David E. Smith, MD, FASAM, FAACT
June 2010: Addiction and Recovery
On May 2, 2009, the American Board of Addiction Medicine (ABAM) and Nora Volkow, MD, director of the National Institute of Drug Abuse, conferred board certification on nearly 1,500 physicians (myself included) representing a wide range of specialties.
In her address at this ceremony, held during the annual meeting of the American Society of Addiction Medicine (ASAM), Dr. Volkow stated that “years of scientific research have proven drug addiction is a brain disease caused by biological, environmental, and development factors—a disease that can have far-reaching medical consequences. . . . Identifying drug use early, preventing its escalation to abuse and addiction, and referring patients in need of treatment are important medical skills” (Kunz and Gentilello 2009). With the passage of health care reform and parity in March 2010, addiction medicine has become a mainstream core benefit.
Forty and more years ago, this would have been barely imaginable. Addictions were stigmatized as moral failings and/or criminal activity. In reality, substance abuse in all its forms, including nicotine/cigarette addiction, alcoholism, and psychoactive dependence, represents our country’s number-one public health problem.
Complementing this is the rise in prescription opioid abuse, particularly in adolescents, where prescription drug overdose deaths in 2008 exceeded all the overdose deaths for heroin, methamphetamine, and cocaine combined. Substance abuse is now the leading cause of death in young people, exceeding even traffic fatalities (Knudsen 2009).
Alcoholism as a disease was clearly described as long ago as the late 1700s by Dr. Benjamin Rush, a physician and signer of the Declaration of Independence (Katcher 1993). However, it wasn’t until the formation of Alcoholics Anonymous (AA) in the 1930s by Bill Wilson and Dr. Bob Smith (no relation) that this concept of alcoholism as disease spread throughout the United States and subsequently the world. Dr. William Duncan Silkworth, in the Big Book of AA, described alcoholism as a disease caused by “an allergic reaction of the body to alcohol” and a compulsion of the mind (Silkworth, 1937).
Addiction to other drugs, however, was specifically excluded from the scope of AA. AA emphasized that drug use other than alcohol was not to be disclosed at AA meetings. This prompted the formation of Narcotics Anonymous in California in the 1950s, which was based on similar twelve-step principles but included recovery from all drugs of addiction, particularly opiates such as heroin, using the catchphrase “clean and sober.”
Initiatives put forth by physicians in the New York Society of Alcoholism, a forerunner of ASAM, prompted the American Medical Association (AMA) to declare in the 1950s that alcoholism was a disease and to reaffirm this position in 1966.
In the late 1960s, the movement to recognize addiction as a disease escalated in California, particularly in San Francisco. Based on the principle that “health care is a right, not a privilege,” the Haight Ashbury Free Medical Clinic (HAFMC) was founded in response to the large number of drug-using youth who flocked to San Francisco’s Haight Ashbury district in 1967 for the “Summer of Love.” The Clinic’s experience with this population led to the philosophy that “addiction is a disease—the addict has a right to be treated” and prompted the almost immediate expansion of Clinic services to drug crisis intervention and detoxification. The San Francisco Medical Society and the California Medical Society provided early support for these endeavors, despite the City’s refusal to address a major public health catastrophe (Heilig 2009).
Dr. David Breithaupt of the University of California, San Francisco, Ambulatory and Community Medicine program, trained medical students at HAFMC. At a recent CSAM-sponsored event in the Haight, Dr. Breithaupt described battling a system that at the time viewed community physicians who treated addiction disease as “outlaws caring for sinners and criminals” rather than “physicians treating a chronic disease.”
It was then illegal to detoxify addicts on an outpatient basis. Nonetheless, when Dr. Donald Wesson and I determined that a phenobarbital withdrawal protocol we had developed at San Francisco General Hospital could be used to detox addicts, we instituted its use at HAFMC’s outpatient Drug Detoxification, Rehabilitation, and Aftercare program, combining medical intervention with psychological counseling and recovery groups. After the Detox program received a substantial federal grant initiated in 1971 by Dr. George “Skip” Gay of HAFMC—a grant that came from the White House Office of Drug Abuse Policy (SAODAP, predecessor of the ONDCP), then headed by methadone maintenance pioneer Dr. Jerry Jaffe—the concept of addiction as a disease was further acknowledged. Supported by the new Nixon White House philosophy that “no addict should have to commit a crime because he can’t get treatment,” due to the increase in the numbers of addicted Vietnam veterans returning to the United States, addiction treatment services in San Francisco increased significantly.
Despite these philosophical trends, physicians were still the targets of punitive action. After the arrest of two Southern California physicians for detoxifying heroin addicts with Valium in an outpatient medical setting, Dr. Jess Bromley recommended that we start a California professional society. By aligning with the California Medical Association (CMA), we could associate nationally with the AMA, an essential step toward overcoming the organized medical establishment’s resistance to efforts to get nonalcohol addictions accepted as diseases.
One of the key organizers of the California Society of Addiction Medicine (CSAM) was Dr. Max Schneider, a Southern California gastroenterologist. Treating cirrhosis of the liver with associated GI bleeds, he became concerned that the existing medical system offered little to treat the causative disease of alcoholism. In fact, all of the founders of CSAM were motivated by the principle that it makes no medical sense to treat the complications of a disease and not treat the underlying chronic medical illness, whether it is a disease of the brain—like addiction—or a disease of the pancreas—like diabetes.
As an appointee to the AMA committee on alcoholism, I introduced the disease model of addiction to the AMA committee in 1976. I coined the term “addiction medicine,” and after much debate it was accepted. Also at that time, Dr. Douglas Talbott, who pioneered the treatment of addicted physicians, introduced the term “addictionology.”
In 1983, individuals in the addiction field met at the Kroc Ranch in California and agreed that a single organization, what has evolved into the American Society of Addiction Medicine, would represent the field. Five years later, ASAM gained acceptance in the AMA House of Delegates as a specialty society with Dr. Bromley as the ASAM delegate and me as alternate delegate (ASAM, 2006).
The AMA accepted the motion introduced by ASAM that all drug dependencies, including alcoholism, are diseases and that medical practitioners should base their medical practice on the disease model of addiction. When ASAM expanded its focus to include cigarette/nicotine addiction, with its associated morbidity and mortality, the AMA granted specialty status with the code of "ADM" after introduction of a resolution by the California Medical Association in 1990 (ASAM 2006).
We had hoped primarily to gain acceptance by organized medicine in the U.S. for addiction medicine (the study and treatment of addictive disease). The specialty now is recognized throughout the world; the International Society of Addiction Medicine (ISAM) has been meeting regularly since its formation in Palm Springs in 1999. The significance of the disease model of addiction is now fully acknowledged by mainstream medicine, to the extent of gaining parity with other medical issues in health care reform.
A 2000 CalData study showed that every dollar spent on treatment saved an estimated seven dollars in health and social costs (CalData study, CSAM News 2000). Kaiser Permanente researchers have also found strong evidence of cost savings (Parthasarathy et al 2001). Meanwhile, the criminal justice system and community and school-based prevention programs have not proved sufficient to turn the tide of substance abuse. Addiction medicine has encouraged medicine to become a major force in dealing with this public health issue: 100 percent of alcoholics and addicts will at some time interface with the medical system.
However, despite compelling evidence for a decade demonstrating excellent cost-benefit outcomes for addiction as a brain disease emphasizing prevention, intervention, and treatment, the battle to implement parity by the sociological and political structure of the U.S. remains to be won. As President Obama stated in his book, The Audacity of Hope, “past history is not dead and buried, it is not even dead.” Addiction medicine’s history demonstrates to the next medical generation that it can both continue the battle to help the suffering alcoholic and addict and further the integration of addiction medicine with mainstream medicine.
David E. Smith, MD, currently serves as chair of addiction medicine at the Newport Academy and as medical director of Center Point. He is an adjunct professor at UCSF and a past president of the American Society of Addiction Medicine and the California Society of Addiction Medicine. He is the founder of the Haight Ashbury Free Medical Clinic.
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