each client? Or would he expect the social workers to spend seven minutes, on average, with every client? What about giving the social workers perscription priveleges? Will a cost/benefit analysis be included?

  16. Lawanna | April 2, 2012 at 4:01 am

    Wonderful blog you have here but I was wanting to know if you knew of any community forums that cover the same topics talked about in this article? I’d really love to be a part of community where I can get suggestions from other knowledgeable people that share the same interest. If you have any recommendations, please let me know. Cheers!

  17. Patrik Karlsson, LCSW | April 2, 2012 at 12:25 pm

    Addiction is not just a medical disease. It is a biopsychosocial phenomena that requires specialized training independent of professional degree. It is absurd to think that one discipline has an advantage over another without specific addiction training. Some of the most complex addiction patients have been successfully treated by an interdisciplinary approach. As far as the research, I urge Dr. Gitlow to return to the literature and notice how level of training is more important than professional discipline. Social workers, MFTs, Psychologists, Clinical Nurse Specialists, etc who are trained in addiction, are just as capable of providing high quality, evidenced based addiction treatment.

  18. Scott Smith | April 2, 2012 at 12:48 pm

    In Oregon we have three levels of Certified Alcohol and Drug Counselor (CADC)-Level 1 requires an associates degree with 1000 supervised clinical hours. Level 2 requires a bachelor degree with minimum 300 alchohol and drug specific education hours and 4000 supervised clinical hours, and level 3 which requires a masters degree and 6000 supervised clinical hours-for all three levels require taking and passing a written exam and for level’s 2 and 3 taking and passing an oral exam. Unless an MD specializes in addiction our CADC’s get more A&D specific education and clinical hours than an MD does. Per our Oregon Administrative Rules we are required to collaborate with other professionals who are part of the over all treatment team for an individual and often this includes educating the medical professional. Everyone has a place at the table but let us not minimize the importance of the addiction treatment professional.

  19. Maia Szalavitz | April 2, 2012 at 9:05 pm

    Who definitely *shouldn’t* be treating addiction if it is a disease or mental disorder is churches, self help groups and other amateurs. These groups can’t have it both ways: if it’s a disease, it belongs to doctors and psychologists and social workers although support groups can be important ancillaries, just as for cancer. If it’s a moral issue, then the churches and spirituality can be *the* treatment. But if I went to a doctor for cancer and he told me to meet and confess and pray as the main treatment for my disease, I’d find another doctor and I think it’s only fair that addiction be given this respect as well.

  20. doogiem | April 3, 2012 at 3:35 pm

    What Maia said!!!!

  21. doogiem | April 3, 2012 at 5:22 pm

    Any traditional addictions treatment provider has a lot to learn from the “Living a Healthy Life with Chronic Conditions” (3rd Edition, 2006, Stanford University) – a workbook for those suffering from diabetes, heart disease, arthritis, and COPD. The workbook devotes only one page (out of 370 pages) to “prayer” and places it (appropriately) in the section entitled “Other Cognitive Strategies” (which also describes visualization, guided imagery, meditation, and self-talk in the chapter “Using Your Mind to Manage Symptoms”). Neither prayer nor meditation is held out to be an absolute requirement in treating any of the common disorders that addiction is commonly compared to. (The reason that spirituality has been held out to be the dominant treatment for addictions has everything to do with history and social phenomena and little to do with actual clinical efficacy). Tom McLellen and others have been saying it for years: it’s time to embrace the “public health” model of addictions. And it may only happen when the “old school” practitioners leave the field!

  22. Fr. Jack Kearney | April 4, 2012 at 6:10 pm

    Until that study is done and proves otherwise, I would send the person I love to a treatment center that ideally has:
    1. An MD to handle medical problems
    2. A licensed mental health professional or two, to diagnose and treat co-occurring disorders
    3. a whole bunch of certified addiction counselors, preferably all from Oregon. (see above…they seem to have decent educational standards!)

  23. Bill Crane | April 10, 2012 at 9:28 pm

    These articles invariably produce comments that reflect a narrow view of the addicted – that they all have loving caring families, have resources to select treatment options, have social support for their recovery, and have the motivations, expectations, and psychological wherewithal to engage in a treatment/recovery process. The reality of addiction tells a different story. Many addicts-alcoholics have long since alienated family and friends, have no visible means of support and see treatment as a vaguely suspicious enterprise. After spending a few years on the streets (sober over 35 years now), I ran into all konds of folks who sought to “save me” and others who were clearly out to simply use or abuse me – and after a while I could not tell one from the other. The anonymity, graciousness and free AA meetings were my ultimate refuge – because I had no other options (and this was good). To expect someone like me to seek help and make sure I was treated by “appropriately trained professionals” is a cruel joke on the real world of addiction. Over the past thirty years, the alcohol and other drug addiction field has not improved, conversely, it has actually gotten narrower and more difficult to access. It’s time the “experts” that keep putting more restrictions on treatment/recovery options to back off. Legitimate research on a full range of recovery approaches has never truly been conducted – only through lobbying by “professional” groups, not objective research, have the various restrictive standards been put in place. They need to spend some time on the streets and talk to those truly addicted to get a sense of the what can actually work for the majority of the severely addicted.

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