TREATMENT FOR ADDICTION MEETS BARRIERS IN THE DOCTOR'S OFFICE

While progress has been made in combating alcoholism and drug addiction in
the United States, the medical establishment is still failing in large
numbers to diagnose the disease in their patients, several experts said at
a recent conference.

"Although doctors and nurses have the best opportunity to intervene with
alcoholics and substance abusers, our research indicates they are woefully
inadequate of even diagnosing someone with this disease," said Joseph
Califano Jr., the chairman and president of Columbia University's National
Center on Addiction and Substance Abuse.

At the conference sponsored by the Columbia center this month, policy
makers and addiction specialists evaluated recent research on addiction,
which affects 2 of 10 Americans at some point in life and costs billions of
dollars for health care each year.

Surveys conducted by the center's researchers found that 9 of 10 primary
care doctors fail to diagnose substance abuse in patients who display
classic symptoms of the problem.

The researchers attributed these failures to insufficient training in the
treatment of addiction, doctors' frustration with afflicted patients, the
common perception among doctors that treatment for substance abuse does not
work, and a poor rate of insurance reimbursement for such services.

Public health policy makers at the Center on Addiction and Substance Abuse
have made several recommendations to address these problems including
increasing formal substance abuse training for medical students, residents
and doctors so they can recognize the symptoms and understand the treatment
tools; expanding coverage provided by Medicare, Medicaid, private insurers
and managed care for treatment; and adding legal accountability for primary
care doctors who fail to diagnose substance abuse or addiction and
encourage their patients to seek help.

Dr. Catherine D. DeAngelis, editor in chief of The Journal of the American
Medical Association and a pediatrician, said that "caring for patients with
substance abuse is one of the most difficult things I have ever had to deal
with as a doctor."

Dr. DeAngelis added: "But I am hardly alone. Doctors are trained to figure
out a specific pathology and effective treatments for diseases. But when
the ailment in question carries a substantial behavioral component, like
substance abuse, physicians get frustrated and don't do as well."

Dr. June E. Osborn, president of the Josiah Macy Jr. Foundation, which is
concerned with the education of doctors, agreed.

"Most doctors want to be helpful as well as knowing exactly what they are
doing," Dr. Osborn said. "They are taught primarily about acute medical
care. In clinical situations where they don't know exactly what they are
doing, doctors tend to walk away and adopt an attitude of blaming the
patient. But there is no place for blame in health care."

Doctors have a particularly hard time accepting that there are no easy
cures for the chronic and often relapsing disease of addiction, unlike
surgical problems that can be corrected by an operation or infections that
can be conquered by antibiotics.

"There never will be a magic bullet against addiction," said Dr. Alan
Leshner, the executive director of the American Association for the
Advancement of Science and the former director of the National Institute of
Drug Abuse. "It's not going to happen."

"But we have treatments available that do work," Dr. Leshner added.
"Doctors need to learn how to match the treatment modality to a specific
patient's needs just as they do for chronic diseases like diabetes or
hypertension."

Surprisingly, scant formal training on addiction and substance abuse is
available in American medical schools. Now, most of them offer only a few
hours on these complex subjects and even less is offered during most
residency or postgraduate programs.

Dr. Stanley E. Gitlow, an internist in Manhattan who has treated patients
with substance abuse problems for over 50 years, suggested that doctors
attend meetings of Alcoholics Anonymous or other treatment groups to hear
what alcoholics and addicts go through and how they recover. "Doctors need
to learn the natural history of this disease," Dr. Gitlow said.

"We must listen to patients," he added. "If a doctor does not have the
clinical picture of substance abuse and its treatment in his head, he won't
be able to help."

Teaching medical students to remain current on certain issues and to work
as team members with social workers and psychologists may help provide them
with tools needed to treat diseases like addiction, said Dr. Louis
Sullivan, the president emeritus of Morehouse School of Medicine.

Dr. Osborn agreed that effective teamwork among doctors and other health
professionals would go a long way in solving the problem. "We need to
rebalance the heavy emphasis on facts that soon become obsolete with
universal tools all doctors need. Students and residents are eager for this
type of curriculum."

One approach involves having medical students sit in all-day treatment
sessions with patients and addiction specialists over a week or more at the
Betty Ford Center in Rancho Mirage, Calif., said John T. Schwarzlose, the
president and chief executive of the center.

Still, another major obstacle to effective treatment is the presumption
among many doctors and patients that it is a matter of personal
responsibility rather than a bona fide disease with treatments that can work.

But scientists are steadily unlocking the critical biological secrets of
addiction and the reasons that some people become addicted to specific
substances but others do not.

And there is promising research to develop medications that may help
addicts overcome their habits.

Dr. Steven Hyman, provost of Harvard and former director of the National
Institute of Mental Health, said: "Choice is a complex issue. We know from
scientific studies that the addicted person has constrained volition once
the brain has been rewired by chronic drug use.

"These brain changes give the utmost priority to scoring drugs or getting a
drink under many circumstances. That does not mean that the person has
become a zombie."

One factor that may discourage doctors from learning about substance abuse,
let alone tackling it in their clinics, has to do with reimbursement from
insurers. Medicaid, Medicare and most private insurance or managed-care
companies offer minimal coverage.

Dr. Christopher L. Barley, a physician in private practice in Manhattan,
said the financial aspect was as critical as any other issue in
discouraging doctors from treating addicted patients.

He said: "How can you maintain a practice, see the numbers of patients you
need to see to earn a living, and successfully treat substance abuse
problems? You can't."

When asked how the medical profession should approach the problem, Dr.
Steven Schroeder, a professor of medicine at the University of California
at San Francisco, said that "insurers and the health care system need to be
more responsive to people with substance abuse problems by covering their
treatment just as we cover asthma or hypertension."

"But the second problem to surmount is the mind-set of doctors themselves,"
Dr. Schroeder added. "They need to see substance abuse not as an either-or
issue, but as a chronic illness. Doctors need to feel successful when they
are keeping people with substance abuse problems out of trouble, even if it
is only for a finite period of time."