Physicians have played a role in the treatment of alcoholism, or as we recognize it today, Chemical Dependence, since the time of Hippocrates. A large amount of this treatment by physicians has been well-meaning but ill-informed. Actually, it has taken a largely lay organization, Alcoholics Anonymous, to show the medical profession the most effective approach to the treatment of this disease. However, most physicians still do not understand what chemical dependence is and what is necessary for recovery from it. This lack of knowledge is largely due to a lack of education at the medical school level. I would like to review some of the history of the medical profession concerning this disease before I consider the important recent developments.
The per-capita consumption of alcohol in colonial times was more than twice what it is today. In fact, the Colonial and United States Navies served a ration of grog, a rum-based drink, to sailors in battle to bolster their spirits.
It was within such a society that Benjamin Rush, the foremost physician of revolutionary times and a signer of the Declaration of Independence, wrote his essay, An Inquiry into the Effects of Ardent Spirits Upon the Human Minde and Body. In this treatise, Dr. Rush decried the use of alcoholic beverages and enumerated the dangers that drinking posed to the individual and to society. He also identified alcoholism as a primary disease, not a symptom of some other malady.
During the 19th century a number of temperance societies came and went, but not much change occurred in the physician's role in the treatment of alcoholism.
In the early part of this century a few prominent physicians addressed the alcohol problem, beginning with Sigmund Freud.
The father of psychoanalysis had a number of theories about why people drank uncontrollably. Unfortunately, his introspective therapies seemed unable to keep people sober for long. Freud himself was possibly addicted to cocaine, and espoused its use for a number of physical and psychological ailments. Cocaine in various preparations was a popular and fashionable drug in the late 19th and early 20th centuries. Only after physicians in this country described some of the deleterious effects of cocaine was it included in the Harrison Narcotic Act of 1914. The temperance movements were gaining considerable momentum during these years. However, physicians were still largely ignorant of chemical dependence as a disease, though they were learning much about the complications.
Dr. Carl Jung, one of Freud's students, was instrumental in our current understanding of chemical dependence as a disease. He is credited by Bill Wilson, the co-founder of Alcoholics Anonymous, with starting the chain of influence which led to Bill's own sobriety and the founding of A.A. Dr. Jung told Roland H. that his type of alcoholism was hopeless without some type of spiritual conversion experience. This took place after a year of psychoanalysis during which he hoped to root out the cause of Roland's drinking. Dr. Jung had come to this conclusion after trying to help many alcoholics and seeing only a few of them recover, usually after just such an experience. Roland had achieved a brief sobriety with the help of Dr. Jung, only to relapse terribly into drinking again, which drove him to seek and follow the psychoanalyst's advice and to follow it to the letter. Roland then went on to have his religious conversion experience and to join the Oxford Groups, where he met Ebby T., an old drinking buddy of Bill Wilson's. Ebby proceeded to get sober, and carried the message to Bill, who applied the wisdom from these men to his own sobriety and eventually to the program of A.A.
Another physician who was influential in Bill's recovery was William D. Silkworth, "the little doctor who loved drunks". Dr. Silkworth treated over fifty thousand alcoholics in his many years at Towns Hospital in New York City. He described alcoholism as "an obsession of the mind that condemns one to drink and an allergy of the body that condemns one to die." He felt that his success rate with alcoholics was approximately two percent prior to the recovery of Bill Wilson and the founding of Alcoholics Anonymous.
Shortly after the founding of A.A., three physicians gave us a fund of knowledge about alcoholism and recovery.
Described as Alcoholics Anonymous' first psychiatric friend, Dr. Harry M. Tiebout helped A.A. understand that true surrender was essential to recovery and was the core of any therapeutic process. Bill Wilson had described this process as "deflation at depth." Dr. Tiebout treated a number of early members of A.A., including Bill Wilson himself, and Marty Mann, one of the first women to recover (and the founder of the National Council on Alcoholism). Dr. Tiebout came to understand Alcoholism as no other psychiatrist had before him, and his writings have helped a number of people to understand this disease and its psycho-dynamics more completely. He wrote that four elements were essential to recovery in A.A.: "hitting bottom, surrender, ego-reduction, and maintenance of humility."
Dr. E.M. Jellinek is recognized as the premier researcher in the field of alcoholism, and was strongly influential as a proponent of alcoholism as a disease. He even went on to typify drinkers into four classes, with the two most severe classes being alcoholics. His writings and descriptions did more for the acceptance of the disease concept of alcoholism and of A.A. as a respectable therapeutic modality than any other medical force of the time. Most every patient in A.A.-based recovery centers in this country encounters the "Jellinek Curve", which describes the progression of the disease.
Robert Holbrook Smith was the first alcoholic to whom Bill Wilson carried the message who eventually remained sober. In the early days of A.A. in Akron, Ohio, Dr. Bob, as he is affectionately known to A.A.'s everywhere, carried the message of recovery to hundreds of suffering alcoholics. Many of these he hospitalized at St. Thomas Hospital, formerly Akron City Hospital. This fact is often forgotten by those who feel that in-hospital treatment is not ever necessary for the induction of recovery. They didn't have fancy drugs like Librium or Tranxene at that time, and detoxification was carried out by administering measured doses of Spiritu Frumenti, or common whiskey. This was still the practice when I worked as a resident physician at St. Thomas Hospital in 1976, though the use of benzodiazepines has now become commonplace. An adjunct to Dr. Bob's treatment was the administration of a mixture of stewed tomatoes, sauerkraut, and Karo syrup. I often wonder how many of the patients we treat today would tolerate this mixture without leaving against medical advice. But then, maybe Dr. Bob's patients really wanted to get well. Another fact about Dr. Bob that is often understated or ignored is the fact that he was addicted to pills as well as to alcohol. This should help cross-addicted alcoholics feel more at home in A.A.
There have developed two models of treatment programs for chemical dependence in this county: the A.A. Model and the Psychiatric Model. The physician's role in each is considerably different.
The A.A. Model treatment programs usually developed as free-standing facilities, staffed almost entirely by people who were recovering from their own alcoholism.
These A.A.-based centers often had very little input from people with degrees, even physicians. If there was physician involvement, it was limited to the performance of histories and physical examinations and the signing of documentary evidence of treatment, requiring the physician to verify with his or her signature the treatment decisions of non-physicians. The obvious problem with this system was that the physician was asked to assume the liability of treatment decisions without being able to give much input to the formulation of those decisions. The actual model of treatment was disease-concept-based, stating that alcoholism is a primary disease process, and not a symptom of some other underlying disorder. This concept is consistent with what Dr. Silkworth taught Bill Wilson, and Bill and Dr. Bob carried to A.A. as a whole.
The treatment of alcoholism and drug addiction by traditional medical professionals has often been relegated to the specialty of psychiatry, possibly because the symptoms of chemical dependence often mimic the symptoms of other psychiatric disorders. Because of this, many psychiatric institutions have developed specialized units for the treatment of alcoholism and drug addiction.
The treatment of these patients was directed by physicians, their psychiatrists. As a result, however, the chemical dependence was viewed and treated as symptomatic, not as a primary disease. Often the treatment included other mood-altering medications, especially anti-psychotics, anti-depressants, and tranquilizers such as benzodiazepines. Little was understood about cross-addiction and drug substitution. Much confusion about terminology also resulted, from which we are still suffering today. How often do you hear people use the term "substance abuse" when "substance addiction" is the intended meaning? And few people appreciate that physical dependence, or withdrawal, or the abstinence syndrome, is not synonymous with or pathognomonic of addiction. Any person can become physically dependent by taking enough drug, but only the genetically susceptible can become truly addicted. Until the helping professions can agree on these terms and their meanings, there will continue to be confusion when we speak of this disease and its treatment.
Over the last 40 years numerous medical organizations and societies have sprung up or become involved with this field in order to help the medical profession learn about and deal with alcoholism and chemical dependence. It is the interest of these societies and their members that has brought us to the point where we can talk about a changing role of the physician in the treatment of chemical dependence.
The American Medical Association is widely believed to have first accepted alcoholism as a disease in 1956. Dr. David Smith, however, has stated that the original resolution to do so was introduced in 1956, but was not officially ratified until 1966. In February, 1987, Dr. Smith introduced a motion that the AMA include all mood-altering drugs in the disease of chemical dependence, and the American Medical Society on Alcoholism and Other Drug Dependencies introduced the same motion in June, 1987. The AMA then passed a resolution that all drug addictions are one disease.
International Doctors in Alcoholics Anonymous started around 1947 with a meeting in a New York doctor's garage. With the exception of the following year, this organization has held its annual meeting every year without fail. The membership is now over 2500, with the last meeting, in Lexington, Kentucky, hosting over 400 recovering doctors and their families or concerned others. Dr. Luke R., of Youngstown, Ohio, has been the beloved Secretary-Treasurer for about 25 years, but now because of his failing health, that job is being carried on by Dr. Dick M., of Minneapolis. IDAA is registered with the A.A. central office in New York, and is open to all health professionals with doctorate degrees who are members of A.A. By supporting the recoveries of these health professionals and providing a forum in which they can network and share information, IDAA promotes the involvement of recovering physicians in the treatment of the disease from which they are recovering.
The American Medical Society on Alcoholism was formed in New York City in 1954, when some physicians who were interested in alcoholism started to meet in the apartment of Dr. Ruth Fox to discuss their common interests and goals. The early attendees of these meetings were Stanley Gitlow, Percy Ryberg, Arnold Zentner, and others, in addition to Ruth Fox herself. They formed the New York Medical Society on Alcoholism with the purpose of sharing information about this disease. Their purpose then expanded to include the education of physicians about alcoholism. Membership began to include doctors from other states and provinces, and the name was changed to the American Medical Society on Alcoholism in 1967. A cooperative relationship was developed with the National Council on Alcoholism, and AMSA then became a component of NCA in 1973. As top personnel changed, some conflicts developed between AMSA and NCA. Dr. LeClair Bissell became President of AMSA about 1975, and the conflicts which had already developed over publications and personnel were intensifying. This eventually led to the split of AMSA from NCA in January, 1983. Membership of AMSA was 500-1000 at that time, with most of the members living in the Northeast part of the U.S. An amicable relationship remained between AMSA and NCA, which has continued to this day.
Some California members of AMSA, with the help of the California Medical Association, formed the California Society for the Treatment of Alcoholism and Other Drug Dependencies in the late 70's. At about that time the California legislature passed legislation that regulated and required licensure of facilities that treated chemical dependence. Part of the regulations stipulated that such facilities must have medical direction, and that these physician directors would have to show expertise and knowledge in the field. The California Society was empowered to develop tests to demonstrate such expertise and knowledge, and these tests were given in 1983 and 1984. They were the first tests of their kind to be given to physicians anywhere. Membership in the California Society was required to take the test, and such membership was limited to physicians who were working or interested in the field and were licensed in California. Because of these requirements, a number of physicians who were involved in the treatment of chemical dependence from other states sought and were given California medical licenses, joined the Society, and took the test. Some very prominent physicians in the field, such as Doug Talbott from Georgia and Max Schneider from California were very nervous about taking the test, considering the impact that failure would have on their careers and credibility. All told, about 200 physicians passed the examination.
Dr. G. Douglas Talbott, an Ohio cardiologist, established in 1975 a treatment program devoted to the treatment of health professionals. This program had the complete financial support of the Medical Association of Georgia. Located just outside of Atlanta, the program has now treated over 1500 physicians for chemical dependence, most of whom are continuing in recovery. With this growing cadre of recovering physicians from all over this continent, a need for a grass-roots organization for the treatment of addictions was perceived by Dr. Talbott. He thus formed the American Academy of Addictionology in 1982. This Academy played an integral role in what was to follow. Most importantly, it made the other, older organizations sit up and take notice. Its existence continues in a quiet way.
The Association for Medical Education and Research, Substance Abuse grew out of the Federally-sponsored Career Teachers program, in which certain interested medical educators were selected to increase the knowledge about chemical dependence in the centers of higher learning. AMERSA has continued to assist and promote this educational effort over the last number of years.
So in the Fall of 1982 there had developed a situation where there were three medical organizations dedicated to the field of chemical dependence treatment, with regional strength but also with national focus and aspirations. The competition and confusion that this would cause concerned a number of people, not the least of which was Dr. Jess Bromley of California. He expressed his concern to Mrs. Joan Kroc, the widow of the founder of the MacDonald restaurant chain.
With the promise of financial support from Joan Kroc and the Kroc Foundation, channeled through the Caduceus Foundation of Georgia Alcohol & Drug Associates, Dr. Bromley, Gail Jara of the California Medical Association, and others began to contact leaders in this field from around the country, to invite them to a meeting at the Kroc Ranch in Southern California. The first meeting took place on February 7th and 8th, 1983, and was chaired by Dr. Talbott. Those in attendance represented the AMA, AMSA, the California Society, the American Academy of Addictionology, the Association for Medical Education and Research, Substance Abuse (AMERSA), the American Psychiatric Association (APA), the National Institute on Alcoholism and Alcohol Abuse (NIAAA), and the National Institute of Drug Abuse (NIDA). The goal of the meeting was to try to find a unity of purpose and organization for the physicians who were interested in the field of alcoholism and chemical dependence. The main outcomes of the 1982 meeting were a new communication between the various organizations and the conclusion that another meeting was necessary.
This second meeting was held between October 2nd and 5th, 1983, and was financed by the American Medical Association. It identified and addressed a number of controversies. One of the most heated was over whether or not their focus should cover drugs other than alcohol. There was also controversy over whether they should strive for recognition as a specialty society. A possible outcome could be that they would ask for incorporation as a subspecialty under psychiatry, internal medicine, or family practice. One of the obvious realizations of the participants was that there was a growing grass-roots movement of physicians who were involved in this field, and that they would need a unified, national voice that could only be provided by an organization with a true national focus, rather than a regional focus like those which had been developed by that time.
The participants were eventually able to put aside their regional loyalties, approaches, and differences and come to a compromise. Some leading physicians in this field, such as Dr. David Smith, feel that these unity meetings were the turning point and birth dates for the specialty of Addiction Medicine. The compromise that was reached invited the American Medical Society on Alcoholism to be the national organization that would be given the task of unifying the physicians from around the country. In return, AMSA was asked to agree to broaden its focus to include all drugs of dependence, and to change its name to the American Medical Society on Alcoholism and Other Drug Dependencies, which it did in 1985. The name of this organization was later changed to its current name of the American Society of Addiction Medicine (ASAM).
The American Medical Society on Alcoholism was then restructured along these lines, and went about the task of developing and administering a certification examination for physicians in the treatment of addictive diseases. Dr. Max Schneider, a former president of the California Society for the Treatment of Alcoholism and Other Drug Dependencies, was elected to be the next president of the American Medical Society on Alcoholism and Other Drug Dependencies. This was fortunate because of the experience he had gained in the formulation and administration of the California tests.
The devising of the AMSAODD examination and its administration was ably assisted by Dr. John Chappel, of AMERSA and the University of Nevada. He and his associates had carried out the same process for the California examination. Dr. Anthony Radcliffe of California also gave expert advice, effort and support, from his experience with the California tests. William Kennedy, of Ohio, chaired the qualifications committee, that reviewed all applicants for their suitability to take the test. The committee looked at the physician's involvement in the chemical dependence field and his or her licensure and standing in the fields of Medicine or Osteopathy. After possible test questions were collected from experts from all over the country, field tests were administered to those who had passed the California exam. Suitable revisions were then made and the examination assembled. Then, on October 17, 1986, the first national certifying examination in chemical dependence was given to M.D.'s and D.O.'s from around the country. The examination was preceded by a review course, and both the course and exam were given at four locations, New York, Atlanta, Chicago, and Los Angeles.
Six hundred and sixty-five physicians took the examination, and 565 passed it. The physicians who had passed the California exam and met AMSAODD requirements were granted the same status as those who passed the AMSAODD exam, and a total of 735 physicians were then certified in the field of alcoholism and chemical dependence treatment. At the annual AMSAODD meeting in April, 1987, which was held in Cleveland Ohio, certificates were presented to those who passed. This meeting represented the culmination of years of effort on the part of many leaders in this field. Emotion ran high, and it was remarkable to see tears in the eyes of some of the people who had worked so hard for that day. Over 600 physicians took the next examination on December 5th, 1987. About 540 of these physicians passed, and their certificates were presented on April 23rd at the last AMSAODD meeting in Washington, DC. That makes 1275 physicians currently certified. As noted above, the name of AMSAODD has since been changed to the American Society of Addiction Medicine (ASAM). I have named only a few of the dozens of wonderful people who contributed to this effort. I especially want to mention the tremendous work of Ms. Claire Osman, the Administrative Director of AMSAODD (now ASAM) for a number of years.
We are now observing in this country the birth of a new medical specialty. We do not yet know just how this will come about, but organized medicine is now given notice that there is a growing group of physicians who have demonstrated that there is a definable body of knowledge in the field of Addiction Medicine, and that this knowledge can be taught and tested. These are two of the pre-requisites for recognition as a specialty. For the treatment field as a whole, this means that centers that treat chemical dependence can now identify those physicians who have the special interest, knowledge, and expertise necessary to offer the best of care to the sufferers of addiction.
Before I conclude, I would like to describe the major source of physicians for the chemical dependence field. It is well known that medical schools in this country do not teach much about chemical dependence as a disease, though they do a good job teaching about the complications of addiction. And since Addiction Medicine is not yet a recognized specialty, there are no residency training programs in Addiction Medicine to prepare physicians for the treatment of this disease. So where do these physicians come from? A few come from other specialties that treat addictions, such as Psychiatry or Internal Medicine. But by far the largest number have come to this field by way of their own suffering and recovery from addiction. The importance of the recovering physician to this field cannot be overestimated, and we are on the verge of identifying and treating more addicted physicians than ever before. This will have the effect of increasing the pool of physicians who have the potential to enter the field, take the certification examination, and contribute to the growth of the treatment field. The effort to find and treat physicians has been supported and advised by the American Medical Association through its impaired physician committee, but the actual delivery of the effort has been mostly carried out by the state medical societies and associations. Though county medical societies and hospital medical staffs have formed committees to assist the impaired physician, the state-level programs are the ones that have the greatest effectiveness and penetration. I will therefore limit my discussion to these programs. It is especially significant to realize that all 50 states now have some type of program to assist the impaired physician. I would like to describe three different types.
Nearly all state medical societies started their impaired physician programs as committees of the society. These committees were made up almost entirely of volunteer physicians who had a special interest in helping their fellows who were suffering. Quite often this special interest was present because the volunteer physician was recovering himself or herself. Even though these committees addressed impairments other than chemical dependence, most of their cases were due to impairment from addictions. And although these volunteer committees did not incur many expenses for the medical societies, they were not very effective in case-finding. Their primary interests were in finding and sending their impaired colleagues to treatment. They could not do much more because of the volunteer status of the members. They were especially unable to carry out any monitoring, advocacy, or re-entry service for those who had completed treatment. These committees are now seen as having only limited success because of the limitations inherent in their volunteer makeup.
In about 1980, California tried to increase the effectiveness of its program by legislative fiat. The Bureau of Medical Quality Assurance, which has the responsibility for licensure of all physicians, was empowered to establish a diversion program for physicians impaired by chemical dependence or other illnesses. This was a good step forward, since chemically dependent physicians who had come to the attention of the licensing board were usually punished. No state licensing board is responsible to provide treatment or rehabilitation, and California was no exception. The rationale behind the diversion program was a good one, since any physician who came to the attention of the board would be diverted to this program and his or her confidentiality maintained so long as he or she complied with the expectations of the program. Once the period of treatment and monitoring was completed successfully, usually after five years if all went well, the physician would be released from the surveillance of the program and his or her record with the board expunged. The primary problem with this program was the fact that it was rather complicated and therefore had a high cost-per-case ratio. Some experts also feel that surveillance for five or more years is excessively long, and therefore somewhat punitive rather than therapeutic.
A third type of program to assist the impaired physician was started in New Jersey in 1982. After a three-year try with a volunteer program, the New Jersey Medical Society and the members of their committee recognized their program's relative ineffectiveness. They felt that a full-time paid medical director would be the answer to their problems. The only difficulty was the fact that the medical society did not have the funds to hire a full-time physician, and to raise membership dues would have meant a drop in membership. The health insurance companies of the state were approached and refused to support this idea financially. Finally, the state-medical-society-sponsored malpractice insurance carrier was approached with the idea that if the Impaired Physician Program's medical director could save them only one malpractice suit per year, the cost of the program would be regained. The other malpractice insurance carrier in the state, not to be outdone, agreed to share in the expense. Then, in September, 1982, Dr. David Canavan was named to be the nation's first full-time paid medical director of a state medical society program to assist the impaired physician. Over the next five years, 383 New Jersey physicians were helped, while in the prior three years only 21 had been helped. Dr. Canavan has also gained the complete trust of the state medical licensing board, and they rely on his expertise to assist them in their deliberations should a physician who has been involved with the impaired physician program come before them. This type of program can also carry out true advocacy and reentry assistance, in addition to monitoring. No previous type of program has been able to address these areas effectively. Other states soon followed suit, and there are now at least nine full-time medical directors of state programs, with at least six states having part-time medical directors. An additional five states have hired full-time non-physician directors to staff similar programs. The great advantage of this type of program is that the director can be recognized as the one person in the state to contact if a physician has a problem. The program is so effective because it is confidential, with the participant assured that the program will not share information with the board so long as the participant complies with the program. In New Jersey, 50% of the referrals come from a colleague of the impaired physician, 20% from the physician himself or herself, and 10% from the spouse, for a total of 80% from these three sources. In Oregon, where the impaired physician program is run by the licensing board and is not seen as either confidential or having advocacy, no referrals come from these sources. As more and more states hire full-time paid medical directors for their programs, more and more impaired physicians will be identified and helped, increasing the potential numbers of physicians who will be interested in the treatment of chemical dependence.
So where does this all take us? What will be the future of physicians in this field? I would like to share some of my thoughts in this area.
I believe that Addiction Medicine will become a specialty of medical practice, like Family Practice and Emergency Medicine have become over the last 15 or so years. Furthermore, I believe that it should and will be a specialty in its own right, not a subspecialty under another specialty. This specialty status will help the chemical dependence treatment field gain the respect it deserves in the mainstream of medicine.
With the changing standard of medical care being brought about by the changes I have described, it is now incumbent upon all physicians to be able to recognize chemical dependence, and to make appropriate referrals for treatment. To fail to do so may soon be seen as negligent, since the resources for treatment and the specialized medical expertise are becoming readily available around the country. A physician who chooses to ignore this common and potentially fatal disease places himself or herself at risk for a malpractice suit.
The Joint Commission on the Accreditation of Hospitals has recently revised its standards for facilities that treat alcoholism and drug addiction. There is now a suggestion that JCAH will be requiring medical direction of chemical dependence treatment. It is also conceivable that these medical directors may be required to have demonstrated knowledge and expertise in the field, by taking a test such as the one given by ASAM. And third-party payers will also be looking at how much medical direction is given in the centers where their subscribers are treated, and the quality of that medical direction will be important to them.
The Addiction Medicine Specialist will be able to manage effectively the treatment of addictions. He or she will have expertise in the disease concept, detoxification and medical management of the withdrawal syndrome, medical complications of chemical dependence, treatment modalities and resources, recovery, and self-help groups, in addition to knowledge of medicine as a whole. This will be true medical-model treatment, with the physician directing the treatment team. He or she will not be someone who just does the histories and physicals and discharge summaries on the patients, and gives rubber-stamp approval of others' treatment decisions. And he or she will be welcomed as an integral part of the treatment team because of the expertise which has been so rare in a physician until now.
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