Psychiatrists who are trained in addiction are in a unique position to identify concurrent psychiatric and substance use problems in individuals seeking treatment for either or both conditions (AAAP, 2017). Because psychiatric problems can affect substance abuse and vice versa, addiction psychiatrists have a significant role in diagnosing and treating both conditions.
Significant advances have been made in the knowledge and understand of the factors that contribute to substance abuse disorders, which have led to the development of therapeutic techniques that are focused specifically on addiction and abuse disorders. Novel pharmacological strategies have been developed and are being implemented to target individuals for whom affective, attentional or anxiety symptoms pose a particular vulnerability to the development of substance abuse or dependence (AAAP, 2017).
Overwhelming data shows that treatment for addiction promotes less substance use, better psychological and physical health, and improved social functioning, while cost-offset analyses show clear (long-term) economic benefits to providing addiction treatment (AAAP, 2017). One of the great challenges of treating patients with addiction is the stigma associated with this disease.
What is Addiction?
Addiction is a complex condition, a brain disease that is manifested by compulsive substance use despite harmful consequence (APA, 2017). It is a disorder involving severe substance use in which its victims have an intense focus on the substance, such as alcohol or narcotics or other drugs, to such an extreme that it becomes the focus of their entire life. Addiction causes distorted thinking, behavior and body functions because of a disruption in the brain’s function that causes intense cravings for the substance.
Brain imaging studies show changes in the areas of the brain that relate to judgement, decision making, learning, memory and behavior control (APA, 2017). These changes to the brain occur long after the drug or substance is ingested and after the intoxication phase. The intoxication phase is the feeling of intense pleasure or calm, increased senses or the “high” users get, depending on the substance they are using. According to the American Psychiatric Association (2017), the misuse of drugs and alcohol is the leading cause of preventable illness and premature death.
Symptoms and Treatments
Symptoms of addiction include impaired control, social difficulties, an increased tolerance and withdrawal symptoms. The symptoms vary depending on the substance being abused. Mental illness is often associated with addiction. In some cases, the mental illness may exist prior to the substance abuse, and in others, the addiction may trigger or compound an existing mental illness.
There are treatments for addiction, although as with some other chronic diseases, there may be cycles of recovery and relapse. First, the addict must recognize they have a problem, which can be difficult for some. Family and friends often intervene and encourage treatment. Unfortunately, many addicts do not receive any treatment for their disease.
Multiple treatments are used by addiction psychiatrists to treat addiction, and many times different treatments are combined to provide comprehensive treatment to the patient. A combination of pharmaceutical medication and individual or group therapy is part of most addiction psychiatry treatment plans. The pharmaceuticals help the patient control cravings or may provide relief for severe withdrawal symptoms. Therapy allows the patient to understand their addiction, examine their behavior and motivation for substance use, develop self-esteem, handle stress in a healthy way and it may address mental health issues as well.
Treatments may also include hospitalization, rehabilitation or therapy community programs that are secure and monitored or outpatient programs. In addition, Alcoholics Anonymous or Narcotics Anonymous are alternative treatment options and support groups for current and former addicts.
There are multiple substances or drugs a person can become addicted to. Those most commonly seen are addictions to alcohol, marijuana, PCP, LSD or other hallucinogens, inhalants (such as paint thinners and glue), opioids (such as codeine, oxycodone, heroin), sedatives, hypnotics and anxiolytics (anxiety medication), cocaine, methamphetamine and other stimulants and tobacco (APA, 2017).
The History of Addiction Medicine in the United States
The recent recognition of addiction medicine as a medical specialty obscures the fact that American physicians have been involved in the treatment of severe and persistent alcohol- and other drug-related problems for more than two centuries (White, 2009). Addictions have been identified as early as the 1700s, mainly as related to alcohol. Significant developments in addiction medicine have been made throughout the 18th, 19th and 20th centuries.
The Birth of Addiction Medicine
The beginnings of addiction medicine took root not in America but in ancient African and Egyptian civilizations. Special methods to care for those addicted to alcohol were developed in ancient Egypt, and references to chronic drunkenness as a sickness that enslaved body and soul date to Heroditus (fifth century BC), Aristotle (384-322 BC), and Seneca (4 B.C.-65 AD) (White, 2009). These earliest identifications of alcoholism were focused more on the individual and their behaviors as opposed to an organized cultural response.
In the United States, Native Americans were the first to develop medical responses to alcoholism. Native tribes, for the most part, resisted the alcohol used as a tool of economic, political and sexual exploitation (White, 2009). The native tribes developed political and legal advocacy groups and organized sobriety-based cultural revitalization movements, in addition to medical treatments for those affected by their addiction to alcohol. Native Americans used botanical agents such as hop tea and trumpet vine root to help reduce the patient’s cravings and to induce aversion to alcohol.
Colonial America
As Colonial American grew, so did the consumption of alcoholic beverages. Medical issues associated with alcohol consumption occurred in the late 1700s, as consumption increased, and the drinks became more potent. In 1774, a philanthropist and social reformist by the name of Anthony Benezet published written work identifying alcohol not as a gift from God (as previously identified) but as a bewitching poison. He also wrote about a person becoming enslaved to the alcohol.
Dr. Benjamin Rush was one of the first physicians to recognize alcoholism as a medical issue. Rush’s work is particularly important given his prominence in Colonial society and his role in the history of American medicine and psychiatry. Rush’s 1784 pamphlet, Inquiry into the Effects of Ardent Spirits on the Human Mind and Body, was the first American treatise on alcoholism, and it almost singlehandedly launched the American temperance movement (White, 2009). In this pamphlet, Rush categorized the symptoms of acute and chronic drunkenness, described the progressiveness of these symptoms, and suggested that chronic drunkenness was a “disease induced by a vice” (White, 2009). Dr. Rush also theorized that drunks could achieve a full medical recovery with proper treatment, although a special facility would be needed (a sober house).
During this time of discovery in America, similar writings emerged in other countries. Further American contributions were made by Christopher Wilhelm Hufeland, who described dipsomania – uncontrollable cravings that triggered physical and mental effects. A few years later, a group of physicians would label this as delirium tremens.
Between 1774 and 1829, America “discovered” addiction through the collective observations of her physicians, clergy, and social activists (White, 2009). It became evident that chronic alcohol abuse was associated with biological issues and consequences that needed medical attention. These earliest pioneers declared that chronic intoxication was a diseased state, and they articulated the major elements of an addiction disease concept: biological predisposition, drug toxicity, pharmacological tolerance, disease progression, morbid appetite (craving), loss of volitional control of alcohol/drug intake, and the pathophysiological consequences of sustained alcohol and opiate ingestion (White, 2009).
Treatments at the time included purging, blistering, bleeding, and toxic medications, in addition to religious conversion. Most physicians would encourage their patients to make a life-long pledge to remain abstinent from alcohol.
It should be noted that opioid addiction was also present during the 1700s and 1800s, as identified by English physician John Jones publication titled The Mysteries of the Opium Reveal’d. In America, there were three events which altered the future of narcotic addiction: the isolation of morphine from opium, the introduction of the hypodermic syringe and the emergence of a patent drug industry (White, 2009). These three events led to narcotics with greater potency, allowed for a more efficient and euphorigenic method of ingestion and increased the availability of narcotics.
Medical Advancements (1830 – 1900)
In Connecticut in 1830, Dr. Samuel Woodward, who worked at an insane asylum, suggested that an institution was needed for those suffering from alcoholism and substance abuse, and that these addictions were physical diseases that required medical treatment, as opposed to Dr. Rush’s abstinence-only solution. What followed throughout the 1830s and 1840s were significant clinical contributions made toward understanding chronic drunkenness that exerted considerable influence on the emerging field of addiction medicine (White, 2009).
Many pathophysiology discoveries were made during this time, such as the effects of alcohol on the stomach and in the blood, different sub-types of alcohol addiction, and possibly the spontaneous combustion of drunks (White, 2009). In France, discoveries were made linking alcoholism to mental illness, as well as the first identifications of drunkenness as a disease.
One of the most significant milestones in the history of addiction medicine was the 1849 publication of Magnus Huss’ text, Chronic Alcoholism (White, 2009). After an extensive review of the chronic effects of intoxication, Huss declared: These symptoms are formed in such a particular way that they form a disease group in themselves and thus merit being designated and described as a definite disease...It is this group of symptoms which I wish to designate by the name Alcoholismus chronicus” (White, 2009).
The Relapse and Recovery of Addiction Medicine (1900 – 1970)
The Relapse
Between 1900 and 1920, addiction treatment institutions closed in great numbers in the wake of a weakened infrastructure of the field, rising therapeutic pessimism, economic austerity triggered by unexpected depressions, and a major shift in national policy (White, 2009). State and national prohibition laws were now the solution to the country’s alcohol and drug abuse problems.
During this time, an alcoholic seeking treatment would find themselves in psychiatric asylums or psychopathic hospitals, although both discouraged the admission of alcoholic patients. Medical literature during this time shifted from a focus on addiction as a disease and instead due to lack of character or morals. Although prohibition initially led to a decrease in alcohol-related problems, numbers were up to previous levels within a year. The Eighteenth Amendment to the U.S. Constitution transferred cultural ownership of alcohol problems from physicians to law enforcement authorities (White, 2009).
Additional legislation passed by Congress through The Harrison Act transferred responsibility for the care of addicts from physicians to criminal syndicates and the criminal justice system by threatening physicians with loss of license and incarceration if they provided any medical treatment other than rapid detoxification to any addict (White, 2009). During this time, the field of psychiatry began to influence the diagnosis and treatment of addiction as well, perhaps due to the decrease in physician treatment.
The Recovery
Two movements had a significant effect on the emergence of addiction medicine: the formation of Alcoholics anonymous and a scientific approach to addiction led by the Research Council on Problems of Alcohol, the Yale Center of Alcohol Studies and a recovery advocacy group that formed the National Committee for Education on Alcoholism. These efforts also led to the legitimizing the need for treatment by a physician.
Throughout the 1940s, 50s and 60s, addiction science grew more sophisticated and more institutionalized, as legislation was passed to approve state and federal funding for alcoholism and addiction treatment. The creating of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA) led to federal, state and local community partnerships that are the foundation of modern addiction treatment (White, 2009).
During this time period, insurance coverage for treatment of addiction was enforced, in part due to the efforts of the Joint Commission on Accreditation of Hospitals, which led to the dramatic growth of hospital-based and free-standing, private addiction treatment programs in the 1980s (White, 2009).
Modern Addiction Medicine
In 1976, Career Teachers and others involved in addiction-related medical education and research established the Association of Medical Education and Research in Substance Abuse (AMERSA) (White, 2009). This led to the development and promotion of addiction-focused research and teaching specialties.
The re-emergence of addiction medicine as a clinical specialty of medical practice has been significantly advanced by two professional associations: the American Society of Addiction Medicine (ASAM) and the American Academy of Addiction Psychiatry (AAAP) (White, 2009). The AAAP was established in 1985 to evaluate medical addiction medical care and clinical practice, in adition to advocating for the American Board of Psychiatry and Neurology to establish addiction medicine as an official sub-specialty medical field.
The ASAM claims the following achievements (White, 2009):
advocating the American Medical Association’s addition of addiction medicine to its list of designated specialties (achieved in June 1990)
offering a certification and recertification process for addiction medicine specialists based on the early work of the California Society of Addiction Medicine
hosting its annual addiction medicine conference,
publishing its widely utilized patient placement criteria,
development of the Principles of Addiction Medicine, and
publishing first the Journal of Addictive Diseases and presently the Journal of Addiction Medicine
The ASAM is perhaps one of the most influential organizations to establish addiction medicine as a legitimate medical specialty. Although the AAAP would soon follow to support addiction medicine and addiction psychiatry.
In 2008, there were more than 14,400 physicians working within a network of 13,200 specialized addiction treatment programs in the United States who help care for more than 1.9 million individuals (White, 2009) (although in 2015, this is a staggering 20 million just 7 years later). In October of 2017, President Trump announced a national emergency due to the incidence of opioid addiction throughout the United States.
As this history has reviewed, addiction medicine rose in the United States in the mid-nineteenth century, collapsed in the opening decades of the twentieth century, but re-emerged and became increasingly professionalized in the late twentieth and early twenty-first centuries (White, 2009).
How to Become an Addiction Psychiatrist
An addiction psychiatrist is a medical doctor who specializes in psychiatry and sub-specializes in addiction psychiatry. A doctor in this medical specialty field receive extensive education and training in general psychiatry as well as in addiction, including recovery, prevention, identification and treatment.
The daily activities of an addiction psychiatrist may include counseling patients, reviewing and updating patient records, creating individual recovery/care plans, including the prescription and administration of medication, running and evaluating diagnostic and laboratory tests, leading group therapy, interventions and working with the families of patients and developing and conducting research.
An undergraduate degree, medical school and a residency are required to obtain a license to practice addiction psychiatry. Many addiction psychiatrists also complete a fellowship and certification as well.
Undergraduate Degree
The first step to becoming an addiction psychiatrist is to obtain an undergraduate degree, although there is no specific requirement for a major. Most students major in biology, chemistry or physics. During the undergraduate degree program, the student will prepare for the Medical College Admissions Test (MCAT), which they need to pass in order to be accepted into an accredited medical school.
Medical School
During medical school, students will spend the first two years in the classroom studying coursework in biochemistry, physiology, medical law and many others. The last two years consist of hands-on training in a hospital or medical center in clinical rotations between different areas, including internal medicine, pediatrics, and psychiatry. This work is done under the supervision of a licensed physician.
Residency
After medical school is completed, a 4-year residency program must be completed in order to develop expertise in patient care. The APA requires a minimum of 36 months of training after the first year of residency in general psychiatry is completed. The addition 3 years allows the resident to focus on a sub-specialty area, such as addiction, psychopharmacology or cognitive behavioral therapy.
Fellowship
After a residency is completed, some students choose to complete a one-year fellowship program to further develop their knowledge and expertise in addiction psychiatry. A fellowship allows the student additional hands-on experience in a sub-specialty, such as addiction psychiatry. Strong fellowships will provide advanced instruction and experience in comprehensive addictions treatment, including screening, diagnosis, behavioral therapies, pharmacotherapies, systems management, treatment planning and consultation (Doctorly, 2017).
Licensing and Certification
An addiction psychiatrist must be licensed in the state they choose to practice in. It is highly recommended the residency be completed in the state the psychiatrist wishes to be licensed in, because of the variation in requirements.
The American Board of Psychiatry and Neurology, Inc. offers certification in the subspecialty of addiction psychiatry to those psychiatrists who meet its criteria for experience and knowledge. All applicants for certification are required to submit documentation of successful completion of one year of ACGME-approved residency training in addiction psychiatry (AAAP, 2017).
The Subspecialty Board Certification in Addiction Psychiatry, given by the American Board of Psychiatry and Neurology (ABPN), has the advantage of official recognition by organized medicine (AAAP, 2017). Both certifying organizations are considered by practicing addiction psychiatrists.
Job Prospects
There is an extreme need for more licensed addiction psychiatrist due to the growing number of people suffering with addiction and substance abuse disorders. The patient population is undeserved, and an increase in mandates for addiction treatment from federal and local governments and third-party payers has led to a demand for credentialed addiction specialists (AAAP, 2017). Opportunities in a variety of medical and clinical settings exist in both private and public settings.
Job opportunities exist in public and private settings, including inpatient residential facilities, substance abuse centers, private practice, within the criminal rehabilitation system, or with a state or federal addiction program. The average salary of an addiction psychiatrist is over $182,000, which is higher than careers in pediatrics, internal medicine and family medicine professionals.
Due to the overwhelming growth of people with addictions, particularly to opioids, the field of addiction psychiatry is expected to grow significantly in the next decade and beyond.
White, W. (2009) Addiction medicine in America: It’s birth and early history (1750-1935) with a modern postscript. In R. Ries, D. Fiellin, S. Miller, & R. Saitz, Eds. Principles of Addiction Medicine, 4th Edition, American Society of Addiction Medicine. Baltimore: Lippincott Williams & Wilkins, Chapter 22, pp 327-334.
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