While some laud as a modern miracle the approval of a new medical specialty in addiction, officially crowned as ABAM (American Board of Addiction Medicine), I have been warning against this eventuality since when it was foreordained in The New York Times in 2011.
It was always apparent in which direction ABAM would take us: The New Medical Approach to Addiction, the Times reported back then, was taking hold in America’s medical schools, where addiction medicine was becoming a recognized specialty. Although the Times< welcomed this development (it was inevitable), it hasn’t improved America’s addictive dispositions—it has made things worse, as shown by our current addiction epidemic.
In 2011 I listed the top 10 problems—none of which has changed—that are apparent in this approach. I post it below with a few (bolded) updates. Plus ça change…
- The new approach isn’t new. The Times acts as though psychiatry has been psychoanalyzing addicts and alcoholics for the last 50 years. It hasn’t. For some time, the dominant assumption in the field has been that alcoholism is a disease, one that is physiologically determined. Certainly with drug addiction, the dominant assumption in the 20th century—one which was invented in its early part—is that addiction is a specific physiological syndrome. (Does the Times think that people believe heroin addiction is psychosomatic?)
- We have inexorably been moving away from defining addiction medically. Due to the idea that heroin addiction is a highly-specific medical syndrome, we were slow coming around to recognizing other drug use—starting with cocaine and nicotine—as addictive, which only occurred in the 1980s. Recent decades are actually all about how addiction is being refocused—even redefined, in terms of what are being called process addictions. But It is not because we know more about how nicotine operates that the Department of Health and Human Services decided it was addictive in 1988, after the Surgeon General’s Report specifically rejected that idea in 1964. Rather we have changed our conception to de-emphasize the chemistry of narcotics.
- Point to the brain and repeat after me: “It’s a disease.” The most distressing sentence in the Times article was: “researchers discovered through high-resonance imaging that drug addiction resulted in actual physical changes to the brain.” What exactly does addiction look like in the brain—can we diagnose it that way? Answer: No, we can’t. If the idea is that drugs produce significant changes in the brain, how does that distinguish them from, say, sex, eating and other primary activities? That things affect the brain does not make them addictions or diseases—or determine whether they are healthy or unhealthy, as Ilse Thompson and I point out in Recover!: An Empowering Program to Help You Stop Thinking Like an Addict and Reclaim Your Life.
- Addiction is no longer about drugs. According to the Times, addiction medicine is about “alcohol, drugs, prescription medicines, nicotine and more—and [the need to] study the brain chemistry involved, as well as the role of heredity.” What goes in that “and more” category? Was the Times aware the DSM-5 was preparing to add gambling to the list of addictions, while holding in abeyance sex, eating and video games? Even at the time its article appeared in 2011 the leading journal in the addiction field, Addiction, devoted an issue to discussing food as addictive?
- The new approach isn’t medical. The argument over treating addiction medically as a brain disease isn’t with psychiatry, but with the 12 steps. Of course, the 12 steps are anything but medical, as my fellow Influence columnist Maia Szalavitz points out in her new book, Unbroken Brain. But the Steps’ identification of addiction as a disease has put them so firmly in bed with disease medicine that they will never be extricated. The American Society of Addiction Medicine (ASAM) from which the new addiction medical specialty grew was founded and dominated by 12-step supporters. How the remaining 12-step true-believers react to a medicalized, non-spiritual view of the “disease” will be fascinating to watch.
- The excluded middle. The Times writes as though the world is divided between psychoanalysis and the 12 steps, on the one hand, and brain chemistry, on the other: “Equally maligned is the idea that psychiatry or 12-step programs are adequate for curing a disease with physical roots. Many people who abuse substances do not have psychiatric problems. …” That addiction may be a remedy for a mental disorder—and it may not be—is by now widely accepted. But in any case, psychological approaches to mental disorders have moved a bit beyond psychoanalysis over, say, the last 50 years. Anyone out there heard of CBT, motivational interviewing, the community reinforcement approach; of Aaron Beck, Alan Marlatt, and—ahem—me? Considerable research has generated effective non-medical approaches to addiction other than the 12 Steps. Will these new medical programs incorporate or ignore them? (The article does note, “Few addiction medicine specialists advocate a path to recovery that depends solely on pharmacology, however.”)
- Pharmaceutical treatments have problems. Although the Times greets new pharmacological treatments as being great breakthroughs, it also has to note some drawbacks, to wit: “Increasing interest in addiction medicine is a handful of promising new pharmaceuticals, most notably buprenorphine (sold under names like Suboxone), which has proved to ease withdrawal symptoms in heroin addicts and subsequently block cravings, though it causes side effects of its own“ (emphasis added). The Times adds, “Other drugs for treating opioid or alcohol dependence have shown promise as well.” But there is a history of pharmacological treatments appearing, being greeted as remarkable new cures, and then—disillusionment. This is now the case with the once-highly-touted use of naltrexone in the treatment of opiate addiction, about which an authoritative review of research found: “the general run of opiate-addicted patients do almost as well given no active medication as when prescribed the opiate-blocking drug naltrexone.” Now, exactly the same has been shown for naltrexone and alcoholism, as I recently pointed out in The Influence. And, of course, it is prescription medications to which Americans are increasingly becoming addicted. The subhead of the Times’idolatrous interview with Nora Volkow, the biggest proponent of addiction medicine, read, “An addiction expert faces a formidable foe: Prescription drugs.”
- The medical approach denies self-cure. As the Times conceived the issue: “’the management of folks with addiction becomes very much like the management of other chronic diseases, such as asthma, hypertension or diabetes,’ said Dr. Daniel Alford, who oversees the program at Boston University Medical Center. ‘It’s hard necessarily to cure people, but you can certainly manage the problem to the point where they are able to function’” through a combination of pharmaceuticals and therapy … “’It’s not surprising to us now that when you stop the treatment, people relapse,” Dr. Alford said. “It doesn’t mean that the treatment doesn’t work, it just means that you need to continue treatment.” Those physical changes in the brain could also explain why some smokers will still crave a cigarette 30 years after quitting, Dr. Alford said.'” So what do we do with the fact that the government’s own research has determined that the large majority of alcoholics cure themselves without treatment? Think about smokers in this regard. Forty million American smokers quit on their own through the 1980s, but the idea that they can do so without pharmacological assistance dwindles with each passing year. This predominance of self-cure holds true for the entire range of addictive substances.
- Those stupid doctors. The fundamental assumption of the article—and the addiction medicine movement—is that doctors are fools: “If the idea of addiction as a chronic disease has been slow to take hold in medical circles, it could be because doctors sometime struggle to grasp brain function, Dr. Volkow said. “‘While it is very simple to understand a disease of the heart—the heart is very simple, it’s just a muscle—it’s much more complex to understand the brain.'”Of course, alternatively, maybe doctors have a healthy respect for real distinctions between cancer and behaviors like smoking and drinking. After all, many doctors have seen people quit smoking and cut back their drinking on their own. The single most empirically validated form of alcoholism treatment is brief intervention, which comprises minimalistic interactions between health care workers and alcoholics where medical personnel point out excessive drinking, set goals and discuss methods to cut back with patients, and then track their progress—usually meaning reduced drinking. How will addiction medicine deal with these realities? Point 8. above suggests that it will ignore them.
- And what about policy? But among the worst consequences of the new official medicalization of addiction is its effect on drug policy reform. Anyone who attended the 2015 DPA conference, in which a beleaguered (if brave) NIDA representative fended off a very skeptical audience, knows this by now. The Times doesn’t juxtapose the massive discussion currently ongoing about drug policy with the addiction medicine movement. But they are deeply entwined. If addiction is a disease caused by drugs—what was that you said about gambling?—it simply makes no sense to loosen penalties and restrictions on drug use, since people will inevitably become hooked when drugs are more readily available. In a fundamental way, the formalized addiction medicine approach challenges efforts to rethink how, as a society, we deal with drugs. If it’s a disease resulting from the effects of drugs on the brain, we’re certainly not going to allow people to use drugs! Would we willingly loosen restrictions on carcinogens in our society? So, given the addiction medicine perspective, how can we accept that people voluntarily take drugs (leaving aside prescription medicines, that is!)? And, as predicted, NIDA Director Nora Volkow has been making this explicit regarding marijuana legalization: “Legalized Cannabis and the Brain: NIDA Sounds the Alarm.” The new addiction medicine specialty won’t result in clear-cut benefits and progress, to say the least. It won’t eliminate the disease of concern as the discovery of germ theory led to the elimination of major infectious diseases. Nobody believes it will, or can. Indeed, it will make the addiction landscape worse..
I pointed all of this out five years ago when the addiction medicine specialty was first being formulated. And all of this is now coming to pass, with the same people who perpetrated these disastrous results now taking a bow.
Stanton Peele is a columnist for The Influence. His latest book, with Ilse Thompson, is Recover!: An Empowering Program to Help You Stop Thinking Like an Addict and Reclaim Your Life. He has been at the cutting-edge of addiction theory and practice since writing, with Archie Brodsky, Love and Addiction in 1975. He has since written numerous other books and developed the online Life Process Program. His website is Peele.net. Dr. Peele has won career achievement awards from the Rutgers Center of Alcohol Studies and the Drug Policy Alliance. You can follow him on Twitter: @.