Overcoming pessimism about treatment of addiction.

ALTHOUGH 13 MILLION TO 16 MILLION PEOPLE IN THE UNITED States each year could benefit from treatment for addiction disorders, less than 25% of them receive it. Negative attitudes of physicians toward diagnosis and treatment of addiction create barriers to their early identification and treatment. In one survey of general practice physicians and nurses, a majority believed that no available medical or health care interventions are effective in treating addiction. Similarly, most physicians do not screen for alcohol or other drug dependence during routine health examinations. This can result in a delay of diagnosis until the addiction has reached an advanced stage and late-stage pathology is evident. Poor outcomes resulting from delayed diagnosis reinforce physician and patient pessimism about the prospects of recovery. Such pessimism about therapy is unwarranted. Even brief interventions are effective in decreasing alcohol intake among problem drinkers. A recent study found that half of the patients in an alcohol treatment program were drinking significantly less a year later, and that 36% of patients were abstinent after 3 years. Another program, involving both long-term residential treatment and outpatient drug-free treatment, led to 50% reductions in cocaine, marijuana, heroin, and heavy alcohol use and illegal activity in a 1-year period. Rates of compliance and efficacy of addiction treatment are similar to rates found in other chronic illnesses such as diabetes, hypertension, and asthma. For instance, less than 60% of adults with type 1 diabetes mellitus fully adhere to their medication schedule, and the rates may be less than 40% in patients with hypertension or asthma. Among adults with type I diabetes, 30% to 50% each year have exacerbations that require additional treatment, as do 50% to 70% of adults with hypertension or asthma. Physicians’ negative attitudes of physicians toward addiction may reflect their experiences in medical school. Medical education about the prevention, diagnosis, and treatment of addiction remains disproportionate to the morbidity and mortality caused by this disease. In the late 1980s, the percentage of required medical school teaching hours on addiction was less than 1%. In a recent survey of preclinical medical students, 20% reported receiving “no training in substance abuse” and 56% listed their training as “a small amount.” Similarly, a recent survey suggested that almost half of all residency programs in primary care, emergency medicine, psychiatry, and obstetrics/gynecology do not have a required substance abuse disorders curriculum. Of the 56% of programs that required this training, the median number of hours was seven, ranging from four to 15 hours, depending on medical specialty. Physicians are therefore often trained to treat the acute medical conditions resulting from drug dependencies, but lack the training to recognize and manage it as a chronic, relapsing illness. The federal government’s policies also demonstrate pessimism toward addiction therapy and prevention. In 1999, more than two thirds of the $17 billion budget of the Office of National Drug Control Policy went to law enforcement, while less than one third went to prevention, treatment, and research combined. These policies ignore the fact that incarcerating persons with addiction is almost 4 times more costly than treating them. In fact, combining criminal justice sanctions and addiction treatment can decrease drug use and related crime. Changing attitudes toward addiction medicine is an ongoing process requiring participation on many levels and has been identified as an important goal by federal agencies as well as private groups. Medical students and physicians would benefit from increased training in the knowledge, skills, and attitudes of addiction medicine. Finally, federal and private financing of addiction treatment needs to better reflect the current understanding that addiction is a chronic and treatable illness.