MEDICINE ADDS SLOTS FOR STUDY OF ADDICTIONS.

There is an age-old debate over alcoholism: is the problem in the
sufferer's head -- something that can be overcome through willpower,
spirituality or talk therapy, perhaps -- or is it a physical disease,
one that needs continuing medical treatment in much the same way as,
say, diabetes or epilepsy?

Increasingly, the medical establishment is putting its weight behind
the physical diagnosis. In the latest evidence, 10 medical
institutions have just introduced the first accredited residency
programs in addiction medicine, where doctors who have completed
medical school and a primary residency will be able to spend a year
studying the relationship between addiction and brain chemistry.

"This is a first step toward bringing recognition, respectability and
rigor to addiction medicine," said David Withers, who oversees the
new residency program at the Marworth Alcohol and Chemical Dependency
Treatment Center in Waverly, Pa.

The goal of the residency programs, which started July 1 with 20
students at the various institutions, is to establish addiction
medicine as a standard specialty along the lines of pediatrics,
oncology or dermatology. The residents will treat patients with a
range of addictions -- to alcohol, drugs, prescription medicines,
nicotine and more -- and study the brain chemistry involved, as well
as the role of heredity.

"In the past, the specialty was very much targeted toward
psychiatrists," said Nora D. Volkow, the neuroscientist in charge of
the National Institute on Drug Abuse. "It's a gap in our training
program." She called the lack of substance-abuse education among
general practitioners "a very serious problem."

Institutions offering the one-year residency are St. Luke's-Roosevelt
Hospital in New York, the University of Maryland Medical System, the
University at Buffalo School of Medicine, the University of
Cincinnati College of Medicine, the University of Minnesota Medical
School, the University of Florida College of Medicine, the John A.
Burns School of Medicine at the University of Hawaii, the University
of Wisconsin School of Medicine and Public Health, Marworth and
Boston University Medical Center. Some, like Marworth, have been
offering programs in addiction medicine for years, simply without
accreditation.

The new accreditation comes courtesy of the American Board of
Addiction Medicine, or ABAM, which was founded in 2007 to help
promote the medical treatment of addiction.

The board aims to also get the program accredited by the
Accreditation Council for Graduate Medical Education, a step that
requires, among other things, establishing the program at a minimum
of 20 institutions. The recognition would mean that the addictions
specialty would qualify as a "primary" residency, one that a newly
minted doctor could enter right out of school.

Richard Blondell, the chairman of the training committee at ABAM,
said the group expected to accredit an additional 10 to 15
institutions this year.

The rethinking of addiction as a medical disease rather than a
strictly psychological one began about 15 years ago, when researchers
discovered through high-resonance imaging that drug addiction
resulted in actual physical changes to the brain.

Armed with that understanding, "the management of folks with
addiction becomes very much like the management of other chronic
diseases, such as asthma, hypertension or diabetes," said Dr. Daniel
Alford, who oversees the program at Boston University Medical Center.
"It's hard necessarily to cure people, but you can certainly manage
the problem to the point where they are able to function" through a
combination of pharmaceuticals and therapy.

Central to the understanding of addiction as a physical ailment is
the belief that treatment must be continuing in order to avoid
relapse. Just as no one expects a diabetes patient to be cured after
six weeks of diet and insulin management, Dr. Alford said, it is
unrealistic to expect most drug addicts to be cured after 28 days in
a detoxification facility.

"It's not surprising to us now that when you stop the treatment,
people relapse," Dr. Alford said. "It doesn't mean that the treatment
doesn't work, it just means that you need to continue treatment."
Those physical changes in the brain could also explain why some
smokers will still crave a cigarette 30 years after quitting, Dr. Alford said.

If the idea of addiction as a chronic disease has been slow to take
hold in medical circles, it could be because doctors sometime
struggle to grasp brain function, Dr. Volkow said. "While it is very
simple to understand a disease of the heart -- the heart is very
simple, it's just a muscle -- it's much more complex to understand
the brain," she said.

Increasing interest in addiction medicine is a handful of promising
new pharmaceuticals, most notably buprenorphine (sold under names
like Suboxone), which has proved to ease withdrawal symptoms in
heroin addicts and subsequently block cravings, though it causes side
effects of its own. Other drugs for treating opioid or alcohol
dependence have shown promise as well.

Few addiction medicine specialists advocate a path to recovery that
depends solely on pharmacology, however. "The more we learn about the
treatment of addiction, the more we realize that one size does not
fit all," said Petros Levounis, who is in charge of the residency at
the Addiction Institute of New York at St. Luke's-Roosevelt Hospital.

Equally maligned is the idea that psychiatry or 12-step programs are
adequate for curing a disease with physical roots. Many people who
abuse substances do not have psychiatric problems, Dr. Alford noted,
adding, "I think there's absolutely a role for addiction psychiatrists."

While each institution has developed its own curriculum, the basic
competencies each seeks to impart are the same. Residents will learn
to recognize and diagnose substance abuse, conduct brief
interventions that spell out the treatment options and prescribe the
proper medications. The doctors will also be expected to understand
the legal and practical implications of substance abuse.

Christine Pace, a 31-year-old graduate of Harvard Medical School, is
the first addiction resident at Boston University Medical Center. She
got interested in the subject as a teenager, when she volunteered at
an AIDS organization and overheard heroin addicts complaining about
doctors who could not -- or would not -- help them.

This year, when she became the in-house doctor at a methadone clinic
in Boston, she was dismayed to find that the complaints had not
changed. "I saw physicians over and over again pushing it aside, just
calling a social-work consult to deal with a patient who is
struggling with addiction," Dr. Pace said.

One of her patients is Derek Anderson, 53, who credits Suboxone -- as
well as a general practitioner who six years ago recognized his signs
of addiction -- with helping him kick his 35-year heroin habit.

"I used to go to detoxes and go back and forth and back and forth,"
he said. But the Suboxone "got me to where I don't have the
dependency every day, consuming you, swallowing you like a fish in
water. I'm able to work now, I'm able to take care of my daughter,
I'm able to pay rent -- all the things I couldn't do when I was using."