- About CSAM
- Public Policy
by Steve Heilig (from CSAM News, Fall 1993 vol. 20 number 3)
June 2010: Addiction and Recovery
San Francisco Roots: The Evolution of Addiction Medicine
David E. Smith, MD, FASAM, FAACT
On May 2, 2009, the American Board of Addiction Medicine (ABAM) and Nora Volkow, MD, director of the National Institute of Drug Abuse, conferred board certification on nearly 1,500 physicians (myself included) representing a wide range of specialties.
- In her address at this ceremony, held during the annual meeting of the American Society of Addiction Medicine (ASAM), Dr. Volkow stated that “years of scientific research have proven drug addiction is a brain disease caused by biological, environmental, and development factors—a disease that can have far-reaching medical consequences. . . . Identifying drug use early, preventing its escalation to abuse and addiction, and referring patients in need of treatment are important medical skills” (Kunz and Gentilello 2009). With the passage of health care reform and parity in March 2010, addiction medicine has become a mainstream core benefit.
Forty and more years ago, this would have been barely imaginable. Addictions were stigmatized as moral failings and/or criminal activity. In reality, substance abuse in all its forms, including nicotine/cigarette addiction, alcoholism, and psychoactive dependence, represents our country’s number-one public health problem.
Complementing this is the rise in prescription opioid abuse, particularly in adolescents, where prescription drug overdose deaths in 2008 exceeded all the overdose deaths for heroin, methamphetamine, and cocaine combined. Substance abuse is now the leading cause of death in young people, exceeding even traffic fatalities (Knudsen 2009).
Alcoholism as a disease was clearly described as long ago as the late 1700s by Dr. Benjamin Rush, a physician and signer of the Declaration of Independence (Katcher 1993). However, it wasn’t until the formation of Alcoholics Anonymous (AA) in the 1930s by Bill Wilson and Dr. Bob Smith (no relation) that this concept of alcoholism as disease spread throughout the United States and subsequently the world. Dr. William Duncan Silkworth, in the Big Book of AA, described alcoholism as a disease caused by “an allergic reaction of the body to alcohol” and a compulsion of the mind (Silkworth, 1937).
Addiction to other drugs, however, was specifically excluded from the scope of AA. AA emphasized that drug use other than alcohol was not to be disclosed at AA meetings. This prompted the formation of Narcotics Anonymous in
Initiatives put forth by physicians in the New York Society of Alcoholism, a forerunner of ASAM, prompted the American Medical Association (AMA) to declare in the 1950s that alcoholism was a disease and to reaffirm this position in 1966.
In the late 1960s, the movement to recognize addiction as a disease escalated in California, particularly in San Francisco. Based on the principle that “health care is a right, not a privilege,” the Haight Ashbury Free Medical Clinic (HAFMC) was founded in response to the large number of drug-using youth who flocked to San Francisco’s Haight Ashbury district in 1967 for the “Summer of Love.” The Clinic’s experience with this population led to the philosophy that “addiction is a disease—the addict has a right to be treated” and prompted the almost immediate expansion of Clinic services to drug crisis intervention and detoxification. The San Francisco Medical Society and the California Medical Society provided early support for these endeavors, despite the City’s refusal to address a major public health catastrophe (Heilig 2009).
Dr. David Breithaupt of the
It was then illegal to detoxify addicts on an outpatient basis. Nonetheless, when Dr. Donald Wesson and I determined that a phenobarbital withdrawal protocol we had developed at
Despite these philosophical trends, physicians were still the targets of punitive action. After the arrest of two Southern California physicians for detoxifying heroin addicts with Valium in an outpatient medical setting, Dr. Jess Bromley recommended that we start a
One of the key organizers of the California Society of Addiction Medicine (CSAM) was Dr. Max Schneider, a Southern California gastroenterologist. Treating cirrhosis of the liver with associated GI bleeds, he became concerned that the existing medical system offered little to treat the causative disease of alcoholism. In fact, all of the founders of CSAM were motivated by the principle that it makes no medical sense to treat the complications of a disease and not treat the underlying chronic medical illness, whether it is a disease of the brain—like addiction—or a disease of the pancreas—like diabetes.
As an appointee to the AMA committee on alcoholism, I introduced the disease model of addiction to the AMA committee in 1976. I coined the term “addiction medicine,” and after much debate it was accepted. Also at that time, Dr. Douglas Talbott, who pioneered the treatment of addicted physicians, introduced the term “addictionology.”
In 1983, individuals in the addiction field met at the Kroc Ranch in California and agreed that a single organization, what has evolved into the American Society of Addiction Medicine, would represent the field. Five years later, ASAM gained acceptance in the AMA House of Delegates as a specialty society with Dr. Bromley as the ASAM delegate and me as alternate delegate (ASAM, 2006).
The AMA accepted the motion introduced by ASAM that all drug dependencies, including alcoholism, are diseases and that medical practitioners should base their medical practice on the disease model of addiction. When ASAM expanded its focus to include cigarette/nicotine addiction, with its associated morbidity and mortality, the AMA granted specialty status with the code of "ADM" after introduction of a resolution by the California Medical Association in 1990 (ASAM 2006).
We had hoped primarily to gain acceptance by organized medicine in the
A 2000 CalData study showed that every dollar spent on treatment saved an estimated seven dollars in health and social costs (CalData study, CSAM News 2000). Kaiser Permanente researchers have also found strong evidence of cost savings (Parthasarathy et al 2001). Meanwhile, the criminal justice system and community and school-based prevention programs have not proved sufficient to turn the tide of substance abuse. Addiction medicine has encouraged medicine to become a major force in dealing with this public health issue: 100 percent of alcoholics and addicts will at some time interface with the medical system.
However, despite compelling evidence for a decade demonstrating excellent cost-benefit outcomes for addiction as a brain disease emphasizing prevention, intervention, and treatment, the battle to implement parity by the sociological and political structure of the
David E. Smith, MD, currently serves as chair of addiction medicine at the
ASAM. 2006. Turning points in establishing the medical specialty of addiction medicine. http://www.asam.org/CMS/images/PDF/Certification/TurningPoints.pdf.
CalData study. CSAM News. 2000.
Heilig S. 2009. David Smith: Pioneering community-based health care. San Francisco Medicine. 2009; 15.
Katcher BS. 1993. Benjamin Rush’s educational campaign against hard drinking. Amer J Public Health. 83(2):273-281.
Knudsen HK. 2009. Barriers to treating alcohol and drug problems among adolescents. Robert Wood Johnson Foundation/Substance Abuse Policy Research Program. www.saprp.org/KnowledgeAssets/Knowledge_Detail.cfm?KAID=20.
Kunz KB and Gentilello LM. 2009. Landmark recognition for addiction medicine. Addiction Professional. 2009; 12-17.
Obama B. 2006. The Audacity of Hope. New York: Crown Publishers
Parthasarathy S, Weisner C, Hu TW, and Moore C. 2001. Association of outpatient alcohol and drug treatment with health care utilization and cost: Revisiting the offset hypothesis. Journal of Studies on Alcohol. 2001; 62(1):89-97.
Silkworth W. 1937. Alcoholism as a manifestation of allergy. Medical Record. 1937; 145:249-251.