What do we lose and what do we gain by calling addiction a disease?
Release Date: 06/18/2024
Poems about the wretched illness experience when your doctor is“clinically detached”
On Becoming a Healer
Writing about the illness experience, medical sociologist Richard Frank described an unspoken agreement with his doctor that if he adopted their detached and clinical language when discussing his illness, "I would have at least a junior place on the management team." Initially it seemed like “not a bad deal," until he experienced the toll it took, concluding that, "No one should have to stay cool and professional while being told their body is breaking down, though medical patients always have to do just that." Through three poems selected by our repeat guest, English professor Laura...
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Assisted Dying: An End-of-Life Care Option or a Line Physicians Should Never Cross?
On Becoming a Healer
A growing number of US states and other nations are legalizing either voluntary euthanasia in which a physician (or designate) administers lethal drugs, or physician-assisted dying in which the drugs are given to the patient to self-administer. Our guest, Erica Baccus, tells us about her husband’s determination to end his life rather than die of Alzheimer’s disease, and the journey they took to Switzerland to make it possible (US laws don’t apply to dementia). His wishes were unquestionably honored. At the same time the procedure has implications we find troubling, especially for...
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Why are we addicted to talking about opioids rather than helping people with chronic pain?
On Becoming a Healer
For years, doctors and those learning to practice medicine were told pain is “the fifth vital sign” and to treat it aggressively – including with opioids, "if that’s what it takes.” A consequent rise in opioid prescribing contributed to the devastating opioid crisis. Then the pendulum swung in the opposite direction, hard, with physicians cutting off opioid prescribing to patients, often without their consent. That too led to suffering with many deaths by suicide. What do these two seemingly opposing trends share in common? Both reflect a failure to embrace current knowledge about...
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Despite It All: stories from women who found joy in medicine despite joining a less than welcoming profession
On Becoming a Healer
From the 1940 to the 1970’s, medicine went from an almost exclusively male club to a profession in which women physicians were commonplace. Our physician guest is Dr. Anne Walling, who has written a book about the experiences of 37 women who attended a Midwestern medical school, Women in Medicine: Stories from the Girls in White This was a time when pornographic images appeared in lecture slides, and sexual harassment and discrimination in the job market were ubiquitous. Despite the misogyny, the women interviewed nearly all expressed gratitude that they were able to have...
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The biopsychosocial model: What would it take to really replace the biomedical model?
On Becoming a Healer
Medical educators generally acknowledge the importance of training doctors who care for the whole patient rather than just treat the disease. Most medical school curricula attempt to teach to that philosophy, but how successful are they, really? Our guest, Robert C. Smith, is a physician and author, who trained with Dr. George Engel, founder of the biopsychosocial model. In his new book, Dr. Smith argues that medical education mostly pays “lip service” when it comes to training physicians who are ready and comfortable serving patients who struggle with...
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“Disability is part of the human experience”: So why not treat it that way?
On Becoming a Healer
Soon after Lisa Iezzoni MD was diagnosed with multiple sclerosis during her first year at Harvard Medical School, from which she graduated in 1984, faculty and administrators discouraged her from practicing medicine. And in her final year they made it impossible for her when the dean’s office refused to write a recommendation letter (now called a Medical Student Performance Evaluation). This week marks the 35th anniversary of the American Disabilities Act which was signed into law on July 26th, 1990. Much has changed since but -- as Dr. Iezzoni, who went on to become an...
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The Extraordinary Dr. Richard Clarke Cabot
On Becoming a Healer
It is difficult to overstate the achievements of Richard Clarke Cabot (1868-1939) a relatively little-known, old-moneyed physician of the early 20th century who was far ahead of his time in how much he contributed, and how willing he was to question his own limitations. Cabot's achievements include: creation and self-funding of the first medical social work service and establishment of the fields of clinical pastoral care and medical ethics. His work offered seminal contributions to the fields of hematology, cardiology, infectious disease, and medical education – including the clinical...
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Emboldened Bullies Come for Medical Education
On Becoming a Healer
In an April 23rd executive order (EO), the president of the United States alleges that the Liaison Committee for Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME) are requiring medical schools and residency programs to pursue unlawful discrimination through DEI policies. The EO calls for the US Department of Education to “assess whether to suspend or terminate” them, and to “streamline the process” for recognizing new accreditors to replace them. In addition, medical journals, including the New England Journal of Medicine, are getting...
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Physicians and Authoritarians: Are We Too Obedient?
On Becoming a Healer
The record of physicians standing up for their values as healers under authoritarian regimes is not good, whether it’s Nazi Germany, the former Soviet Union, or Iraq, with behaviors ranging from assisting in torture, to psychiatric hospitalization for political reasons. And sadly, it’s often without any coercion. More subtly, physicians may go along with authoritarian regimes' demands, thinking they can just "stay above the fray." But is that possible? Already, other professional institutions, including academia and law, have struck deals in the hope they they can move on,...
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Caring for Patients or Policing Them? Prescription Drug Monitoring, Doctors and Opioids
On Becoming a Healer
Prescription Drug Monitoring Programs (PDMPs) were originally designed for law enforcement to monitor patients and physicians for criminal behavior before it became available to health care professionals. Physicians and pharmacists often find PDMPs helpful because they can verify what a patient tells them and will often decide not to prescribe or dispense opioids if they discover their patient has been going to multiple providers and pharmacies. But is that health care or policing? Who benefits and who is harmed? Those are questions we consider with our guest, Elizabeth Chiarello, PhD,...
info_outlineThe National Institute on Drug Abuse defines addiction as a “chronic disease” occurring in the brain – Many believe this definition can help to reduce stigma. But, is it helpful in the care of individual patients? In this episode we discuss what we gain and what we lose when we speak of people with addiction as having “diseased brains.”
The view of addiction as a chronic disease has traction, supported first by mid 20th-century alcoholism research, and then by a flood of brain imaging and neurophysiologic studies. Functional MRIs highlight changes in the brain, whether the addiction is to a substance like alcohol or opioids, or to a behavior such as gambling or disordered eating. Many authorities suggest that the “brain disease” designation is not only correct on scientific grounds, but that it also advances a social priority: to blunt stigmatizing concepts of addiction as a weakness or moral failing.
However, many neuroscientists disagree with the brain disease model. Without disputing the brain science, they note that all learned behaviors change the brain, not just addiction. Also, people who reduce or stop use often report they chose to make that change because of new opportunities or intolerable consequences. The brain disease argument invites a second criticism: arguably, it lets unfettered capitalism off the hook – predatory industries spend billions to get people addicted. Calling it a disease of an organ conveniently focuses attention away from a predatory system.
Why does this debate matter for clinicians and patients? Saul interviews co-host, Stefan Kertesz, who is a primary care doctor and a board-certified addiction medicine specialist. Together we consider how addiction is a part of the human condition, which includes how we learn, how we relate to the environment in which we live, and how we are shaped by experiences.
Nearly everyone has habits that are problematic to varying degrees. How we think about addiction can shape our approach to patient care across a wide range of clinical interactions.