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.