"There is urgent need for widespread and early education of the medical profession, legislators, administrative authorities and laity into the facts of addiction disease… As a definite clinical entity of physical disease, addiction is practically untaught in the school and unappreciated by the average medical man… In the light of available clinical information and study and in the light of competent laboratory research we are forced as a profession to admit that we have not treated our addiction sufferers with sympathetic understanding and clinical competency and that the blame for the past failure to control the [narcotic] drug problem rests largely upon the educational inadequacy of our medical profession, and institutions of scientific and public health education." —Ernest S. Bishop, MD, FACP Published in the American Journal of Public Health, July 1919 It has been almost a century since physician Ernest S. Bishop, as excerpted above, urged that the medical community change its approach to treating patients with addiction. In short, he suggests that the profession as a whole can no longer ignore their responsibility to combat the "drug problem," specifically because it had been deemed "a definite clinical entity of physical disease." It is revealing that to this day, addiction still carries the burden of negative stigma, though it is recognized as a disease process that causes pathological change to the brain. The American Society of Addiction Medicine has stated that, "Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships and dysfunctional emotional response." Further, similar to chronic medical disorders, "Addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death." If training programs were to place emphasis on these symptoms, key changes in perception would occur, replacing outdated ignorance or learned prejudice. This would revolutionize addiction education for medical professionals. These changes may be closer than once expected; on March 14, 2016, when the American Board of Medical Specialties recognized Addiction Medicine as a new subspecialty in the field. This opportunity will recruit new individuals into the field, expand the workforce and, most importantly, establish new faculty positions at teaching institutions. The announcement looks at a top down approach towards pushing for change, providing hope those who suffer from the disease of addiction and the loved ones lives whom addiction affects. As Robert J. Sokol, MD, President of the American Board of Addiction Medicine and The Addiction Medicine Foundation, remarked in their press release of this event, "This landmark event, more than any other, recognizes addiction as a preventable and treatable disease, helping to shed the stigma that has long plagued it." Patrick O'Connor, MD, Immediate Past President, further commented, "It will also mean more visibility for this subspecialty among medical students and residents, and will ultimately increase the number of physicians who are trained and certified as addiction medicine specialists." Despite these changes, it is difficult to look past how the medical community still treats patients who suffer from addiction. As a third year medical student, a physician once advised me in regards to a patient, "In all reality, this patient is an addict, and there is nothing we can do about that." Although this is by no means the first and/or most extreme example of physician bias towards the addict, it left a searing impression of the discriminatory treatment endured by those who suffer from addiction. In that moment, the patient was stripped of their identity and was reduced to a label placed on them by the chief practitioner of the medical team. Though I am not oblivious to the persistent misperceptions among physicians that they cant change the habits of addicts and thus are burdened by time spent frivolously to this end, it was especially disheartening to hear in an educational setting. This attitude perpetuates the stagnancy referred to in Bishop's article, written almost one hundred years before a licensed physician stood before me and denied there was "anything we could do about" a patient suffering from addiction. In 2012, CASA Columbia performed the groundbreaking study titled "Addiction Medicine: Closing the Gap Between Science and Practice," the results of which indicated that the disease of addiction affects over 40 million individuals in the U.S. alone. An analysis of this figure reveals that addiction affects more U.S. citizens than heart disease, diabetes, and depression combined. Further, these results yield an even more frightening statistic: only one in ten of these forty million individuals will receive any treatment. Comparatively, over 70% of patients suffering from heart disease, diabetes, and depression receive medical care. The disparity can be viewed as a result of the negative stigma attached to addiction; Whereas addiction is viewed largely as the result of "poor lifestyle choice" rather than altered brain chemistry, these other disease processes are widely accepted by the medical community as somehow more "legitimate." In recent years, the issue has made its way into the political conversation. Several politicians have used their voices to bring attention to the issue and speak out for change. Peter Shumlin, governor of Vermont, spoke against the heroin and opiate epidemic in his State of the State speech in 2014, "The time has come for us to stop quietly averting our eyes from the growing heroin addiction in our front yards while we fear and fight treatment facilities in our backyards." In September of 2015, the White House Office of National Drug Control Policy put on a symposium, co-hosted with The Addiction Medicine Foundation a Symposium, entitled "Medicine Responds to Addiction," which spotlighted the critical need for medical training. In this vein, it aimed to bring together federal agencies; medical leaders from primary care, emergency, preventive medicine, and representatives from medical schools across the country to help build the addiction medicine workforce. To date, there are 37 addiction medicine fellowship programs in the U.S and three in Canada. Organizations such as the Hazelden Betty Ford Foundation have been working at the front lines of this battle, establishing an addiction medicine fellowship training program in California and defending their work in a social climate still recovering from a "War on Drugs" mentality. The foundation serves as a stronghold for science-based treatment, educating thousands of students, residents, physicians and additional health care providers on the disease of addiction. One example of their work is the Summer Institute for Medical Students [SIMS] program that educates medical students through a weeklong full exposure to the disease. Subjects spend their time working alongside patients and their families while they undergo the processes of holistic methods of recovery. Foundation Executive Director of Medical and Professional Education Joseph Skrajewski touts the immersive experience as being "life-changing for participants as they are given the opportunity to see addiction through the viewpoints of those living with it. It is critically important as it's the first real exposure they've had to a disease that affects upwards of 10% of the U.S. population." By providing learning platforms such as this, the Hazelden Betty Ford Foundation has opened the eyes and minds of future and practicing medical professionals. Data from the organization's annual report on the SIMS program, shown below, demonstrates that their strategy is largely successful. The Addiction Medicine Foundation's goal is an addiction medicine fellowship or department of addiction medicine at every medical school in the country by 2025. Fellowship programs train physicians to be expert clinicians, to provide consultation to other providers, to serve as faculty and move the needed content more broadly across medicine. Schools could also build upon the work Hazelden Betty Ford Foundation and others have started and work to expand such efforts. The Liaison Committee on Medical Education could do their part by requiring schools to integrate requirements for the education of students on the topic of addiction. To take a page from those in recovery: Grant us the serenity to accept the things we cannot change, courage to change the things we can, and wisdom to know the difference. We must begin thinking of those who suffer from the disease of addiction as patients with symptoms rather than healthy people making poor decisions. The future of medicine can only benefit from a greater understanding and improved response to addiction. The realization of Dr. Bishop's century old goal cannot be put off any longer. Survey Statement %"True" Before % "True" After I feel comfortable assessing a patient for addiction. 14 88 Addiction is NOT due to a lack of willpower or choice. 91 98 As a physician, I am comfortable talking to addicts about their addiction/behavior. 33 92 I am comfortable talking to family members about problems they have due to a loved one’s addiction. 38 90 I understand that addiction is a brain disease. 56 100 I know the Twelve Steps and how they are used in treatment and for longterm recovery. 18 92 I understand the roles of a sponsor in a patient recovery program. 15 90 Patients who are mandated to go to treatment do as well as those who choose to enter a program. 52 78 I recognize what medications are most likely to “trigger” a relapse for recovering adults. 18 82 I know what community resources are available for patient referral, regarding treatment and Twelve Step programs. 20 95 Mark Biro, MS3 Case Western Reserve University School of Medicine (Class of 2017). Kristina Biro BA English Major Cleveland State University.