Why Doctors Can't Deal With Addicted Patients

By Ruth Fowler 05/09/11

Just because your physician took a Hippocratic oath doesn’t guarantee that he’ll be able to confront you about hitting the bottle. (Or that he’ll treat you like a human being.)

Some doctors simply push pills on patients who have substance problems.

Lauren is always amazed when she hears people in her 12-step group share that a doctor or therapist coerced them into AA. “I hear so many people say, ‘My shrink refused to keep treating me unless I came here,’” she says. “And that simply wasn’t my experience.” Lauren relates how, in her twenties, she was hooked on a cycle of Ambien and cocaine. Her psychiatrist didn’t seem to realize she had a problem, despite the fact she was getting repeat prescriptions from him for sleeping pills (as well as anti-depressants). One day, after another session in which she’d broken down for the umpteenth time, Lauren admitted she was abusing cocaine and medication. It was an unconscious cry for help to a medical professional—but no help was forthcoming. Her psychiatrist merely told her that if she didn’t report her regular cocaine use to those in her group therapy, he would. A few weeks later, he informed her that he couldn’t help her anymore as he “couldn’t deal with her problems.” He then refused to give her any more anti-depressants, asked for $300 dollars, and sent her off with a prescription for three month’s worth of Ambien.

Lauren got lucky. After her money ran out and she had a similar experience with another therapist, she was contemplating driving her car into oncoming traffic when she managed to make it to an AA meeting instead. When she was a year sober, she received a bill from that old psychiatrist and immediately wrote him back—reminding him that he had refused to treat her, had denied her access to anti-depressants, and yet had given her enough Ambien to kill herself. “If I hear from you again, I will report you to the American Medical Association,” she wrote. She never heard from him again.

At no point during Lauren’s interactions with her primary care doctor, group therapist or psychiatrist did any of these professionals directly confront and address Lauren’s obvious substance abuse problem. “I was a wreck—suicidal, totally depressed,” she recalls. “The weirdest thing was I later found out my primary care doctor, who I used to score painkillers from, was sober and in AA. And yet he didn’t seem to register that I had an issue.”

Lauren’s story highlights the biggest challenge facing patients in a society where addiction still struggles for recognition and acknowledgment. In the medical community, this is primarily because most doctors themselves do not recognize addiction until it is too late—or may even harbor latent prejudices about addicts and alcoholics which are uncorrected by exposure, experience or medical training. This is primarily because the traditional focus of the medical community has been on the consequences of addiction—for example, cirrhosis of the liver or Hepatitis B, rather than on the complex, underlying causes of the disease.

Regarding the problem of addiction, until recently, there has been little a primary care physician can do except offer patients detoxification. A 2003 survey carried out by Columbia University’s Center for Addiction and Substance Abuse revealed that doctors do not receive adequate training when dealing with patients suffering from addiction or alcoholism. Dr Nasir Naqvi, a Fellow in Addiction Psychiatry at Columbia University, sees the failings of the medical field in this respect as “a story of individual practitioners who are either ignorant of what they are being taught in medical school and residency, or who cannot overcome their individual moral biases in order to help their patients.”

This is partly the fault of the American medical system. It wasn’t until 2008 that Congress passed the Parity Bill, which ensures that mental health and substance abuse is covered under insurance. Dr. Tom McLellan, a psychologist, psychiatry professor and former Deputy Director of the Office of National Drug Control Policy, sees doctors’ ignorance in treating addiction as a direct consequence of the fact that until recently, it was excluded from insurance plans and mainstream medicine. “The Parity Bill is one of the greatest gifts that’s ever been given to the insurance industry,” he says. “By actively treating substance abuse problems, they’re going to get far greater returns than from the other very expensive healthcare it generates later.”

What The Parity Bill means is that your primary care doctor is now reimbursed for screening, counsel, follow up sessions, family sessions, medications, and in-home visits for addiction / mental illness related problems —exactly the kind of care that a patient might receive for hypertension and diabetes. According to McLellan, the significance of this is that these diseases are similar to alcoholism in that “you can’t get them unless you have the gene, but to develop them even with the genetic predisposition, you have to eat to excess, smoke, refuse to exercise—or, in the case of addiction, abuse alcohol and substances.” McLellan says that those doctors who—as in Lauren’s case—were once loath to diagnose addiction and the mental health issues it entailed are finally finding time to study the topic, now that it’s become comparably compensated under insurance plans.

Of course, this doesn’t change the fact that many patients are still in denial about the magnitude of their problem and a doctor must be able to judge the right moment to broach the issue. The same Columbia study that proved that doctors don’t receive enough addiction-related training also found that many physicians—47%—found it difficult to discuss misuse of prescribed medication with their patients.

How, then, should a doctor deal with an addicted patient?

According to Scott Bienenfeld, a New York based addiction expert, they should have a basic understanding of addiction, preferably through specialized training with societies such as the American Society for Addiction Medicine or the American Academy of Addiction Psychiatry, and they should display a basic level of proficiency in screening for addictive disorders.

In addition, they should try to keep up with the massive changes regarding medical understanding of addition In the past 20 years, major discoveries about the brain’s reward generating dopamine system—and the effects of drugs of abuse on this system—addiction is now morte treatable than it has ever. Incredible advances in science have allowed have helped to dispel damaging myths that addiction is merely a social, psychiatric disorder that belongs in the realm of the weak-willed, the immoral or the dysfunctional. While we were once subject to PSA’s telling us all drugs would turn our brains into fried eggs, Nora Volkow’s work, for example, allows us to actually see how heroin, nicotine, cocaine, meth, and alcohol work at a neurological level—and this has not only heralded new, more effective medication to treat both cravings and addiction, while creating more trained specialists.

In the process, psychiatry has had to shift towards a more biological framework. Notwithstanding the advances in understanding and treatment, and despite the increased awareness of medical malpractice regarding the misuse of medication, personal bias among physicians still means there is some way to go before the treatment of addiction reaches a universally recognized standard.

What is that standard? Bienenfeld suggests that a physician’s responsibility to the addicted patient is to first ensure that their physical health is stabilized before referring them to a seasoned addiction specialist who can do a full evaluation and advise them on the best ways to detox as well as specific medications that may help. The addiction specialist should also recommend methods such as Relapse Prevention Therapy—a blend of coping skills training, lifestyle modifications and cognitive therapy—and Motivational Interviewing, which is similar in its approach.

Every doctor I spoke to also said they’d recommend a 12-step group to an addicted patient but most emphasized that they can only strongly make this suggestion—meaning, they can’t require it. Bienefeld suggests though, that the process of detoxing, going to an addiction specialist, and working on underlying issues can sometimes help patients realize the breadth of their problems, which in turn makes them find the idea of attending a 12-step meeting more acceptable.

“As an addiction specialist, you realize that lying, shame, and perceived judgment are part of the addiction and recovery slip cycle,” says Dr. Greg Dillon, another New York based addiction specialist. “A patient needs to work through that. I do prescribe medication in the service of treating some forms of underlying anxiety, depression and cravings—but extremely sparingly.” Bienenfeld notes that it’s important for the addiction specialist to try to identify co-occurring problems—many of which a therapist or primary care physician simply does not have the expertise to adequately treat—such as depression, phobias, mood disorders and actual physical pain.

The short answer to how doctors should treat their addicted patients is that if the patient has demonstrated a clear addiction, it’s the physician’s responsibility to help get them off it. Repeat prescriptions for Vicodin without any other question than “Where’s my check?” may make you think you have a great, understanding doctor—but this isn’t the case. Sometimes, of course, people get addicted to pain medication they need—a particularly complex episode of Intervention focused on Brooke, a 20-something former cheerleader whose painful rheumatoid arthritis demanded a degree of pain control and a doctor who could help her manage pain without descending into addiction.

But ultimately, once a doctor has confronted a patient’s addiction, the responsibility for recovery lies entirely with the patient. That’s when, as every doctor will surely testify, other people in recovery—meaning the non-medical professionals—are the greatest help. Knowing this, Naqvi, Bienenfeld and Dillon believe that medical professionals who specialize in substance abuse, addiction and recovery have a responsibility to get out into the community at a grassroots level—attending NA, AA and other 12-step meetings to speak to recovering addicts and alcoholics so that when they recommend patients go there, they know what and why they’re recommending it. Which means that if you landed on this article because your doctor suggested you hit up a 12-step meeting, before you blow up at them, perhaps consider hightailing it along to your local community center or church basement.

And maybe take an MD along with you.

British-born author, screenwriter and journalist Ruth Fowler lives in Venice, California and has written for The Village Voice, The Guardian, The Huffington Post, The New York Post and The Observer. Her memoir, No Man's Land, which documented her pre-sobriety experiences as a stripper in Manhattan, was published by Viking in 2008. She also wrote about nursing your way back to health.

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