The American Board of Addiction Medicine just put out for comment its newly completed Scope of Practice for Addiction Medicine. (http://www.abam.net/files/Addiction_Medicine_Scope_of_Practicet_V1_2009.pdf) That document basically describes what Addiction Medicine physicians do. The document came to my attention when a colleague found fault with a recent media show on “addiction to plastic surgery” and pointed out that, to the positive, ABAM had finished its document. So I took a look. The question on my mind is whether or not ABAM will consider anything addiction if it doesn’t have to do with drugs or alcohol.
The first paragraph is ambiguous to the point of whether or not addiction can involve something other than drugs or alcohol. It refers to the job of the Addiction Medicine physician as someone who cares “for persons with addiction, for the individual with substance-related health conditions, for persons who manifest unhealthy substance use, and for family members whose health and functioning are affected by someone’s substance use or addiction.”. This list leaves open the possibility that “persons with addiction” may include more than individuals with “substance-related health conditions.” The second paragraph is also ambiguous on this point. “Addiction medicine specialists often offer treatment for patients with addiction or unhealthy substance use” leaves open that the patients with addiction may not have unhealthy substance use but rather addiction using something other than substances. However it is in the third or last paragraph that I think the Board’s intention becomes clear. “Some addiction medicine physicians limit their practice to patients with addiction or other patterns of unhealthy substance use.” This sentence tells me that addiction is a pattern of unhealthy substance use and is one among many patterns of unhealthy substance use. So it seems clear that ABAM, like ASAM, limits the idea of addiction to substances. I think this has great implications for what will happen to Addiction Medicine.
The public, as expressed in the “addiction to plastic surgery” media piece, does not seem to have the idea that addiction is limited to substances. It could be that they are using the word incorrectly. It could be that the word addiction has been so overused that it no longer means anything. It could be that people just mean “use too much” when they say addiction. It could be, so I asked a group of people for whom the word addiction is very meaningful, recovering addicts. Not one of the people with addiction that I asked was offended by the use of the term addiction to plastic surgery. Each understood that the pain of that person was as great as their own. None made fun of it. None thought that their addiction was limited to drugs or alcohol. None thought that addiction treatment should be limited to people with “unhealthy substance use.” But it could be that since I asked people with a brain illness that they may be mistaken. What does science have to say?
Much of the recent work in imaging has focused on the midbrain reward system. Several researchers have show that the same pattern of decreased dopamine receptor density exist in heroin addicts, compulsive overeaters, compulsive gamblers, alcoholics and other groups of addicts tested. Blocking dopamine increases craving in compulsive gamblers just as it does in smokers or alcoholics. It seems that what is important is not the substance or behavior but rather what that substance or behavior does to the midbrain dopamine tone. I have read nothing that convinces me that a scientific brain based definition of addiction would be limited to substances. While there are scientists who say that it is, I find glaring holes in their arguments which generally fall back to an appeal to authority rather than the data. But why would anyone be interested in limiting addiction to substances if it actually isn’t? Who benefits from that?
There is a large entrenched industry for addiction treatment. The origins of the industry are too complex to get into here, but the entanglements between the fight to have addiction treatment recognized as real treatment and addiction as a real disease have led to politics and finance sometimes pushing reality into the back seat. There are billions in government money in the budgets of the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism. What if addiction was bigger than drugs and alcohol? We’d have to change the names. In fact, there was a push to do that but the websites for these institutes haven’t changed. The status quo would be greatly upset by expanding the idea of addiction to more than substances. The odd thing is that most people with addiction and their families aren’t so impressed with the status quo.
So where will it end? My prediction, and I hope I’m wrong, is that ASAM and ABAM will remain firmly in the camp of addiction being a substance use problem. The consumers however will begin demanding a greater breadth of services than is traditionally offered by Addiction Medicine. Where will they go? Probably to the people with the answers. But the road to the people with the answers will be not as straight or safe as they would be if they were part of Addiction Medicine. Because Addiction Medicine will not allow the concept of addiction to non-substances, patients will be more exposed to risk until they do find those with answers. And when they do find those with answers, the answers will put Addiction Medicine out of business. Organized Addiction Medicine is approaching its last chance to save itself from being overcome by events. It has one last chance to get on board with the rest of the world. Unfortunately it seems to be ignoring the opportunity.
© Howard C Wetsman MD FASAM