So what does an addiction doctor do?

Addiction medicine is probably one of the most fascinating and diverse fields in all of medicine, and it encompasses so much that sometimes it’s hard to explain to people exactly what it is we do! We are an unusual specialty because people don’t always think of us the way they might think of a cardiologist or a surgeon. And yet, every year about 100,000 Americans die from acute drug overdoses, mostly from opioids. About 500,000 Americans die annually from smoking-related diseases. About 180,000 die annually from alcohol-related diseases. A huge number of these people never receive high-quality, evidence-based treatment for their underlying addictions even as we spend zillions of dollars on the end results - and that’s a huge failing of our medical system that I hope to help fix in my own tiny corner of the world.

Addiction is a disease as old as humanity itself. When exposed to addictive substances or behaviors, the human brain’s reward pathways have always had a tendency to go “haywire”. For example, it doesn’t matter if you’re a Chinese person in the midst of the opium wars 170 years ago or an Ohioan in the midst of the OxyContin blitz of the 2000’s — when exposed to these types of stimuli, our brains stop responding to normal rewarding things like food, sex, family, and love, and we fall into that spiral known as addiction.

Addiction doctors work across a huge variety of settings, ranging from residential rehabs, prisons, hospital wards, outpatient clinics, literally on the streets, and everywhere in between. One common misconception is that we’re all psychiatrists. We come from all types of “primary specialties” to arrive at the subspecialty of addiction medicine, including (but not limited to) psychiatry, family medicine, internal medicine, and emergency medicine. Addiction physicians are privileged to form truly deep bonds with our patients, in a way that’s really uncommon in our impersonal modern medical system. We guide our patients through every step of recovery, from detox to thriving long term recovery. We are in our patient’s corner, judgement-free, through thick and thin. We walk with our patients through the valley of the shadow and together we emerge into the light. That’s what we do.

For some people, we only need to do counseling and close follow-up. For others, we might need to support them through a complex hospital-based detox followed by medication therapy, treatment of associated mental health issues, and we might also help with socioeconomic needs like writing letters to help with housing or DCF. In really intense cases, we might even be working on panels to decide interventions like heart valve replacements and liver transplants. Since addiction and chronic pain are often closely intertwined, and since patients who suffer from addiction often find it impossible to convince doctors to treat their pain, addiction medicine physicians also often get involved with pain management to some degree. In addition to all of this, many of us in the field also feel compelled to fight for policy changes and culture change on a larger scale. For example, addiction medicine physicians (including myself) go to Washington to advocate for our patients, and also engage in advocacy and policy decisions locally.

Addiction treatment isn’t just about taking a pill or going to group. It’s about rebuilding joy and community. It’s about learning to appreciate beauty again, feeling the warmth of the sun again. So while we have really effective and exciting medical therapies, humanism is a core part of our work. Recovery is certainly not one-size-fits-all. One person’s recovery might focus on medication and other Western medicine interventions, while someone else’s recovery might involve… reconnecting with a love for fishing or art. For most people, the path to recovery encompasses a whole range of strategies.

Unfortunately, today very few people are able to access full spectrum addiction care. A lot of the care out there is done piecemeal, and a lot of people don’t even know help is out there. For example, if someone goes to the hospital for a heart problem triggered by heavy drinking, that person will almost certainly see a cardiologist and might even be advised to cut back on alcohol - but will almost never be referred to an addiction specialist, and would be even less likely to receive any number of highly effective, FDA-approved medications for alcohol addiction. As another example, it’s all too common that individuals who present to the hospital for an opioid overdose are simply revived with Narcan and sent back out the door, without being offered buprenorphine (Suboxone), methadone, or other life-saving medications. In one recent study, only 23% of patients who came to the emergency room with an opioid overdose were even given Narcan to take home at discharge! And not only are treatment rates woefully low, but they are woefully inequitable. For example, males and Black individuals are much less likely to be offered treatment for opioid addiction, and subsequently die at much higher rates of opioid overdoses compared to other demographic groups.

Addiction medicine physicians treat a huge spectrum of disorders. Alcohol and opioids probably would come to mind for most people, but we actually help people with everything from nicotine to marijuana to benzodiazepines all the way to issues like gaming and gambling. The research on social media is still in its infancy, but social media companies are very, very well aware of how to harness and short-circuit the human brain’s dopamine reward system to create addictive behaviors. There are already people in this field who are specializing in the treatment of digital-based addictions, and as more research comes out, I wouldn’t be surprised if this becomes a bigger part of the field as a whole.

Basically, addiction medicine is a really high-stakes mixture of internal medicine, neurology, psychiatry, old-fashioned doctoring, holistic medicine, and public health.

My mission, and the mission of everyone in this field, is to help people recover - whatever their definition of recovery might be - and to live the lives they deserve. If you’ve read this far, thanks and let me know if I can somehow help.