According to Dr. Howard Wetsman, the biggest problem in addiction medicine is the fact that society doesn’t differentiate between substance abuse and addiction, even though they are two very different things. Wetsman explains that substance abuse is a normal brain doing stupid things with drugs and alcohol, while addiction is an ill brain trying to feel normal.
“Those are two very different phenomena, but they don’t look that different to the average person,” says Wetsman. “What the average person sees is ‘that guy drinks too much or that guy uses drugs or that guy has a personality change’ and so they think they’re both together.
“Let’s say a guy is alcoholic and he goes to his doctor. His doctor says, ‘Well I want you to drink less.’ Alcoholics can’t drink less. People with addiction can’t drink reasonably. That’s part of the illness.” He continues, “You may take someone who has a normal brain who’s just abusing the substance and teach them to use rationally, reasonably, safely, moderately. But you can’t teach the illness to do that because the illness isn’t in the teachable part of the brain.”
The part of the brain where addiction takes hold is called the midbrain, and it’s a much more powerful part of the brain than the cortex. Wetsman equates telling someone who has an addiction to cut back to telling someone who is diabetic to will their blood glucose to go down. But Wetsman explains that addiction is a real disease with a real neurobiology that’s quite well-defined.
There is no cure for addiction. It is a chronic – incurable – illness. But there is good treatment, so diagnosis isn’t a death sentence. There is no reason why someone with proper treatment shouldn’t die with the disease rather than of the disease, according to Wetsman.
The biggest problem, he says, is getting patients, their families and their doctors to understand the difference. “It’s not unusual at all to have people who’ve been in treatment for a long time – we teach them all the right words, teach the family all the right words and then there’s a relapse and the family comes back with all the old beliefs. ‘We told him he should not do that’ – as if telling was gonna do that. These beliefs are so ingrained in there so deeply.”
All of Wetsman’s patients are offered genetic testing when they come into the clinic in order to help the doctors pick the right medicine for each individual patient.
“One of the first guys who got the genetic test had done really well on his medicine. His family had done well, too. They came to family night every week – they were very involved in treatment. And he brought his dad with him to go over the results.
“They came into my office, I was going over the results with them, and I was saying ‘you remember how you told me that cocaine doesn’t work, only opiates work?’ And I showed him the genetics and why he responded to opiates and didn’t respond to cocaine and why this medicine worked and that other medicine you tried previously didn’t work. And his dad is just sitting quietly.” He continues, “At the end of the time I said, ‘Do you guys have any questions?’ and his dad said, ‘Well I don’t have any questions, but I gotta tell you that I’ve been coming to family night every week and I’ve been calling this a disease just like you told me to do. And I’ve been saying all the right words, but it wasn’t until this minute that I realized this wasn’t his fault.’
“We never think of diabetes as somebody’s fault or high blood pressure as somebody’s fault,” Wetsman says, “but it’s always, the person with the disease of addiction, it’s his fault because the first reach for the beer or the first reach for the drug looks like a voluntary act. That is the toughest part about addiction medicine – getting people to understand the difference.”