By Peter Martin

Paul Devenyi is hardly an old cynic! Rather Dr. Devenyi has a tremendous amount of clinical experience as an internist dealing with patients who have medical complications of drug use disorders.  He voices opinions which many would endorse and he expresses them well, indeed.  His perspective is clearly guided by the patients he has seen, those who are fairly late in their addiction, when the physical consequences of drug/alcohol abuse begin to overwhelm the clinical presentation.  This may well explain our different perspectives.  All the same friends can differ without acrimony and can both be correct to some extent.

We are not doing as well with type-2 diabetes as Dr. Devenyi suggests, or stated otherwise, the outcomes are not much worse in addiction than in other common medical conditions.¹  Accordingly the health care system is definitely shivering (paraphrasing Devenyi) and some of the principles employed in addiction treatment might actually benefit those with obesity and type-2 diabetes -  if only internist/endocrinologists would recognize that the problem in these type-2 diabetes patients is substantially affected by their behavior (overeating) and the insulin resistance may emerge as a consequence (if you feed a rat excessive amounts of a high fat diet, it will develop insulin resistance, as do humans, probably).²

Second, loss of control typically occurs in the very early stages of addictive disorders,³ not just in the later stages as Dr. Devenyi implies.   Devenyi’s perspective makes sense, because as an internist, he predominantly saw patients at a stage when various end-organs were affected by behaviors that had been ongoing for sometimes a decade or more.  It is the longitudinal study of those with family histories of addiction that has allowed us to state that neuropsychological deficits may precede the development of addictive disorders.⁴  Plenty of research suggests that such subtle abnormalities of brain wiring may be strongly influenced by genetic factors, a series of investigations that has its origins in Begleiter’s seminal findings in boys at risk for alcohol dependence published about three decades ago.⁵

I do not dispute Dr. Devenyi’s notion that "social engineering" represented by “educators, the media, police, judges, social agencies, etc. could have [an] impact on the prevalence and perhaps the outcome of addictions “.  However, I do not believe the medical profession can wash its hands of these self-destructive out-of-control behaviors which are squarely in the realm of psychiatry.  In fact, it is just such issues that now are permeating the rest of medicine, and hence, expertise in management of these behaviors is increasingly of interest to physicians outside of my specialty.

Finally, let me close with mention of that poor alcoholic soul on a desert island without alcohol - let us hope he will have access to a medical school rather than alcohol.  But who is to say he will become a psychiatrist?  In my opinion, he may equally well turn to internal medicine or surgery….

Paul, it is quite enjoyable having this intellectual joust with you, and I sense that you have enjoyed it as well.  Perhaps at this stage, we might have input from other colleagues in our community.

References

(1)                 McLellan AT, Lewis DC, O'Brien CP, Kleber HD. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA 2000; 284 (13):1689-95.

(2)                 Pendergast JS, Branecky KL, Yang W, EllacottKLJ, NiswenderKD, Yamazaki S. High-fat diet acutely affects circadian organization and eating behavior. Eur J Neurosci 2013; 37(8): 1350-6.

(3)                 Koob GF, Le Moal M. Plasticity of reward neurocircuitry and the 'dark side' of drug addiction. Nat  Neurosci 2005; 8(11): 1442-4.

(4)                 Tarter RE, Kirisci L, Mezzich A et al. Neurobehavioral disinhibition in childhood predicts early age at onset of substance use disorder. Am J Psychiatry 2003; 160(6): 1078-85.

(5)                 Begleiter H, Porjesz B, Bihari B, Kissin B. Event-related brain potentials in boys at risk for alcoholism. Science 1984; 225 (4669): 1493-6.

Peter R. Martin
October, 31, 2013.