Addiction Treatment: Science and Policy for the Twenty-first Century

Although research has fueled amazing progress in the understanding of addiction over the past 2 decades, its effect on perception, practice, and policy has been modest and the disease of addiction remains mired in stigma, shame, and lack of public funding.¹ Furthermore, there is not even a consensus on the definition of recovery from addiction.² Neuroscience-based research has produced new and effective treatment modalities, but their implementation has been slow. Most physicians have had little formal training in addiction medicine, and few programs offer medical students a clerkship experience despite the prevalence of this disease and its enormous societal impact. Even addiction professionals are often in disagreement over appropriate treatment. Contributing to this may be the fact that the 2 avenues to advanced certification—the American Society of Addiction Medicine and the field of addiction psychiatry—have differing philosophies as well as separate examinations.

Currently there seems to be an increasing receptiveness to new science-based information on addiction medicine, with positive implications for practice, perception, and policy. In Addiction Treatment: Science and Policy for the Twenty-first Century, the authors call on the wisdom of leading thinkers in the field of addiction to provide a glimpse of what this progress might look like. These experts provide their insights on where the field is as well as where it should be heading, with the ultimate goal being to “stir debate and stimulate thinking.”

The introduction by former US Surgeon General Everett C. Koop begins with the admonition that when discussing addiction, one should first address the elephant in the living room, tobacco. Dr Koop goes on to discuss addiction in general, reminding readers that society is fighting the disease, not those who have it. He calls for compassion and “appropriate and flexible treatment” that should be as “easy to find as the addictive drugs themselves.” However, he also states that a “delicate balance must be struck between holding people responsible for their behavior and working to identify the driving forces behind it,” providing a reminder that having the disease of addiction provides a reason for behavior rather than an excuse.

The rest of Addiction Treatment is divided into 3 sections, the first of which addresses treatment models and emerging science. Here, new concepts involving loss of control, motivation, reward, nutrition, and more effective treatment paradigms are discussed as well as the application of recent computer-based technology. In this section, readers are reminded that some recent research has shown that the “confrontational, coercive attempts to take away a person's choice or responsibility or to invoke shame ultimately fail.” Also included is a call for the need to understand why many physicians are not prescribing opiate-replacement therapies such as buprenorphine or methadone, despite their demonstrated efficacy over other interventions.

The middle section is devoted to special populations, with topics that include pregnancy, adolescence, human immunodeficiency virus, and prisons as well as a chapter on trauma centers that we found to be especially stimulating—and disturbing. Here the authors provide insight into how current insurance statutes impede the diagnosis and treatment of addictive disorders. A delightful essay entitled “Addiction Art and Science” follows, in which readers are reminded that persons with addictions are more than just “biological wiring” and that addiction must be understood from more than just a scientific perspective.

The final section covers health care, social, and policy issues. It begins with an essay by Alan Leshner, PhD, former director of the National Institute on Drug Abuse and current editor in chief of the American Association for the Advancement of Science, in which he discusses the emerging science of addiction, highlighting the amazing discord between scientific knowledge and public perception. Leshner also discusses the responsibility of the scientific community to educate the public and the need to provide evidence-based treatment rather than that based on personal ideology. Other topics addressed in this section include social justice, the role of the Food and Drug Administration, behavioral intervention, confidentiality, and the marketing of alcohol to youth.

Throughout the book, the overall theme is concordant with Dr Koop's introduction supporting the disease concept of addiction and the value of abolishing stigma. However, the final section includes some thought-provoking essays that express opposition to these views. The first, by Sally Satel, MD, challenges the idea that stigma should be avoided; the second, by Stanton Peele, PhD, JD, challenges the whole disease concept itself. Such balance makes this book even more valuable as a resource for the busy physician.

Addiction Treatment is not encyclopedic or all-inclusive in the topics covered, and the chapters are brief. Not emphasized were recent studies showing that contingency management, ongoing drug testing, active management of relapses, and a long-term continuing-care approach are associated with favorable results. These strategies are routinely used by effective programs for monitoring addiction in physicians.³ In fact, a recent 50-state study reveals a 5-year physician recovery rate in excess of 80%.⁴ Research has shown that clinicians often use differing approaches (and often treatment modalities) when caring for physicians vs nonphysicians with the same diagnosis.⁵ Perhaps efforts to ensure that the same high standard of addiction treatment and monitoring is provided to both groups would be worthwhile.

Furthermore, common practices used in medical and oncology outcomes research should likewise be used to gauge outcomes in addiction medicine. While 20 or 30 days of not smoking cigarettes is a good start, the 5-year follow-up common in outcomes studies should be the gold standard. If addiction is a chronic relapsing and lifelong illness, anything short of this is likely to provide false starts, false promises, and misdirected hope. However, as the authors stated, the book was written to “stir debate” and “stimulate thinking” rather than provide a comprehensive text. The brevity of the book and the conciseness of the essays add to the book's readability, and the opposing viewpoints provide balance and highlight the lack of consensus on the treatment of addiction. Addiction Treatment provides a broad overview of where the field seems to be heading and achieves its goal by provoking debate over the best way to get there.