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This is probably the second most important question in the field of addiction treatment, the first being whether or not addiction is an illness. I think it’s clear where I fall on the answer to that question, but once addiction is a illness, then comes the question of the role of medication in it’s treatment.

The field seems divided, but it’s always been divided. There are always been those that thought that any medication for an someone with addiction would interfere with recovery, and while anti-depressants have largely become acceptable to this crowd, there are still a few who think even this is too much. This seems to stem from two ideas as far as I can tell. The first is the belief that authentic suffering is required for true recovery and anything, even medication, that blunts that suffering will delay recovery. The other source seems to be the desire for “natural” recovery, I suppose stemming from the idea that it is the unnatural drugs that have caused the problem in the first place.

The second pole of the division is the group that has always advocated agonist maintenance treatment for addiction as a total treatment. This group seems based fundamentally on the need to restore biological function as the only goal of treatment. The idea being that the illness is purely physical and once it’s fixed the person is normal. Of course there are many people in the middle, perhaps even most people, but these two poles seem to define the field.

I think these two groups have reached their polar opposite conclusions because of polar opposite views of the illness. The biological group sees a physiologic derangement that needs fixing. They historically have not paid enough attention to what happened to the person’s character structure during the years that the illness was active. The other group seems to be focused on the effect of the drug and gives little thought to the possibility of an underlying, even genetic, physiological derangement that caused the problem. With this background in mind, let’s look at how the two groups visualize drugs and medicine.

The “take no medicine” group sees any agent that acts at the same site or in a similar way to a drug as a drug and believe that it has no use in the treatment of addiction. The famous, or infamous, example of the day is Suboxone. It’s a partial opioid agonist and does what it does at the opioid receptor. Therefore this group says it is an opioid and therefore anyone who takes it is not “clean.” While this view is not mainstream, the belief system is influential and there are several treatment centers set up according to this philosophy.

The “medication is enough” group sees any agent that relieves suffering as a medication. It doesn’t matter where it’s used or if it is abusable, as long as some effort is made to limit the abuse. It doesn’t matter how it acts or how it relieves suffering. In the case of Suboxone, this group responds enthusiastically to the ability to provide opioid (partial) agonist treatment in an outpatient setting, releasing them from the restrictions of the methadone clinic. Again, while this view is not mainstream, the belief system is influential and there are several academic writers speaking about such “medication only” regimens. Their nod to psychosocial treatment is to have a nurse call once a week to make sure you’re taking your medication.

Of course both groups are wrong and their errors are based on ignorance and fear. The “no medicine” group is afraid that doctors will just load up addicts on other drugs that will lead to similiar if not larger problems in the future, not only delaying recovery, but doing actual harm. The medication only group is afraid that non-medical professionals will run the show requiring ideologies and belief systems of the patients and picking who lives and who dies according to who accepts the ideology of “the cult.” The examples that each group can site are real, but very rare.

As in all things a middle path must be found. I cannot tell you what “the” middle path is, I can only tell you mine. Is my path any less of an ideology than the extremes? I hope so. The evidence that leads me to this path is too voluminous to put here, but most of it is in previous posts and my book. For me a drug is what we use now to change how we feel now; it is the epitome of self will attempting to control nature. A medication is what I take no matter how it makes me feel acutely because it is a treatment for an illness; it is the epitome of surrender to a fact of nature. Is there any role for drugs in recovery? I don’t think so. That means there’s no role for overeating, smoking, compulsive sex, compulsive exercise, compulsive gambling or spending, etc in recovery, because once we have the disease of addiction we can use many if not all of those things as a drug. Is there a role for chemicals which act at the same site as some drugs? I think so. But to be medications they must be taken like medications. In my experience it is rarely the chemical in the medication that causes the problem but rather how it is used.

Medication is a tool, not a solution in the treatment of addiction. As long as both sides in the debate embrace the extremes we will see continued problems and confusion for patients and other stake holders. A good topical example is Suboxone. There is so much fear and hype around the medication that some doctors who are approved to use it refuse to write prescriptions for it because they are afraid of running afoul of the FDA or DEA. And, it’s not so out of the question either. The federal government must be open to comments by all citizens and, unfortunately, some of them are presenting hype and fear. Government, even governments that strive to be data driven, can be driven by political pressure no matter how divorced from reality the source of the pressure is. I know professionals in the field who will not speak their mind at professional meetings for fear of peer reaction. The result is that hundreds die of overdoses of full opioid agonists because the “no medicine” group can find and present in hysterical fashion a few cases of Suboxone abuse.

If addiction is a disease, then we should treat it like one, and those that treat it should be treated like those that treat other diseases. They should be held to the same standards as others, not greater standards. The result of the fear and ignorance is that there are fewer people treating addicts than there could be because people who treat addicts in an attempt to stop abuse of drugs are held to a higher standard than those physicians who provide abusable drugs in an attempt to stop pain. As with most things we, as a society, are the source of our own problems.

I am very interested in organized medicine reworking the current definition of addiction. There are two problems with the definition as provided by DSM IV currently. The first is that the definition is limited to substance dependence and doesn’t allow for addiction using behaviors or what are commonly called process addictions. The second problem is that the definition is based on behavior rather than biological state. In the last entry I spoke of ASAM’s and ABAM’s use of the current defining ideas. Lately, in the healthcare debate, a lot of people have been looking at Canada, so I thought I would too as there is a Canadian Society of Addiction Medicine as well. Here’s the definition of addiction that they put on their website:

Addiction (Adopted 99.10.14) – A primary, chronic disease, characterized by impaired control over the use of a psychoactive substance and/or behaviour. Clinically, the manifestations occur along biological, psychological, sociological and spiritual dimensions. Common features are change in mood, relief from negative emotions, provision of pleasure, pre-occupation with the use of substance(s) or ritualistic behaviour(s); and continued use of the substance(s) and/or engagement in behaviour(s) despite adverse physical, psychological and/or social consequences. Like other chronic diseases, it can be progressive, relapsing and fatal.
Consider adding qualifiers such as full, partial remission, etc. based on DSM IV.

You can see right away that the CSAM doesn’t limit the idea of addiction to substances, and you know I’m happy to see that. Look at the date. This has been their definition for over 10 years. The other day I received a communication from a friend at ABAM who had read my last entry. He pointed out that while the current definition is limited to substances, they would be open to reviewing the limitation when evidence warrants. It looks like CSAM had enough evidence 10 years ago.

But here’s the problem. For those who don’t believe the current evidence for addiction involving behavior rather than substances, CSAM’s definition looks just as ideological as ASAM’s. It comes down to what you believe. That’s because CSAM’s definition lacks any biological focus as much as ASAM’s. It’s a very inclusive definition, but doesn’t exclude enough to be very useful. Any member of American Medicine can look at this definition and quickly decide it doesn’t offer more than the current one in use by ASAM. Progress generally happens when your neighbor one ups you, not when he doesn’t.

If I gave both definitions to a non-addiction physician, I doubt he or she would find either useful in terms of making a diagnosis in a biological sense. You can tell when you have a useful idea when everyone else starts to use it. I have a lot of friends in medicine who don’t practice Addiction Medicine, and they are not drawn to take either of these definitions as useful. That’s one of the reasons they mostly shy away from helping addicts. They have nothing to go on, and doctors like to know what they are doing.

CSAM’s definition is, I think, better than ASAM’s, but still has a way to go. My Canadian friends might take issue with what I feel is a lack of biological focus in their definition. They may point to the sentence that starts “Common features..,” but that’s just it. These are common features, not defining features. To be useful, the definition of an illness must be discriminating enough to tell the doctor what to do. While CSAM’s is better than ASAM’s in including more, it’s less than a helpful improvement because it includes too much. It would include those patients I’ve labeled as “Compulsive Use Syndrome” that are biologically driven to continue to use after first using but are not driven to restart once stopped. There aren’t many doctors who would find it useful to include both groups of patients in the same definition as the treatment would be entirely different.

I’m glad CSAM’s definition is different than ASAM’s. Diversity is good. When everyone is doing one thing in any environment, it’s the beginning to the road to extinction. That’s a big reason why we need definitions based on biological reality rather than someone’s interpretation of a patient’s behavior. DSM has created an ideology of addiction, not a clinical definition. And as the environment changes, the ideology can’t. That’s the end of the road to extinction. I wonder what the Mexicans think.

© Howard C Wetsman MD FASAM