SAN FRANCISCOMEDICINE - California Society of Addiction ...

Addiction and Recovery
San Francisco Roots
The Evolution of Addiction Medicine
David E. Smith, MD, FASAM, FAACT
On May 2, 2009, the American
Board of Addiction Medicine
(ABAM) and Nora Volkow, MD,
director of the National Institute of Drug
Abuse, conferred board certification on
nearly 1,500 physicians (myself included)
representing a wide range of specialties.
In her address at this ceremony,
held during the annual meeting of the
American Society of Addiction Medicine
(ASAM), Dr. Volkow stated that “years
of scientific research have proven drug
addiction is a brain disease caused by
biological, environmental, and development
factors—a disease that can have
far-reaching medical consequences. . . .
Identifying drug use early, preventing its
escalation to abuse and addiction, and
referring patients in need of treatment
are important medical skills” (Kunz and
Gentilello 2009). With the passage of
health care reform and parity in March
2010, addiction medicine has become a
mainstream core benefit.
Forty and more years ago, this would
have been barely imaginable. Addictions
were stigmatized as moral failings and/
or criminal activity. In reality, substance
abuse in all its forms, including nicotine/
cigarette addiction, alcoholism, and
psychoactive dependence, represents
our country’s number-one public health
problem.
Complementing this is the rise in
prescription opioid abuse, particularly
in adolescents, where prescription drug
overdose deaths in 2008 exceeded all the
overdose deaths for heroin, methamphetamine,
and cocaine combined. Substance
abuse is now the leading cause of death
in young people, exceeding even traffic
fatalities (Knudsen 2009).
Alcoholism as a disease was clearly
described as long ago as the late 1700s
by Dr. Benjamin Rush, a physician and
signer of the Declaration of Independence
(Katcher 1993). However, it wasn’t until
the formation of Alcoholics Anonymous
(AA) in the 1930s by Bill Wilson and Dr.
Bob Smith (no relation) that this concept
of alcoholism as disease spread throughout
the United States and subsequently
the world. Dr. William Duncan Silkworth,
in the Big Book of AA, described alcoholism
as a disease caused by “an allergic reaction
of the body to alcohol” and a compulsion
of the mind (Silkworth, 1937).
Addiction to other drugs, however,
was specifically excluded from the scope
of AA. AA emphasized that drug use other
than alcohol was not to be disclosed at AA
meetings. This prompted the formation
of Narcotics Anonymous in California
in the 1950s, which was based on similar
twelve-step principles but included
recovery from all drugs of addiction,
particularly opiates such as heroin, using
the catchphrase “clean and sober.”
Initiatives put forth by physicians
in the New York Society of Alcoholism,
a forerunner of ASAM, prompted the
American Medical Association (AMA) to
declare in the 1950s that alcoholism was
a disease and to reaffirm this position in
1966.
In the late 1960s, the movement to
recognize addiction as a disease escalated
in California, particularly in San Francisco.
Based on the principle that “health care
is a right, not a privilege,” the Haight
Ashbury Free Medical Clinic (HAFMC)
was founded in response to the large
number of drug-using youth who flocked
to San Francisco’s Haight Ashbury district
in 1967 for the “Summer of Love.” The
Clinic’s experience with this population
led to the philosophy that “addiction is
a disease—the addict has a right to be
treated” and prompted the almost immediate
expansion of clinic services to drug
crisis intervention and detoxification. The
San Francisco Medical Society and the
California Medical Society provided early
support for these endeavors, despite the
City’s refusal to address a major public
health catastrophe (Heilig 2009).
Dr. David Breithaupt of the University
of California, San Francisco, Ambulatory
and Community Medicine program,
trained medical students at HAFMC. At
a recent CSAM-sponsored event in the
Haight, Dr. Breithaupt described battling
a system that at the time viewed community
physicians who treated addiction
disease as “outlaws caring for sinners and
criminals” rather than “physicians treating
a chronic disease.”
It was then illegal to detoxify addicts
on an outpatient basis. Nonetheless, when
Dr. Donald Wesson and I determined that
a phenobarbital withdrawal protocol we
had developed at San Francisco General
Hospital could be used to detox addicts,
we instituted its use at HAFMC’s outpatient
Drug Detoxification, Rehabilitation,
and Aftercare program, combining
medical intervention with psychological
counseling and recovery groups. After the
Detox program received a substantial federal
grant initiated in 1971 by Dr. George
“Skip” Gay of HAFMC—a grant that came
from the White House Office of Drug
Abuse Policy (SAODAP, predecessor of
the ONDCP), then headed by methadone
maintenance pioneer Dr. Jerry Jaffe—the
concept of addiction as a disease was
14 15 San Francisco Medicine April June 2010 www.sfms.org