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Addiction: bridging the emotional barrier to effective care


People who suffer from addiction don’t always put their best foot forward.  Often an individual under the influence (or withdrawing from) a substance will engage in all kinds of unsightly, anti-social behaviour.  From my limited medical student window into their life, I get to witness some of this behaviour up close.  Perhaps they are acting out, tearing up the bathroom of the emergency department.  Perhaps they smell.  Perhaps they are vomiting on themselves, or are destroying the veins in their arms with repeated injections.

There can be a visceral reaction to a person in one of these states, one that I find is useful to acknowledge.  This dark, knee-jerk response consists of an overwhelming feeling of disgust for someone who is slowly killing themselves with alcohol or other substances.  I must sheepishly admit that it is an emotion I have experienced often enough.  Sometimes, it is only after taking a deep breath and focussing on the facts, that I can slowly find my way to back to a place of healing and empathy.   In these moments, I must say to myself: “This is a person with an illness. They are experiencing the symptoms of that illness and their ability to choose freely has been severely impaired by biology and social circumstance.”

Over the past 40 years, scientific consensus has grown around various permutations of the medical model of addiction.  This is the idea that addiction is best understood as a chronic, relapsing brain disorder.  While an exhaustive review of this model is would be too long for this article, an area of research I would like to highlight is the concept of compulsivity.  The habitual drug-seeking and drug-using behaviours of an addict are increasingly understood to be “compulsive,” that is, not fully under conscious control.  Put another way, an addict quite literally may not be aware of their own decision-making process while pursuing and using their drug of choice.  This compulsive process becomes increasingly entrenched in an addicted brain over time, as the ability to prevent poor decision-making is “beaten to the punch” by the faster-acting brain circuits responsible for addiction.

These ideas contrast with more traditional moral notions of addiction, wherein the use of substances has been understood as a free choice, thereby holding the sufferers of addiction wholly responsible for their own fates. Adherents to the moralistic viewpoint tend to be resistant to the establishment of treatment programs and facilities with goals other than total abstinence.  These would include such harm reduction measures as needle-exchanges, safe injection and inhalation sites, methadone therapy, and managed alcohol programs.  Cultural resistance to the medical model and to harm reduction persists despite mountains of evidence in support of such programs and despite copious research linking addiction to adverse childhood experiences, ADHD, and other mental illnesses.

Unfortunately, moralistic views of addiction persist within the medical profession.  Attitudes of trainees towards alcoholic patients appear to become increasingly negative over the course of medical training.  Further, research has shown that alcoholic inpatients are frequently defined by hospital staff as “management problems rather than as patients with a medical illness to be diagnosed and treated.”  Other studies have made clear that physicians often fail to adequately screen for substance abuse issues or to make appropriate treatment recommendations when these issues are identified.  Finally, as many people who struggle with addiction can attest, they often learn to avoid health care providers explicitly because of the stigma they are likely to encounter.

Much of the criticism of this dreary situation has focused on reform of medical education.  To be sure, there are problems in this area.  As is the case for many non-traditional subjects, precious little time is spent on addiction in medical school. There is currently only one certified fellowship training program in addiction medicine in the whole country (a new program opening this summer in Vancouver will make two). There are also few available role models with relevant expertise, thus perpetuating a negative cycle in future generations of trainees.  Over time, we will hopefully have more physicians in this country who are specialists in addiction, with the necessary skills to supervise rehabilitation programs, prescribe methadone, and other related activities. This slowly growing cadre will be able to serve as teachers and role models for future generations of trainees.  But while we wait for capacity within the system to build, there is much that health care professionals can do to improve the way we deliver care to patients who are struggling with addictions today.

I’m not suggesting that all physicians need specialized training in this area.  I understand that this kind of work is challenging and not of interest to many.  However, I believe everyone in health care should hone an attitude that understands addiction and its symptoms as medical problems, and to assist patients in accessing appropriate care for their condition, just as we would for any illness beyond our scope of practice.  To be able to do this, we as health care practitioners must be able to get past the visceral reaction I described.  There are tools available to help us, including widely available evidence and a Continuing Medical Education program.  We as a health care community need to address our own attitudes and emotions before any real progress can be made in this area.

This is not a one-time process, but rather one that should be repeated as often as necessary to continue to make wise choices.  In this way, perhaps we have more in common with our addicted patients than we would like to acknowledge.  As an addiction interferes with the free, rational choices of its victims, so too does the emotional reaction that can rise quickly in our throats interfere with the rational choices we would prefer to make as providers.  Only by acknowledging this emotion and letting it go can we hope to serve the most vulnerable before us.

Ryan is a fourth year medical student at the Windsor campus of the University of Western Ontario. Follow Ryan on Twitter @ryan_herriot

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6 comments

  1. catherine mitchell

    thank you Ryan for your honesty and your reminder to your fellow practitioners that they have a responsibility of CARE to all who need medical assistance

  2. kathy hardill

    Thanks for this Ryan – your honesty is refreshing, as is your willingness to self reflect; anyone with an interest in neurodevelopmental biology would be encouraged to read canadian physician gabor mate’s book “in the realm of hungry ghosts” – the first few chapters of which describe some fascinating connections between adverse early life experiences and human brain development – which very logically provides an understanding of the missing neurological connections which individuals often try to rectify later in life through the use of substances; similarly, if one does a google search for “ACES study” there is some similarly compelling longitudinal research on huge numbers of HMO enrollees by doctors anda and felliti linking adverse childhood experiences with later risks for substance use – as mate asks, “why has such well documented data failed to influence mainstream medical, social and legal understandings of addiction?” – when i teach people about approaches to addiction in primary care, i describe substance use as being about symptom relief from underlying issues, and i emphasize that there are ALWAYS underlying issues – the obligation for health care providers is to get to what those are, and offer help – judging behaviour one finds abhorrent may be a first impulse, but few people who use substances compulsively find it very helpful – i think the author is correct when he suggests medical education, and i would add nursing education, are woefully inept at preparing us to provide ethical, compassionate care to people with substance use issues – from the smoker whom we blame for their COPD exacerbation to the injection user who contracts hepatitis C to the alcohol user who’s liver is toast – we all too often smugly judge “weak” or “undisciplined” people who’ve brought their problems on themselves – it really should be an expectation of all health care providers to work through one’s values around substance use, and to practice from an understanding of the actual epidemiology of compulsive substance use, just like we do for any other health issue, rather than from a place of superiority and judgment – thanks for this

  3. Lisa Lefebvre

    Ryan, you have taken the words right out of my mouth and written this more eloquently than I ever could. As the Program Director of the only Addiction Medicine Fellowship program in Canada thus far (can’t wait for the Vancouver fellowship to take its first cohort!), I applaud you for speaking out!
    Every physician should read this.

  4. Ritika

    Thanks for this Ryan. I’ve always found it interesting how society has so much empathy towards children witnessing or experiencing trauma in the form of emotional, physical or sexual abuse and yet none for that same child when he/she grows up and starts using. Most of the people I see in my practice who use have lots of childhood trauma, and also feel a lot of shame about the fact that they use. Nobody WANTS to be ‘a drug addict’, which should compel us to ask what could possibly have happened to them that compelled them to go down this path? We should endeavour to maintain that same empathy we would feel for a child experiencing trauma, as more often that not, the person suffering from addictions is just that child all grown up.

  5. Ryan Herriot

    Thanks for the kind words, folks. Always nice to have fellow travellers.

    Ritika, you read my mind. I think next I’d like to tackle the broader consequences of childhood trauma in terms of all sorts of mental illness, not just addiction. I imagine that most people are basically compassionate but lack the facts about this kind of thing. I’m always optimistically feeling that if we just put the correct info into people’s hands, the world will change. I guess that’s what this site is all about.

  6. Maria Carlsen

    Thanks Ryan for sharing this emotional article.
    Everything you whrite is what we hear every day. For that reason it makes it more emotional wenn our clients read your article.

    Good luck and i will folow you!

    Maria Calsen
    http://www.miroya.nl/verslavingszorg (Netherlands)

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