To the Editor:  

I was very pleased to read “Improving Physician and Medical Student Education in Substance Use Disorders” by Stephen A. Wyatt, DO, and Michael A. Dekker, OMS III,¹ in the September 2007 supplement to JAOA—The Journal of the American Osteopathic Association. Only briefly mentioned in this article, however, are the troubling attitudes of physicians regarding substance use disorders (SUDs). 

Physicians commonly respond to these patients with distain and frustration, accepting the view common in our society that substance abuse is “...attributable to morally compromised or pathological individuals who were not properly inculcated in childhood with normal American values such as self-control and respect for the law. These individuals must be disciplined and punished by authorities.”² Therefore, addressing SUDs is seen as a waste of clinical effort that has been referred to as “therapeutic nihilism.”³ 

In a study published in 2002, physician satisfaction in treating patients with alcohol- or drug-abuse disorders was found to be only 49% and 31%, respectively.⁴ Furthermore, according to a study published in 2006, beliefs persist among physicians that patients with SUDs are guilty of overusing healthcare, detracting from the care needed by other patients.⁵ When physicians have the opinion that SUDs are voluntary disorders by addicts who “do it to themselves” and who refuse to change their behaviors, then our progress in education, screening, intervention, and treatment for patients with these disorders is seriously impaired. Fortunately, current understanding of the scientific basis of SUDs refutes such misconceptions. 

The belief that addicts cause their own problems ignores the fact that genetic predisposition accounts for 40% to 60% of the etiologic basis of addiction.⁶ An individual may initially use alcohol or a drug for its euphoric effect—with genetic predisposition playing a part in an abnormal need for this euphoria. However, substance abuse becomes progressively less voluntary as the brain's learning processes are altered by the biochemical effects of the substance of choice.⁷ Thus, current scientific evidence has begun to reveal that individuals with SUDs have been genetically “primed” to try alcohol or drugs and to subsequently become addicted to these substances. 

Certainly, many of us in the healthcare professions have been frustrated by patients with SUDs who seemingly refuse to change their behaviors. Scientific evidence reveals, however, that the brain's mesolimbic dopamine pathway is altered in individuals suffering from addiction.⁷ An abnormally high stimulation of this pathway results in an extremely strong drive for drugs. Learned drug-associated cues then become essentially irresistible because of the drug-induced impairment of planning and decision-making pathways in the prefrontal cortex.⁷ Simply put, sensitized reward “go pathways” become unchecked by impaired executive “stop pathways.” 

Physicians need to be aware of effective treatments that are available to help addicts change their behaviors. These treatments include pharmaceutics-based management, brief intervention, motivational interviewing, and cognitive-behavioral approaches.⁶ In fact, the treatment of patients with SUDs is just as successful as treatments for patients with other chronic illness, such as asthma, hypertension, and type 1 diabetes mellitus.⁶ 

A scientific understanding of the chronic disease of addiction demonstrates both the fallacy of common myths surrounding SUDs and the efficacy of treatments available for patients thus afflicted. The challenge to the healthcare community regarding SUDs is to fulfill our role in patient screening, intervention, and treatment—and to move beyond myths.