Chemical dependence is the protean disease of our generation. There is hardly a physician in active practice who does not encounter this disease on a regular basis. Even those who may not see such patients directly should be able to recognize the many manifestations and complications of addiction.
For the purpose of this discussion, I will use the terms "addiction" and "chemical dependence" interchangeably. This condition should not be confused with the separate and distinct conditions of chemical abuse and physical dependence. Though similar in appearance, chemical abuse is usually less severe than chemical dependence, does not have the symptoms of loss of control and compulsion, and does not require any genetic predisposition for its appearance. It can be thought of as a learned condition rather than a true disease. Physical dependence may occur in any individual whose brain and body have become tolerant to a mood-altering chemical such as alcohol or morphine, and does not have to be associated with addiction or abuse. An example of such an individual who is physically dependent would be an anxious patient who is being treated with a benzodiazepine, has taken only the prescribed dosage for many years, and should be withdrawn slowly if the medication is to be stopped. Such an individual cannot be said to be addicted, though they are surely tolerant to the drug and physically dependent.
Chemical dependence is a genetically-induced, biochemically-expressed disease with psycho-social consequences. (Goodwin, D.W., et al., 1973; Bohman, M., et al., 1978, 1981, & 1984; Cloninger, C.R., et al., 1981 & 1983; and others) The disease concept of chemical dependence states that addiction is a primary disease process, and that it has psycho-social phenomena associated with it which are consequences rather than causes. Treatment which adheres to this concept has been much more successful in bringing the addict into recovery than treatment that views addiction as a symptom. This means that the addict is not ultimately responsible for his or her disease of addiction, since without the genetic predisposition, the disease would never show up. One may argue that the person is responsible for taking the drink or drug that brings out the disease in the predisposed individual, but who in our society totally avoids the use of all mood-altering chemicals for their entire life? And we do not yet have the technology to predict who is genetically predisposed, though such technology is on the horizon. So if we accept the disease concept as it is understood and presented here, why do we still allow ourselves to blame the addict for being addicted? This is tantamount to blaming the diabetic for his or her disease.
Alcoholism is a specific type of chemical dependence, in which the drug of choice is ethyl alcohol. Many substances show what is called "cross-addiction" to the alcohol, but they have essentially the same effects on the central nervous system that alcohol has, specifically that they will induce the various stages of anesthesia with increasing doses. Such substances, such as the barbiturates and benzodiazepines, may be used to substitute for the alcohol and be administered therapeutically in the alcohol abstinence syndrome, of which the most severe form is delirium tremens. The alcoholic will also spontaneously substitute such drugs if they are more available than the alcohol. In general, we are finding very few "pure" alcoholics under the age of 35 these days, and this cutoff age rises each year. Most all addicts under the age of 35 are "cross-addicted", with other drugs, especially cannabis or cocaine, being used in conjunction with the alcohol.
The addict who uses drugs other than alcohol in our society may obtain these drugs by either legal or illegal means. Federal law mandates that most mood-altering chemicals must be obtained by prescription. Others may be obtained by illegal means only. This places such drugs, such as heroin and cannabis, under black market economic status. Even prescription drugs enjoy a significant profile on the black market.
Drugs which are obtained either over the drug store counter or by prescription are the "legal" drugs. Again, it is only the mood-altering drugs which maintain a high level of popularity with the abusing or addicted population. Because of this, the physician will often be faced with the dilemma of deciding whether the patient being treated truly needs the drug being prescribed, or is simply feigning his or her symptoms in order to obtain the drug. For too many physicians, the effort or time necessary to make such a decision is too great, and he or she will simply write out a prescription for the requested drug or a substitute in order to be rid of the patient. This may lead to the physician being identified as an easy target for the drug-using crowd, and he or she will end up being deluged with visits by such patients.
Various estimates have been made of the overall incidence of chemical dependence in our society. In actuality, the incidence varies depending on the racial heritage of the individual, with about 10% of the white race descended from Northern European stock being addicted to alcohol or other drugs. The incidence in the Black race is slightly lower, and that of Mediterranean peoples significantly lower. The highest incidence of any gene pool is in some of the Native American tribes. Suffice it to say, a significant portion of any doctor's practice will include those with chemical dependence.
These addicted individuals have no particular set of characteristics which may be used to typify them. Many studies have been done to try to delineate the addictive personality, but to date, none have been able to do so. This disease encompasses all ages, races, creeds, economic levels, and both sexes. A physician may have no trouble suspecting that addiction may be active in a young, unkempt adult male who is demanding narcotic medications, but may have more difficulty with the middle-aged daughter of a couple that he or she has treated, loved, and respected for many years. Such a woman may tend to hide her drinking from everyone, maintain a respectable social standing and community activity, and to all appearances be the model of a fine mother, wife, and employee until her disease is far-advanced and no longer amenable to control and cover-up. But on the way to this far-advanced stage of her disease, she probably will have obtained multiple prescriptions for controlled substances from her well-intentioned but unsuspecting physicians. In just such a way, she becomes as cross-addicted as the drug addict on the street.
As with other diseases that find expression in multiple ways, a high index of suspicion is the first prerequisite in making the diagnosis. If a physician gets an inkling that addiction may be complicating the picture, it probably is. This is the corollary to the adage that if a person thinks he may have a problem with alcohol or drugs, he probably does.
Many physicians admit patients to the hospital who are not their own because of taking call for the Emergency Department. This means that they will encounter many patients who require hospitalization because of complications of their chemical dependence. Few of us need to be reminded that many of these people are not very desirable as patients, because of non-compliance with ordered treatments, demands for mood-altering chemicals, frequent lack of personal hygiene, and lack of family and financial support. They are often given the absolute bare minimum of therapeutic interventions, then discharged without the true underlying reason for their admission, their addiction, being addressed. And this is not surprising, because the addict will often set things up to achieve an early discharge in order to return to the unsupervised use of alcohol or drugs. If the physician should try to address the presence of the addiction, he or she will usually meet with a wall of denial, which is symptomatic of the disease of addiction. Such denial serves to keep the disease active, and to keep the addict from the specific help he or she so desperately needs.
With all of the above mechanisms in play, it is no wonder that there is an antipathy between physicians and addicts. The addict is seen as life's most undesirable individual, the addict cons and manipulates the physician to get what he or she wants, the physician who addresses the primary disease is rebuffed, and the physician who falls prey to the conning and manipulation has lost that most important element of the doctor-patient relationship, the respect of his or her patient.
The physician who is also addicted presents many uncomfortable situations to his or her colleagues. The incidence of addiction in the physician population probably is not any higher than in the general population, but the expression of the disease is somewhat different. A higher percentage of physicians are poly-addicted, due to the greater availability of mood-altering pharmaceutical drugs in the physician's environment. If the addiction is affecting the physician's coworkers and showing up in the hospital or office, it is already far-advanced. And when a physician is addicted, his or her colleagues often act as if nothing is wrong. This has come to be known as the conspiracy of silence. The overall effect of this silence is to allow the disease to progress without diagnosis or therapeutic intervention. This vicious cycle then continues until the situation gets so bad that it can no longer be ignored. At this point the state medical board often gets involved, and the physician may receive punitive reactions to this disease rather than a therapeutic response. The other all-too-frequent occurrence in the addict, physician or not, is suicide, when the disease becomes far-advanced.
We in the State of Michigan have been fortunate in that we have had a group of caring physicians who are interested in helping their colleagues who are addicted or suffer other forms of impairment. This group, the Steering Committee to Assist the Impaired Physician of the Michigan State Medical Society, has been doing its work on a relatively quiet and voluntary basis for a number of years. However, such a system, though effective for those who come under its care, is unable to identify most physicians who are in trouble, simply because of its voluntary and part-time nature.
A system has been brought into being in Michigan, modeled after the very effective programs in other states. This system is one in which there is a part-time paid physician who works for the state medical society to identify the impaired physician and arrange for appropriate therapy, as well as provide post-treatment follow-up, monitoring, and advocacy. This program is enjoying the full cooperation and support of the state medical licensing board, with the confidentiality of participating impaired physicians maintained at all times. The only exceptions to this confidentiality would occur if the physician was referred by the board or requires their involvement for other reasons, such as non-compliance with the program or for the commission of a felony. Though this impaired physician program will work with all types of impairments, the vast majority of these types of problems in physicians are due to addiction to alcohol or drugs. The physicians' program in Michigan is called the Physicians Recovery Network, and is directed by Douglas Macdonald, MD. Dr. Macdonald can be reached at (810) 391-4742.
Another program has been in effect in Michigan since the summer of 1994, which has been created through legislation, and is supported through an increase in license fees for the licensed health professions which are covered by this program. The program is called the Health Professionals Recovery Program (HPRP), and covers fifteen health professions, to provide non-disciplinary monitoring of the recovery of addicted or mentally ill professionals as they rebuild their lives and return to practice. The HPRP is currently administered by the Michigan Health Professional Recovery Corporation (MHPRC), and can be reached at 800-453-3784.
All physicians learn about the complications of chemical dependence in their training, but very few learn about this process as a primary treatable disease. In fact, we are often taught that alcoholics and drug addicts are the way they are due to some underlying psychiatric or social disorder, and that once this disorder is rooted out and treated, the addict will no longer need to use alcohol or drugs.
But this view of addiction as a symptom is all-pervasive in our society, leading us to blame the addict for the disease, or even to blame the chemical which is used. The usual approach is to believe that if the addict were only more strong-willed, moral, intelligent, or religious, he or she would be able to stop without outside help.
The stigma that is still attached to this disease affects how the physician views addiction and its complications. As an example of this, one should consider the diagnoses which are entered on a death certificate once an addict dies. They include all the symptoms and secondary effects of addiction, such as traumatic events from motor vehicle accidents, cirrhosis of the liver, injuries from falls or fights, cardiomyopathy, gastrointestinal bleeding, hypertension, hemorrhagic stroke, and multiple other conditions that are directly caused by or are associated with chemical dependence. Such identification of these immediate causes of death without mentioning the underlying process of addiction covers up the full toll that this disease takes from our society. This same error of misdiagnosis or under-diagnosis occurs with hospital admissions, often supported by the stance of some health institutions of not admitting or treating alcoholics or addicts for their primary diagnosis. It is generally estimated that when all these effects are considered, chemical dependence is the third leading cause of death in the United States, behind heart disease and cancer.
In many ways, physicians and hospitals are guilty of promoting the stigma of this disease. This stigma is no different than for other diseases, such as tuberculosis, epilepsy, leprosy, etc., before their causes were understood and effective treatment devised. Other helping professions are being effective in this treatment, and it is time for physicians to learn about this disease and its treatment and to take their place alongside these other professionals in guiding the addict to recovery.
One of the best ways the physician can help addicts is to avoid becoming subject to their search for drugs through the prescription method. There are four ways that a physician's prescribing practices can come to the attention of the Medical Board. They are by the physician being disabled, dishonest, duped, or dated. The disabled or impaired physician has been addressed above. The dishonest physician will enter improper prescribing practices because of secondary monetary or sexual gain. The duped physician is either tricked by the manipulative or malingering patient, or brought to improper prescribing by means of blackmail. The dated physician has not kept up on modern prescribing practices, and requires education, or in the most extreme cases, limitation or supervision in order to not employ improper prescribing of controlled substances. The methods of getting "high" are legion, and it is the physician's duty to keep up on the latest methods addicts are using to obtain and use drugs so that he or she does not become an unwitting accomplice to this process.
The final way that physicians will impact the addicted patient is through his or her referral process. It is most important, once addiction has been identified in a patient, that the patient be referred to specialists who are comfortable and competent in treating chemical dependence as the primary disease that it is. We know today that in order to recover, the addict must remain abstinent from the use of all mood-altering chemicals. Only when this abstinence is well-established can the addict go on to gain the other elements of recovery in their emotional and spiritual spheres. Physicians are typically most competent to deal with the physical effects of disease, but usually have little inclination to deal with spiritual or sometimes even emotional matters. But the addict needs growth emotionally and spiritually in order to gain a full and comfortable recovery. Physicians who are doubtful of this are invited to attend some open Alcoholics Anonymous or Narcotics Anonymous meetings in order to gain a better understanding of what is required for full recovery from this disease. Whether the physician refers to AA, NA, or competent treatment facilities, he or she should be familiar enough with the processes of addiction and recovery to be part of an effective support system for the recovering addict, by avoiding the prescription of mood-altering drugs and encouraging the continuing effort needed for long-lasting recovery.
There are many ways that a physician will encounter and impact those with the disease of chemical dependence. But the most dangerous encounters will only come as a result of ignorance about this important and prevalent disease. In order to be an effective physician for these patients, one should be knowledgeable, compassionate, supportive, and at times confrontive. But none of these attributes will be possible if the physician is ignorant of what addiction is and how it is treated. It is hoped that this discussion has helped to bring such knowledge to your disposal.
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