When it comes to addiction treatment, doctors have a superpower. Even if you’re not board certified in addiction (most of us are not), you possess knowledge and skills uniquely suited to caring for patients with addiction. Many professions purport to treat patients with substance use disorder, but the physician’s toolkit makes us uniquely effective at treating people with addiction. I can teach you how to unlock this hidden power if you’re interested.
Substance use disorder is a complex chronic disease. It is best understood to consist of three domains of dysfunction: biological, psychological, and social. The biological domain includes physiological dependence, withdrawal, medical complications of drug use, and underlying chronic diseases. The psychological refers to the disordered thoughts and emotions that drive addictive behavior. The social domain is the broadest and includes factors ranging from individual relationships, family dynamics, social support, peer groups, employment, community engagement, politics, and social policy.
This conception of addiction as a tripartite disease is known as the “biopsychosocial model.” It informs treatment and provides a framework for measuring outcomes in recovery.
The biological domain
By virtue of our training, physicians are the best-suited professionals to treat the complicated physiological dysfunction secondary to drug dependence, withdrawal, and any medical complications of substance use. For this reason, patients with substance use disorder already seek your services, even if you aren’t advertising addiction treatment services.
We are also blessed to live in an era with many effective medications for the treatment of drug and alcohol addiction, such as buprenorphine for opioid use disorder (which can now be prescribed by any physician with a DEA number) or naltrexone and acamprosate for alcohol use disorder. These tools are not a cure for substance use disorder, but they increase the odds of long-term success and are an excellent method to engage patients in treatment.
You may need a refresher in medications for opioid use disorder, medications for alcohol use disorder, or outpatient alcohol detoxification. In that case, I’d recommend the MICARES program, which has an excellent series of educational resources containing the latest science about addiction and its treatment (they are intended for individuals preparing to take the ABAM boards but are free of cost to all). ASAM also offers clinical best practices and guidelines on its website. These guidelines are a fantastic and free resource to improve your clinical skills when treating substance use disorder and dependence. (For instance, did you know that carbamazepine is a scientifically sound treatment for mild alcohol withdrawal?)
It’s best to view substance use disorder as a chronic, relapsing disease that requires ongoing maintenance therapy. This conception of addiction frames it similarly to diabetes or hypertension. Like type II diabetes, patients need medical treatment, but treatment adherence highly depends on psychological and social factors.
As physicians, we are already familiar with the skills necessary to assess and intervene when patients with chronic diseases do not adhere to their prescribed course of treatment. Is it simply a knowledge gap, and the patient needs education on how to inject insulin? Perhaps they are worried about the implications of using insulin and need encouragement or motivational interviewing. Maybe they can’t afford the insulin, and we can sign them up for an assistance program.
In this light, you are already practicing according to the biopsychosocial model that I described at the beginning of the article! If you can manage an uncontrolled type II diabetic, you can apply these skills to treat substance use disorder patients. These skills are what the “psychological” and “social” domains of treatment consist of.
The psychological domain
I’m not going to lie to you. Addiction treatment also requires deeper psychological and social needs beyond medication adherence. However, the non-specialist can either learn these skills or partner with a subject matter expert (i.e., psychologist or therapist) to address these needs, similar to how you might already either counsel diabetics on a diet or refer them to a dietitian.
Regardless of the particular substance, patients with substance use disorder benefit from therapy to address the underlying thoughts and emotions that drive their disorder behaviors. In my experience, this is the most significant perceived barrier to providing care for substance use disorder.
Cognitive-behavioral therapy (CBT) and narrative therapy are the two schools of psychological therapy most commonly used in addiction treatment. Thankfully, both are widely taught, making finding a therapist easier. If you are ambitious, you can take self-directed courses in CBT from Beck Institute (as in Dr. Aaron Beck, the inventor of CBT); the skills taught by CBT are applicable in many different clinical scenarios and everyday life.
Even if you cannot provide formal CBT therapy to your patients with substance use disorder, your therapeutic presence helps. All that’s necessary is to demonstrate your concern for the patient and listen attentively to their concerns. “Therapeutic listening” is more powerful than we give it credit for.
The social domain
At this point, you might be asking, “I understand how physicians can treat the biological and psychological domains of substance use disorder, but how the heck do I address the social dynamics of substance use disorder?” Fair question.
You can do little regarding a patient’s finances, living situation, or family dynamic. Those factors are out of your hands. However, you can counsel the patient to delete their dealer’s phone number, stay with their parents during the initial period of outpatient treatment, and join a support group (in person or online) to gain some new sober friends.
Once again, your therapeutic presence is the most impactful tool to provide social support to patients with addiction. Regular visits to your clinic give structure to an otherwise disordered life and inspire accountability, which is essential to recovery. In this context, accountability doesn’t mean punishment for failure; instead, it refers to the dedication to pursue treatment.
You can also foster social support by letting your patient know you are a safe person with whom they can confide. At the first visit, I make a point to tell each person that relapses are not a sign of failure but rather a part of the recovery process. Patients should be encouraged to report relapse to drug or alcohol use as soon as possible, so we can address it before it becomes a more significant problem.
Implementing addiction treatment
It sounds like a lot, but you’ll quickly find that addiction treatment is not dissimilar to the treatment of any other chronic disease. Moreover, patients with substance use disorder are like any other patients; in fact, they are likely already among your patients! Providing treatment for addiction in your medical clinic helps normalize that treatment and is a great boon to patients who would otherwise need to navigate the highly commercialized and predatory “addiction treatment” industry.
If you’ve read to this point, you’re likely interested in providing addiction treatment to your patients, but you may be hesitant due to the laws surrounding medical care for addiction. Perhaps you’ve heard you need a special state license to provide addiction treatment services.
If that’s the case and you’re worried about legal liability, you can rest easy. So long as you’re not dispensing methadone, providing inpatient treatment (at a facility other than a hospital), or treating patients held involuntarily or court-ordered to drug treatment, you typically do not need a special license. Most state laws give physicians wide latitude to care for their patients’ needs, including those with substance use disorder.
The same goes for malpractice carriers. If your policy covers patient care, it covers substance use disorder treatment because addiction treatment is medical treatment. This fact is valid if you follow best practices and clinical guidelines. If you intend to treat patients with “alternative therapies” such as ketamine, transcranial magnetic stimulation, or another novel approach, you should check with your carrier first.
If you intend to advertise addiction treatment services specifically, it is best to check with a lawyer first, as your state’s law may have specific requirements you need to follow, or this may require a license. If you wish to advertise addiction treatment on Meta (Facebook and Instagram) or Google (the search engine and YouTube), you will need third-party certification from a company called LegitScripts; they are an auditor that verifies businesses are qualified to provide certain services, addiction treatment among them. That said, most readers only intend to treat their existing patients rather than seeking out patients with substance use disorder and can ignore this advice.
One final point on legal matters, just in case you missed it: any physician with a DEA license can prescribe buprenorphine products for the treatment of opioid use disorder! You no longer need a special waiver or training. However, note that the buprenorphine product must be FDA-approved for treating opioid use disorder, meaning that Belbuca (low dose sublingual) and Butrans (transdermal patch) cannot be prescribed for OUD. Methadone for opioid use disorder remains restricted to specially licensed clinics.
Unlocking your superpower
Regardless of your specialty, you will encounter patients with substance use disorder. I hope I have convinced you that SUD is a chronic disease that is amenable to treatment like any other chronic condition. You can successfully treat patients with addiction in the comfort of your clinic rather than referring them to the quasi-medical addiction treatment industry. All it takes is a change of mindset–discovering your innate superpower to address and intervene on all three axes (biological, psychological, and social) that underpin addiction.
If you’re interested in learning more or need a confidence boost, seek the mentorship of a local addiction specialist or advocate who can advise you on the nuances of treatment and offer second opinions on clinical decisions. If you don’t know any local physicians who fit this bill, don’t hesitate to contact me with your questions. (I don’t even charge. As old Hippocrates said: “I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine …”)
Jack McGeachy is an emergency physician and addiction medicine specialist.
