They are seen every day in doctors' offices, outpatient clinics and hospital emergency rooms: men in their 50s with bleeding ulcers; young adults pulled from car crashes; middle-aged women fighting a losing battle against chronic pain.
As dissimilar as they seem, many of these patients are also suffering from another illness -- alcohol or drug abuse – that is at the root of the more obvious ailments that keep them cycling through the medical system. Even so, their addiction is rarely addressed by doctors.
A recent comprehensive report by the National Center on Addiction and Substance Abuse (CASA) at Columbia University found that most doctors fail to identify or diagnose substance abuse "or know what to do with patients who present with treatable symptoms."
Only about 10 percent of the 22 million Americans with a drug or alcohol problem receive treatment, the report found. After including 18 million other people whose only addiction is to nicotine, it estimated that 40 million Americans are addicted to one or more substances. And although effective treatments exist, "the vast majority of people in need of addiction treatment do not receive anything that approximates evidence-based care," researchers concluded.
Despite its prevalence and impact -- addiction is linked to more than 70 diseases or conditions and accounts for a third of inpatient hospital costs, according to CASA -- the subject is rarely taught in medical school or residency training. Of the 985,375 practicing physicians in the United States, only about 1,200 are trained in addiction medicine, a scarcity of skills that poses a "formidable barrier" for patients, CASA concluded.
A new training program underway at 10 academic medical centers around the country, including the University of Maryland Medical Center in Baltimore, seeks to address this acute shortage by offering one- and two-year residencies in addiction medicine to physicians who have finished training in another specialty, such as family practice or internal medicine.
The program, launched in July 2011 and sponsored by the American Board of Addiction Medicine, seeks to attract more doctors to the field and to persuade organized medicine to approve the medical treatment of addiction as an officially recognized subspecialty, similar to cardiology or sports medicine. Currently that designation belongs only to addiction psychiatry, which is open only to psychiatrists, not primary-care doctors.
"Addiction so much affects the quality of care we deliver," said internist Jeffrey Samet, ABAM's president and a professor at the Boston University School of Medicine. "If you don't address drug or alcohol abuse, you can't begin to control a patient's diabetes."
The training program could not come at a more auspicious time. The federal Substance Abuse and Mental Health Services Administration estimates that up to a third of the 30 million Americans who may gain health insurance under the Affordable Care Act have a substance abuse or mental health problem.
"Given the increase, the potential need for physicians is extraordinary," said Wilson Compton, director of the division of epidemiology, services and prevention research at the National Institute on Drug Abuse. "In the last 10 to 15 years, we've seen a marked increase in medical interventions" to treat addiction, Compton said, referring to several new medicines such as buprenorphine to ease withdrawal and blunt cravings in people addicted to opiates, a class of drugs that includes heroin, codeine and painkillers such as oxycodone. "You need a workforce who understands and can prescribe these drugs appropriately."
Three drugs, including naltrexone, have been approved in recent years to treat alcohol abuse.
Psychiatrist Devang Gandhi, who heads the University of Maryland's addiction residency program, said that the need for treatment has become increasingly apparent to his colleagues outside psychiatry. "I think there's more recognition in medicine that addiction is present and you can't just shut your eyes to it," he said.
While interest in addiction medicine residencies may be growing, funding remains a problem. Although 10 medical centers agreed to train 28 doctors in the first year of the program, money was found for fewer than half of those slots.
One way around that obstacle is to fund residencies, which are traditionally financed by the Centers for Medicare and Medicaid Services and cost about $80,000 per doctor annually, through hospitals, professional medical groups or the Department of Veterans Affairs. Psychiatrist Michael Miller, an ABAM board member who helped establish the addiction medicine residency at the University of Wisconsin School of Medicine and Public Health, said the VA has funded a position for a doctor who will work with returning veterans who have substance abuse problems.
Not Like 'Intervention'
Despite the popular view of addiction treatment, shaped by such reality television shows as A&E's "Intervention," which ends with an addict's stay in a distant and expensive inpatient facility, most treatment for drug and alcohol abuse takes place in outpatient settings near a patient's home. Chief components of treatment are often medications, behavioral therapy and supportive programs.
"The nature of treatment has changed" in the past 10 to 15 years, said Richard Blondell, a professor of family medicine at the State University of New York at Buffalo, who heads the ABAM's committee on training. Studies have bolstered the view of addiction as a complex brain disease, not a failure of willpower or a deep-seated psychological problem.
"We used to think that somebody who was an alcoholic had a behavior problem, and if you just figured out what happened during toilet training you could fix it," he said. Now, rather than "trying to fix the underlying psychological problem, it may be better to fix the underlying biological problem."
In Blondell's view, there is another compelling reason to train more doctors: raising standards. "Sometimes, underqualified physicians gravitate to addiction medicine," he said.
In many cases, physicians are only minimally involved in treatment. The qualifications of addiction counselors, who provide the bulk of treatment, are often meager. Six states have no minimum educational requirement, CASA found, while 14 require only a high school diploma. The group's report recommends that addiction courses be added to the required curricula of medical school and training programs.
The daughter of a New York social worker, internist Christine Pace said she has always been drawn to working with disadvantaged patients. But as a third-year medical student at Harvard several years ago, Pace said, she "met a lot of patients struggling with addiction and was really frustrated by how poorly served" they were by doctors and by how little doctors knew about treatment.
Pace said she was shocked and upset when doctors rolled their eyes after a patient bounced back into the hospital with endocarditis -- a heart infection seen in IV drug users -- or severe gastrointestinal bleeding caused by alcoholism.
"We're not trained to deal with patients who are addicted," said Pace, who recently completed Boston University's year-long addiction residency. "We end up feeling powerless and frustrated -- and doctors don't like to feel frustrated and powerless."
Gandhi, of the University of Maryland, agreed. "The patient population tends to be more complicated and difficult," he said, adding that addiction is not a glamour specialty like cardiology. Doctors may not "be reimbursed for the services they provide because they're not doing procedures. And they would much rather do what they are familiar with and what they're paid for."
But for some newly minted residents, the lure is the chance to affect patients' lives in a significant way.
Karsten Lunze, who trained as a pediatric cardiologist in his native Germany before coming to the United States to study preventive medicine at Johns Hopkins and Harvard, decided to become an addiction clinician-researcher. He finished the Boston University program in July and has joined that school's faculty as an addiction specialist.
"I was looking for a field that would allow me to make a big impact," said Lunze, adding that he was "struck by the extent of addiction among American patients."
Treating substance abuse patients, he added, can have "a profound impact on their lives. It's humbling to see what resources our patients can mobilize and how resilient they are."
SUNY's Blondell echoed that sentiment. "I see more impressive successes in addiction than I did in family medicine." Among them is a history teacher in his early 40s who grew up in a family of alcoholics but never drank. After the man suffered a herniated disk and underwent failed back surgery, he became addicted to narcotic painkillers. When his doctor refused to prescribe them, he bought them illegally. His job and marriage imperiled, he sought treatment from Blondell, who put him on buprenorphine, which he took for several years.
Combined with the medicine, which helped him kick his addiction, the man underwent counseling and attended Narcotics Anonymous meetings. Now in recovery, "he's working, and his marriage is stable," Blondell said.