To really understand how far we have come in addiction medicine requires perspective on the environment for the very first drug clinics. When Jimi, Janis and Jerry ruled the airwaves, both addicts and the physicians who treated them faced prosecution and jail time. Simply being an addict was a crime under the Harrison Narcotic Act and individuals could get a life sentence for third time possession of marijuana.
When I entered the field in the 1960s, a very different view was starting to take hold, thanks to the work of the University of California San Francisco Medical Center’s Dr. Fred Meyers and Dr. Joel Fort who recognized addiction as a disease, not a crime. Their belief that addicts had a right to treatment became a “civil rights movement for addicts.”
This idea served as a founding principle of the Haight Ashbury Free Clinic. Located in the center of San Francisco’s anti-war and free speech movements, amongst rock bands, concert venues, and thousands of people living the life of drugs, sex, and rock ‘n roll, it offered free detox services to anyone at the door, with the philosophy that healthcare for addicts ought to be a right, not a privilege.
Today, that radical idea has become mainstream, and is a central tenet of the Affordable Care Act (ACA) or Obamacare. At the time, it precluded access to traditional funding, so Janis Joplin put on Dr. Sunday’s Medicine Show to support us and the Grateful Dead and Jefferson Airplane did benefits to help us keep the doors open. And, we created Rock Medicine to provide medical services at huge outdoor festivals and concerts.
In the following years, Janis, who alternated between alcohol and heroin, overdosed. There was the Grateful Dead bust for marijuana and the beginning of the movement to decriminalize marijuana. Heroin addiction began to escalate, but no in-patient detox service existed. There really was no field of addiction treatment yet. We developed a technique that used long-acting phenobarbital as a substitute for shorter-acting drugs such as barbiturates, alcohol and benzodiazepines on an outpatient basis. We layered on adjunctive medications, added counseling and Narcotics Anonymous meetings and created a free outpatient program that treated about 100 addicts a day.
Still, we ran the risk of arrest. To mainstream programs like ours and keep us out of jail, the California Society of Addiction Medicine organized, with a goal of protecting doctors who treated addicts from criminal prosecution if they used appropriate techniques. Similar organizations arose around the country, eventually coalescing into the American Society of Addiction Medicine (ASAM).
We now know that addiction is a chronic, relapsing, potentially fatal brain disease. Treating just the acute signs and symptoms does not work. Patients will relapse and return. It must be addressed as chronic disease that needs ongoing monitoring and support. Treating opioid addiction as a mainstream disease in the primary care setting makes that continuing care more likely and studies have found that when patients can receive Suboxone with other medical services, they come in to treat their addiction, but also take better care of their diabetes and hypertension.
As addiction medicine became mainstream, we also learned more about how it affects the brain. Addiction directly targets the brain’s limbic system, causing the four C’s of the addiction cycle: craving, compulsion, loss of control, and continued use in spite of adverse consequences. Essentially, addiction hijacks the nucleus accumbens in the brain, prioritizing the drug above basic needs like eating and sleeping. This type of brain “re-wiring” can potentially lead to neurodegenerative diseases or neuropsychiatric impairment, which is especially disturbing when one considers that the peak incidence for addiction is 15 – 21 years of age, and that adolescents are more prone to addiction and to drug-induced psychosis.
Studies have shown a genetic component to addiction as well. For example, a person with decreased D2 receptors in their brain has a higher risk for addiction, while those with increased D2 receptors will have a lower risk. These studies also provide avenues for new treatment methods. Repeated low intensity reward activates D2 and helps the brain to restore balance during recovery to addiction. In the absence of sophisticated genetic testing, clinicians can obtain critical information just by asking “Do you have a family history of alcoholism or are there drug dependencies?”
Current research also indicates that environmental factors, such as childhood trauma, can cause genetic transmission alterations, making an individual more susceptible to addiction. This observation also works in reverse – psychosocial therapy techniques such as yoga and meditation can modify gene expression in a positive way.
In the last five decades, addiction medicine has become a recognized, mainstream specialty, rather than a suspected criminal enterprise, through ASAM and the American Board of Addiction Medicine (ABAM), influencing all branches of medicine impacted by addictive disease and its consequences. With the passage of the ACA, President Obama’s allusion to “health care is a right, not a privilege,” and parity, substance use disorders are included as mainstream medical disorders to be diagnosed and treated like other chronic diseases such as diabetes.
We’ve made huge advances in understanding addiction, and those advances have been crucial in creating an integrated treatment approach that addresses addiction as a chronic disease instead of a moral failing, crime or acute event. Now addiction treatment is part of national healthcare policy and there is widespread discussion of how to increase access. We’ve come a long way from the first free clinics dependent on rock and roll fundraisers.