Pubdate: Mon, 11 Jul 2011
Source: New York Times (NY)
Copyright: 2011 The New York Times Company
Contact: http://www.nytimes.com/ref/membercenter/help/lettertoeditor.html
Website: http://www.nytimes.com/
Details: http://www.mapinc.org/media/298
Author: Douglas Quenqua
Bookmark: http://www.mapinc.org/rehab.htm (Treatment)

MEDICINE ADDS SLOTS FOR STUDY OF ADDICTIONS.

There is an age-old debate over alcoholism: is the problem in the 
sufferer's head -- something that can be overcome through willpower, 
spirituality or talk therapy, perhaps -- or is it a physical disease, 
one that needs continuing medical treatment in much the same way as, 
say, diabetes or epilepsy?

Increasingly, the medical establishment is putting its weight behind 
the physical diagnosis. In the latest evidence, 10 medical 
institutions have just introduced the first accredited residency 
programs in addiction medicine, where doctors who have completed 
medical school and a primary residency will be able to spend a year 
studying the relationship between addiction and brain chemistry.

"This is a first step toward bringing recognition, respectability and 
rigor to addiction medicine," said David Withers, who oversees the 
new residency program at the Marworth Alcohol and Chemical Dependency 
Treatment Center in Waverly, Pa.

The goal of the residency programs, which started July 1 with 20 
students at the various institutions, is to establish addiction 
medicine as a standard specialty along the lines of pediatrics, 
oncology or dermatology. The residents will treat patients with a 
range of addictions -- to alcohol, drugs, prescription medicines, 
nicotine and more -- and study the brain chemistry involved, as well 
as the role of heredity.

"In the past, the specialty was very much targeted toward 
psychiatrists," said Nora D. Volkow, the neuroscientist in charge of 
the National Institute on Drug Abuse. "It's a gap in our training 
program." She called the lack of substance-abuse education among 
general practitioners "a very serious problem."

Institutions offering the one-year residency are St. Luke's-Roosevelt 
Hospital in New York, the University of Maryland Medical System, the 
University at Buffalo School of Medicine, the University of 
Cincinnati College of Medicine, the University of Minnesota Medical 
School, the University of Florida College of Medicine, the John A. 
Burns School of Medicine at the University of Hawaii, the University 
of Wisconsin School of Medicine and Public Health, Marworth and 
Boston University Medical Center. Some, like Marworth, have been 
offering programs in addiction medicine for years, simply without 
accreditation.

The new accreditation comes courtesy of the American Board of 
Addiction Medicine, or ABAM, which was founded in 2007 to help 
promote the medical treatment of addiction.

The board aims to also get the program accredited by the 
Accreditation Council for Graduate Medical Education, a step that 
requires, among other things, establishing the program at a minimum 
of 20 institutions. The recognition would mean that the addictions 
specialty would qualify as a "primary" residency, one that a newly 
minted doctor could enter right out of school.

Richard Blondell, the chairman of the training committee at ABAM, 
said the group expected to accredit an additional 10 to 15 
institutions this year.

The rethinking of addiction as a medical disease rather than a 
strictly psychological one began about 15 years ago, when researchers 
discovered through high-resonance imaging that drug addiction 
resulted in actual physical changes to the brain.

Armed with that understanding, "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.

Central to the understanding of addiction as a physical ailment is 
the belief that treatment must be continuing in order to avoid 
relapse. Just as no one expects a diabetes patient to be cured after 
six weeks of diet and insulin management, Dr. Alford said, it is 
unrealistic to expect most drug addicts to be cured after 28 days in 
a detoxification facility.

"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.

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," she said.

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. Other drugs for treating opioid or alcohol 
dependence have shown promise as well.

Few addiction medicine specialists advocate a path to recovery that 
depends solely on pharmacology, however. "The more we learn about the 
treatment of addiction, the more we realize that one size does not 
fit all," said Petros Levounis, who is in charge of the residency at 
the Addiction Institute of New York at St. Luke's-Roosevelt Hospital.

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, Dr. Alford noted, 
adding, "I think there's absolutely a role for addiction psychiatrists."

While each institution has developed its own curriculum, the basic 
competencies each seeks to impart are the same. Residents will learn 
to recognize and diagnose substance abuse, conduct brief 
interventions that spell out the treatment options and prescribe the 
proper medications. The doctors will also be expected to understand 
the legal and practical implications of substance abuse.

Christine Pace, a 31-year-old graduate of Harvard Medical School, is 
the first addiction resident at Boston University Medical Center. She 
got interested in the subject as a teenager, when she volunteered at 
an AIDS organization and overheard heroin addicts complaining about 
doctors who could not -- or would not -- help them.

This year, when she became the in-house doctor at a methadone clinic 
in Boston, she was dismayed to find that the complaints had not 
changed. "I saw physicians over and over again pushing it aside, just 
calling a social-work consult to deal with a patient who is 
struggling with addiction," Dr. Pace said.

One of her patients is Derek Anderson, 53, who credits Suboxone -- as 
well as a general practitioner who six years ago recognized his signs 
of addiction -- with helping him kick his 35-year heroin habit.

"I used to go to detoxes and go back and forth and back and forth," 
he said. But the Suboxone "got me to where I don't have the 
dependency every day, consuming you, swallowing you like a fish in 
water. I'm able to work now, I'm able to take care of my daughter, 
I'm able to pay rent -- all the things I couldn't do when I was using."
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MAP posted-by: Jay Bergstrom