Think about a patient with addiction. He seeks attention for his illness and would like treatment. Should he go to a counselor, a nurse practitioner or a physician? How would his treatment differ in each case? If you’d like to shake things up further, please add psychologists and social workers to the mixture.
If our hypothetical patient is seen by a nurse practitioner in an ambulatory setting yet fails to improve with respect to his addiction, has he failed medical treatment? Would the next step be for the patient to see a physician? Or would it be to enter a more intensive treatment setting?
Our nation is moving quickly toward an environment in which a greater quantity of medical care will be delivered by clinicians who have not attended medical school. Interestingly, we already have that environment in the field of addiction, and have had that scenario for decades. What we do not know, however, is whether this approach is efficacious for the treatment of patients.
Take a simple research study: 200 patients with newly diagnosed addictive disease are divided into two groups matched by age, sex and socioeconomic background, as well as by drug of choice. One group is seen by addiction specialist physicians, the other by addiction specialists who are not physicians, and both are seen with the same frequency and intensity. At 12 months, determine whether there is a difference between the two groups in terms of recovery rate as defined by abstinence and functional improvement.
The study has never been performed.
No one has ever bothered to determine whether social workers are better than physicians at treating addictive illness, or whether physicians are better than psychologists. And though no one has ever bothered to determine if surgical nurses could perform appendectomies successfully, or if counselors can treat life-threatening illnesses like cancer, there has not been a need to answer those questions. So addiction is in an odd place: there is no proof that non-MD/DO care has sufficient quality to be utilized as a replacement for physician-based treatment, yet non-physician treatment already represents the standard in many locations. And of course, there is no proof that non-MD/DO care does not have sufficient quality either.
In the vast majority of patients coming to my practice, prior misdiagnosis or mistreatment reigns high on the problem list on initial intake. Patients treated incorrectly for depressive illness when they have sedative-induced depression, patients treated with combinations of sedatives and stimulants for alleged anxiety accompanying ADHD, patients with known alcoholism prescribed benzodiazepines for mild insomnia or anxiety: the list goes on and on, with physicians in my community being as much to blame as other clinicians.
Addiction is a complex lifelong disease which, if unaddressed, commonly results in death of the patient. Shouldn’t we have some research to determine to whom these patients should be referred?
Stuart Gitlow, MD, MPH, MBA, is Executive Director of the Annenberg Physician Training Program in Addictive Disease and Associate Clinical Professor at the Mount Sinai School of Medicine. He is Acting President of the American Society of Addiction Medicine.
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