Calling All Doctors!

By Susan E. Foster and Linda Richter 03/15/15

A call for a seismic shift in the way we treat addiction.


Introduction: The proactive prevention and treatment of substance use disorders is one of the best bargains in medicine—particularly because of the immense pain and costs that impact substance users, their families and society when addiction goes unprevented and untreated. Unfortunately, the medical system is still lagging in the identification and treatment of addictive disorders. We spend far more time and money treating the consequences of substance misuse and addiction than we do on preventing and treating them in the first place. Linda Richter and Susan Foster want to stop the insanity, and they have a plan to do so…Richard Juman

Sixteen percent of the U.S. population ages 12 and older—40 million people—have the disease of addiction involving nicotine, alcohol, illicit or controlled prescription drugs. This is more than the percentage with heart disease (27 million), diabetes (26 million), or cancer (19 million). We know that addiction is a complex and progressive brain disease. We know that a wide range of risk factors increases the chance of developing the disease. We know that it often co-occurs with many behavioral disorders and drives over 70 other diseases requiring medical attention. And, we know that in many cases it can be prevented, treated and effectively managed. In spite of these facts, only about one in 10 people with addiction involving alcohol, or drugs other than nicotine, receive any form of treatment! That’s compared with the over 70% of people in need of treatment for other prevalent and treatable health conditions like hypertension, diabetes, and major depression who do receive treatment. Of those who do receive some form of treatment, few receive evidence-based care. Fifteen years into the 21st century, why are we still tolerating this vast disconnect between science and practice?

A basic public misunderstanding of the disease is, of course, a major factor resulting in associated stigma that keeps people from seeking help and that keeps health-care providers from identifying and addressing the disease. But the medical profession has successfully overcome stigma before by adopting science-based care (e.g., TB, depression and HIV/AIDS). In the case of addiction, however, the type of care available to the millions of people with a treatable disease is still too often limited to peer-support groups or "treatments" long on self-help and short on science—and often provided completely outside of medical practice.

Even though the medical profession recognized addiction as a disease in the mid-1900s, it largely sidestepped it, resulting in insufficient financial resources allocated to it and little-to-no training in how to prevent, detect, or treat it. We now find ourselves facing an enormous chasm between what we know and what we do, with an addiction treatment workforce that is inadequate both in size and capability to provide needed services. This is not only bad for patients, it is unfair to the thousands of dedicated treatment providers who struggle with limited resources and none of the medical training required to provide treatment for a medical condition.  

This state of affairs is inimical to the public health and costly to taxpayers. It is also contrary to the public’s beliefs and expectations regarding the role that qualified health professionals should play in addiction care. In its 2012 report, "Addiction Medicine: Closing the Gap between Science and Practice," CASAColumbia published the results of a national survey of adults that asked respondents to indicate where they would turn for information or help if someone close to them had an addiction problem. Nearly half of the respondents (47%) indicated that they would turn to a health professional such as their physician (28%), a health professional other than their primary care physician (20%), or a mental health professional (9%).

Similarly, another national survey, sponsored by the Community Anti-Drug Coalitions of America (CADCA), found that 65% of adults said they would turn to a health-care provider for a problem involving alcohol. Contrast these findings with a second set of analyses published in CASAColumbia’s report showing that only 5.7% of referrals to publicly funded treatment nationally come from a health-care provider. Rather than health professionals, the largest proportion of referrals to addiction treatment in the United States comes from the criminal justice system (44.3%), underscoring the fact that addiction typically is addressed only after it has resulted in profound social consequences for the individual and society.

According to the CDC, 82% of adults had contact with a physician or other health-care professional in the past year. Yet, most doctors, and other health-care professionals that they see, fail to identify risky substance use, diagnose addiction, or provide interventions to those who need it.  

Instead, they devote time, attention, and resources to the consequences and secondary complications of the disease, allowing this public health epidemic to advance at a huge cost to society. Each year, public spending on addiction and risky substance use alone is close to a half trillion dollars. Yet amazingly, for every dollar federal and state governments spend on substance-related costs, less than two cents goes to prevention or treatment while 96 cents goes to pay for the consequences! There is no other disease in which this upside-down paradigm even remotely applies.

In recent years, policymakers and the medical profession have begun to awaken to the perils of continuing along the path of excluding addiction care from medical practice. The social, health, and financial costs of dealing with the consequences of the disease, rather than providing effective prevention, early intervention, and treatment for it simply have become untenable. Recent advances in health-care reform have allowed for better insurance coverage for addiction-related care, including screening and brief interventions.

To build a workforce of physicians trained in effective prevention, treatment, and disease management, the American Board of Addiction Medicine Foundation is developing addiction medicine fellowship training programs across the country, and an increasing number of physicians are choosing to take advantage of this emerging specialty training opportunity. To date, 27 programs have been accredited with a goal of 65 programs by 2020. This means that a growing workforce of physicians trained in addiction will be available to provide quality treatment and help guide primary care providers in intervening effectively with patients who are at risk for, or who have addiction.  

Despite these promising advances, however, reducing the vast discrepancy between the number of people in need of effective prevention and treatment, and the number who receive it, will require a concerted effort on the part of the medical profession as a whole to take ownership of this problem and ensure that every health professional is well prepared to address it. It will also require policymakers to step up efforts in publicly funded programs to support and regulate addiction treatment as a core component of routine health care. And finally, it will require a more educated public—to better understand risky substance use and addiction as public health and medical problems and the role each of us can play to help ensure effective prevention and treatment for one of this country’s most prevalent and pervasive diseases. 

Linda Richter, Ph.D, is the Director of Policy Research and Analysis at CASAColumbia. Her work focuses on examining policies that can help integrate addiction care into mainstream medical practice, educating the public and health professionals about evidence-based addiction care, translating the science of addiction for lay audiences, understanding the substance-related attitudes and beliefs of both the general population and health care professionals, and improving substance use and addiction prevention and treatment, particularly among young people and women. 

Susan E. Foster is the Executive Director of The National Center for Physician Training in Addiction Medicine at the American Board of Addiction Medicine Foundation. The National Center is responsible for expanding physician workforce capacity to meet the needs of the American public for prevention, intervention, treatment and management of addiction. Prior to joining the foundation, Susan served as Vice President and Director of Policy Research and Analysis at CASAColumbia.

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