Dr. Wasser's Thoughts on Substance Abuse

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The practice of Addiction Medicine has changed in the last few years.  When I started in this practice, I could keep patients in the hospital for 14 days and  everyone got rehab.    Everyone was expected to go to AA or NA.  The use of psychiatric medications was frowned upon.

Additonally, after the detox period, I was expected to leave the patients care; the counselors became the main providers of care.  Counselling was the sole treatment emphasized.  If a patient felt this was not the best treatment for them, they were labelled as resistant or in denial.  The counselors would than attribute the responsibility for failure solely to the patient.  It would never occur to them that the treatment provided was insufficient or wrong.

The scene has changed. 

These days, managed care severely limits inpatient detox and rehab treatments.  Patients often have to make due with very short stays.  After a brief stay, the patient is referred to an outpatient counseling program with little to no medical follow-up.  Many patients require more services.  They often relapse when they have no one to turn to.

While this is unfortunate, it is not only the insurance companies fault.  It has been difficult to show that inpatient treatment leads to improved outcomes compared with outpatient treatment.  However, inpatient treatment is clearly more expensive so the insurance companies cut back on this first.  In addition, many patients pursue inpatient treatment like it's a magical solution without really being motivated to change their behavior.  A lot of patient also pursue inpatient treatment to satisfy legal or job requirements and not because they are ready to change.  Lastly, in this economy people cant stop working.  For these reasons, inpatient treatment has become more more difficult or impractical to do.

This is the situation in which I have been practicing for years.  To make up for a lack of inpatient detox, I have adapted various detoxification protocols for outpatient use.  I treat both the intense, early physical withdrawal syndrome as well as the milder physical and psychological syndromes seen weeks or months later.

Another big change in Addiction Medicine has been the use of Suboxone.  This has made the long term treatment of opiate addictions a chronic medical problem.   The counsellors are now forced to work with physicaians like myself.  Since I am more involved in chronic treatment, I also identify and treat co-occurring medical and psychiatric problems.  

Another  role for the doctor has emerged in addiction treatment.  There has been an explosion in the understanding of the mechanisms that lead to drug and alcohol cravings.  Multiple areas of the brain are involved.  Imbalances in these areas lead to an abnormal "hunger"  for a substance.  These imbalance can be addressed with medications.  These medicines should be combined with counseling to achieve maximal outcomes.

In my website, I have tried to explain how the various drugs of abuse work.  I describe the abnormalities of the brain that predispose to drug use.   I list the various treatments and medications that help as well as review the mechanisms by which they work.  I also discuss side effects.

These treatments do make a difference.  You can be helped.

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