Addiction Treatment in the Era of Translational Medicine

Background: A Brief History of Treatment and More Recent Challenges Modern approaches to the treatment of alcoholism in the United States can be traced to the pioneering work of Drs. William Silkworth and Edward Jellinek, as well as the networking which occurred in the context of the so-called "Oxford Groups" so-named by a group of Oxford alumni who had aligned themselves with the philosophy of Frank Buchman. The indirect association of the founders of Alcoholics Anonymous with these groups played a role in the establishment of AA in 1935. (Kurtz 1979) A keystone of AA was the understanding of alcoholism as an illness amenable to interventions free of moral judgment. While medical interventions were limited at that time to detoxification efforts and the support of other alcoholic individuals in recovery, by mid-century a hybrid model of treatment emerged, known as the Minnesota Model. This utilized the disease concept of alcoholism re-introduced popularly by Jellinek, and the twelve-step approach of AA in a standardized, "one size fits all" manner. (Cook 1988) What developed from this approach was a standardized, 28 day inpatient approach to the treatment of alcoholism based on the disease concept, with programmed lectures, active engagement in group therapy, and AA attendance that came to dominate non-opioid addiction treatment paradigms for the next thirty-five years. Economic forces in the mid-1980's, occasioned by upward inflationary pressure in the healthcare arena, the lack of evidence that more expensive inpatient care was any more effective overall than less expensive outpatient care, and the establishment of the managed care industry began to forcefully challenge this model. In addition, with the introduction of the concept of dependence by Edwards and Gross, a gradual shift began, focusing on earlier intervention efforts involving the broad spectrum of alcohol problems rather than solely on more advanced cases of alcohol addiction. (Edwards 1976) An additional shift occurred de-emphasizing treatment setting and emphasizing the intensity of intervention. Specific manually driven and reproducible psychosocial interventions such as cognitive-behavioral therapy, family therapies, motivational enhancement and more specialized group therapy techniques were introduced and added to the development of a very different treatment paradigm. In time patient placement criteria, with the preeminent model being that developed by the American Society of Addiction Medicine, added an important degree of objectivity that contributes to more systematized treatment and treatment outcomes research. (ASAM 1996) While the hard science of the pathophysiology of alcohol and other non-opioid addictions strayed far behind the economic forces shaping change, the same cannot be said for the development of more specific interventions for the care of those addicted to opioids. An abstinence only model for most opioid addicts was associated with a miserably high rate of recidivism outside of intensely monitored programs such as therapeutic communities, and remained so until the introduction of methadone maintenance by Dole, Nyswander, and Kreek in 1964. (Dole 1965) Opioid agonist therapies, when properly applied and administered, have been associated with substantial cessation of rates of illicit use, an improved quality of life for compliant individuals, sharp drops in crime directly and indirectly associated with illicit opioid procurement, and normalization of trait physiologic parameters associated with the actively addicted state. (Kreek 2005) Access to treatment however, has been limited by a number of statutory and social factors, until the introduction of buprenorphine maintenance (offered in the general medical setting by specially trained providers) earlier in this decade judiciously circumventing many of the statutory barriers which previously existed for methadone maintenance programs. (O'Brien 2004) Despite its success, the maintenance strategy has been the focus of at times intense criticism. …