They are seen every day in doctors' offices, outpatient clinics and hospital emergency rooms: men in their 50s with bleeding ulcers; young adults pulled from car crashes; middle-aged women fighting a losing battle against chronic pain. • As dissimilar as they seem, many of these patients are also suffering from another illness — alcohol or drug abuse — that is at the root of the more obvious ailments that keep them cycling through the medical system. Even so, their addiction is rarely addressed by doctors.
A recent comprehensive report by the National Center on Addiction and Substance Abuse (CASA) at Columbia University found that most doctors fail to identify or diagnose substance abuse "or know what to do with patients who present with treatable symptoms."
Only about 10 percent of the 22 million Americans with a drug or alcohol problem receive treatment, the report found. After including 18 million other people whose only addiction is to nicotine, it estimated that 40 million Americans are addicted to one or more substances. And although effective treatments exist, "the vast majority of people in need of addiction treatment do not receive anything that approximates evidence-based care," researchers concluded.
Despite its prevalence and impact — addiction is linked to more than 70 diseases or conditions and accounts for a third of inpatient hospital costs, according to CASA — the subject is rarely taught in medical school or residency training. Of the 985,375 practicing physicians in the United States, only about 1,200 are trained in addiction medicine
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A new training program under way at 10 academic medical centers around the country seeks to address this acute shortage by offering one- and two-year residencies in addiction medicine to physicians who have finished training in another specialty, such as family practice or internal medicine.
The program, launched in July 2011 and sponsored by the American Board of Addiction Medicine (ABAM), seeks to attract more doctors to the field and to convince organized medicine to approve the medical treatment of addiction as an officially recognized subspecialty, similar to cardiology or sports medicine. Currently that designation belongs only to addiction psychiatry.
"Addiction so much affects the quality of care we deliver," said internist Jeffrey Samet, ABAM's president and a professor at the Boston University School of Medicine. "If you don't address drug or alcohol abuse, you can't begin to control a patient's diabetes."
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The federal Substance Abuse and Mental Health Services Administration estimates that up to a third of the 30 million Americans who may gain health insurance under the Affordable Care Act have a substance abuse or mental health problem.
"Given the increase, the potential need for physicians is extraordinary," said Wilson Compton, director of the division of epidemiology, services and prevention research at the National Institute on Drug Abuse.
"In the last 10 to 15 years, we've seen a marked increase in medical interventions" to treat addiction, Compton said, referring to several new medicines such as buprenorphine to ease withdrawal and blunt cravings in people addicted to opiates, a class of drugs that includes heroin, codeine and painkillers such as oxycodone. "You need a workforce who understands and can prescribe these drugs appropriately."
Three drugs, including naltrexone, have been approved in recent years to treat alcohol abuse.
Despite the popular view of addiction treatment at inpatient facilities, most treatment for drug and alcohol abuse takes place in outpatient settings near a patient's home. Chief components of treatment are often medications, behavioral therapy and supportive programs.
"The nature of treatment has changed" in the past 10 to 15 years, said Richard Blondell, a professor of family medicine at the State University of New York at Buffalo, who heads ABAM's committee on training. Studies have bolstered the view of addiction as a complex brain disease, not a failure of willpower or a psychological problem.
"We used to think that somebody who was an alcoholic had a behavior problem, and if you just figured out what happened during toilet training you could fix it," he said. Now, rather than "trying to fix the underlying psychological problem, it may be better to fix the underlying biological problem."