In 2018 about 70,000 people died from an unintentional drug overdose, 80,000 from alcohol, and approximately half a million from tobacco in the US alone. Unfortunately, this is the tip of the iceberg. The prevalence for opioid use disorder in the US is about 2.5 million, alcohol use disorder is another 15 million, and tobacco use disorder is a staggering 30 million! For the third year in a row the average life expectancy has decreased in the US primarily due to “diseases of despair” including addiction, depression, and suicide. The opioid epidemic has finally forced us to turn our attention to addiction. Unfortunately, addiction trained staff is hard to come by, causing many nascent programs to falter before they take off. In my opinion, one important reason for this discrepancy is the lack of education, both didactical and clinical exposure, to addiction treatment. This is simply unacceptable. It is time we demand addiction be given the attention it deserves throughout medical training and beyond.
A patient is admitted for alcohol withdrawal. The typical treatment is a benzodiazepine taper, fluids, vitamins, and a roll of the eyes followed by some off handed remark such as “This patient will be back, they all are” or “Can’t you just stop? You’re killing yourself”. A second patient comes in after an accidental opioid overdose, taking too many prescribed oxycodone pills for his chronic pain. This patient likely receives a confrontational lecture and labeled a “pill seeker”, at best a dose reduction in the prescribed opioids is made. A third patient comes in for a COPD exacerbation that smokes a pack of cigarettes per day. They would receive steroids, oxygen, perhaps some antibiotics, a “tsk tsk” for smoking, and if lucky, a nicotine patch while inpatient. All three of these common patients are grossly undertreated. All three medical issues have effective, evidence based, treatment. For the patient with alcohol use disorder, why aren’t we prescribing naltrexone or acamprosate, discussing outpatient options or harm reduction? For the second patient with opioid use disorder, why aren’t we talking about buprenorphine, methadone, and intramuscular naltrexone? For our third patient with tobacco use disorder, suffering from the number one preventable cause of death, how are we not discussing varenicline, combination nicotine replacement, bupropion, or setting a quit date? All of these treatments are potentially life saving. Instead of assuming it’s a moral failure, or there’s nothing we can do, it’s time to treat the disease, not just the complication. We would never consider it acceptable to treat diabetic ketoacidosis without addressing the underlying diabetes. Why do we accept it for addiction?
Medicine is a career based on apprenticeship. If we attendings turn away from treating addiction our residents will internalize this stigma believing addiction to be untreatable or undeserving of treatment. Alternatively, and speaking from experience, medical students and residents are incredibly motivated after being exposed to thoughtful addiction treatment. And why wouldn’t they? Treatment is highly effective. Treatment is not complicated, nor insurmountably costly. Patients are incredibly thankful to have a non-judgmental ear. Their stories are highly compelling. Patients are mostly motivated to change, even if they have difficulty reaching their ultimate goal. Medical residents leave motivated, optimistic, and excited to “finally” have a way to treat patients with a substance use disorder.
No matter the field, a significant cohort of patients will suffer from addiction. From didactics to clinical exposure our addiction curriculum is grossly inadequate as a whole. This lack of training is leading to a deepening of stigma, leaving patients untreated, and ultimately a lack of adequately trained clinical staff to address these very same issues. So if you are a student or a resident, demand your program increase the amount of time dedicated to addiction. Your voice really matters and administrators will listen. If you are on staff, consider your own stigma and your own practices. It is much more satisfying to treat the actual disease as opposed to placing yet another band-aide and maintaining the jaded belief that nothing will help anyways. At a minimum, recognize that there are highly effective medical treatments available to patients, that their disease is not a moral failing. Take the time to listen to your patient, to hear their story, to learn from them. Teach your students or be ready to learn from your students. Either way, addiction is never going away, and right now it is a leading cause of morbidity and mortality. Our lack of treatment and education is our failing, not theirs. It’s time to demand addiction education be thoroughly taught, not as an aside, but with the urgency it deserves.