Keeping Up with the Constantly Changing Field of Addiction

Every generation has to grapple with inherited wisdom in the light of new times and new circumstances. Old shibboleths about addiction are being discarded as new perspectives become available.

Allow me to introduce myself. I have recently retired after practicing psychiatry and addiction medicine for over 40 years. Before that, I marinated in a home with an alcoholic father.

I say “marinated” because from an early age I absorbed much of the thinking and beliefs underlying addiction and codependence. The alcoholic’s distorted belief in willpower became my guiding principle for the first part of my life, as did the codependent’s focus on pleasing others in order to feel worthwhile.

A lot of healing lay ahead for me. Fortunately, my innate curiosity guided me in directions that made it increasingly easier to free myself from these early influences. Wise mentors and the principles of Al-Anon nurtured personal healing, and the growing body of addiction science helped me understand how to be of service to addicts and those in recovery.

I practiced during a time of massive change in the field of addiction. The greatest change has occurred in the area of my greatest interest—marijuana. When I began practice, possession of marijuana could land you in prison. Now nearly 70 million Americans can purchase cannabis products legally for recreational purposes, and over 200 million are free to use it medicinally.

When I first experienced marijuana in the late 1960s, we knew virtually nothing about how it worked. Mystical explanations flourished in the absence of scientific knowledge. Today, marijuana researchers have discovered that an entire marijuana-like natural chemistry pervades out brain and modulates all other brain chemistry.

When I began practicing addiction medicine, the only opiate addicts were “other people”, out on the street people, criminals. Then the pharmaceutical companies revved up their marketing departments and convinced physicians to treat pain as another vital sign, as important to stop as bleeding. Now more people die of an opioid overdose every year than died during the entire Vietnam war, in every city, town and rural area, in every racial group and financial class. Proof, again, that addiction is truly an equal opportunity destroyer.

In the 1980s America experienced a wave of attention paid to the young and adult children of alcoholics. Family treatment became a staple in rehab centers. Then the wave of attention ebbed, leaving only a low level of understanding that early life with an addicted parent can be brutal and traumatizing, or merely scary and confusing, leaving scars scattered throughout your personality.

On the brighter side, medications have been developed to make quitting alcohol, tobacco, and opioids easier. Buprenorphine has taken opiate replacement out of federally restrictive methadone clinics and made it more available in doctors’ offices.

Cocaine imported from South America morphed from a high end drug to crack for the masses, and then people largely switched to methamphetamine, brewed in garage, motel room and kitchen makeshift labs across the country.

The War on Drugs came, shrank, and threatens always to come again. It never effectively reduced Americans’ demand for drugs, but it did make prisons a growth industry. Blatant racial disparities in enforcement were ignored, if not even politically motivated. Now, America has wearied of the government’s unsuccessful War on Drug users and their families. California rose up and rejected the Drug War when voters legalized medical marijuana in 1996.

The treatment industry has gone through cycles of change. At the beginning of my career, every community hospital was converting unused beds to 30-day cash cow cookie cutter rehab units. Then managed health benefits (slyly called managed “care”) correctly questioned standard 30-day inpatient treatment, but went overboard with limiting it to a few days at a time, repeatedly requiring mountains of proforma paperwork to extend treatment and underpaying clinicians. Today, despite allegedly having parity with other medical illnesses, we still have no real system of addiction treatment, especially for youth.

High end rehab spas remain free to overpromise, while those dependent on their medical insurance, or without even that, wait and search for whatever help they can find. Drug abusing teens with parents who are either rich or able to refinance their homes get transported out of state to wilderness programs and therapeutic boarding schools, while the majority of youth needing treatment end up in juvenile justice or go without.

The medical community’s earlier neglect of addiction, fueled by physicians’ lack of training, sense of impotence, bias against “self-imposed” illness, lack of time and pay to commit to actually counseling people, and so much more, has gradually begun to change. Addiction medicine has been recognized as a legitimate specialty, with structured training programs. This has brought a more scientific, evidence-based perspective into addiction treatment.

The increasing integration of drug treatment and psychotherapy has been very encouraging. Too many ill-paid workers in the field have still not received adequate training to further this integration, but progress is being made. Recognition of the role untreated trauma plays as a barrier to recovery has contributed to this integration.

Twelve-Step programs remain as strong and vitally important as ever. Clinicians continue to learn how to use treatment into augment recovery guided by these principles

There is still so much to do. This blog will share the insights coming from a career that spans all the changes described above. Along with my recent book, From Bud to Brain: A Psychiatrist’s View of Marijuana, I am doing my best to record what I have learned from patients, from science, and from personal recovery work—insights from a life devoted to understanding addiction and helping all those who need healing from its direct and indirect effects.

I invite you to weave what you like into new perspectives on addiction, and leave the rest.