Addiction in Medicine

Addiction In Medicine

Robert L. DuPont, M.D.

My longstanding admiration for the ACCA has been heightened by spending the last two days with this unique group of leaders of American medicine. Your organization is distinguished not only in research and teaching but also in the quality of character of its members. This is a group of physicians it is fun to be with.

Wesley W. Spink, M.D., my father-in law and long-time Professor of Medicine at the University of Minnesota, made this meeting the highpoint of his year for three decades. These annual gatherings were an important source of renewal and self-affirmation. My appreciation of the ACCA has been further enhanced by the membership of my brother Herbert L. DuPont, M.D. your current president, and a protégé of Dr. Spink.

Tonight I take off from Abraham Verghese’s marvelous book The Tennis Partner, a breathtakingly honest story of medical education, friendship and finally of death from drug addiction.^1,2 This morning while waiting for the gym to open I had the chance to talk with the ACCA President-Elect, Frank Abboud. He told me about two of his experiences with addiction in his faculty. The first was a senior professor who retired with dementia related to his alcohol use that was made more tragic by his continued drinking and his family’s covering it up. The second story was of a younger faculty member whom Frank found slumped over his desk dead with a needle in his arm. These are examples of how many physicians experience addiction, not only in their practices but in their personal lives, as an incomprehensible and cruel disease from which many sufferers never recover.

Addiction hooked me following completion of my training at Harvard Medical School and the National Institutes of Health in 1968, when, inspired by my heroes John F. Kennedy and Martin Luther King, Jr., I chose prison. I joined the District of Columbia Department of Corrections with the goal of using my medical skills to help solve a significant social problem, crime. Basic epidemiological work led to the recognition that the heroin epidemic that began in the mid 1960s was driving the crime rate in Washington as it was elsewhere around the country. Focusing on the public health response using heroin addiction treatment, under the energetic leadership of the mayor, Walter Washington, between 1970 and 1973 the city-wide program that I founded and directed, the Narcotics Treatment Administration (NTA), treated 15,000 heroin addicts. Our pioneering efforts helped to cut the crime rate in the nation’s capital by 50% over that short time. These results were widely published, including in the New England Journal of Medicine and Science.^3,4

As a reward, or punishment depending on your point of view, I was nominated by the President and confirmed unanimously by the Senate to become the second White House Drug Czar in 1973 at the age of 37. That same year I became the first Director of the National Institute on Drug Abuse (NIDA) a post I held under three Presidents, Nixon, Ford and Carter. Leaving the government in 1978 after 12 happy years, my wife and I founded the non-profit Institute for Behavior and Health, Inc. to further our efforts to reduce illegal drug use in the country. In this role we worked without the benefit of the bully pulpit of the federal government but with a freedom that the government cannot permit. Since 1971 I have known -- and respected -- all 11 White House Drug Czars and all 5 directors of NIDA, a period of time which encompasses the terms of 7 presidents. I am proud that some observers of my career have called me the Forrest Gump of drug abuse because I have been involved in just about every major development in this new and by now quite large medical field. I have traveled the world learning about addiction from laboratories to international organizations and from clinics to morgues. Beyond these public roles I have maintained a private practice seeing my own patients for four decades, sometimes seeing three generations in single families. Since 1980 I have been Clinical Professor of Psychiatry at Georgetown Medical School, a post that has permitted me to be actively involved in medical education. With that as background let me now turn to my study of addiction.

Addiction is unique in the way it corrodes the character and the relationships of the sufferer. The addict not only has the disease but over time the addict becomes the disease. Addiction often remains hidden, even from those it is killing. This stealthy disease has been called by people who live close to it “cunning, baffling and powerful."⁵ It is that.

Tonight I hope to provide what the radio newsman from another era, Paul Harvey, called “the rest of the story” about addiction. I will focus not only on what distinguishes this disease from other common diseases but I will also focus on the miracle of recovery, the side of addiction that too few physicians see. It is this side that animates my career and that is the inspiration for my talk tonight.⁶

Addiction is not the problem of withdrawal. Most of us learned in medical school that the hallmark of addiction is that when the addict stops drug use he experiences withdrawal, the horrible tortures of the body suddenly deprived of the drug on which it depends. In this view the drugs that produce withdrawal symptoms are the prototypes of addictive drugs – heroin is the model. Seen this way, the treatment of addiction is detoxification, as if the addict freed from the hook of drug dependence would be freed from the disease.

Because marijuana and cocaine did not produce dramatic withdrawal symptoms when their use was stopped they were widely seen as non-addicting. This conceptualization of addiction set the stage for these two drugs to become the “gateway” illegal drugs because their use was widely seen as benign.⁷ How many alcoholics stopped drinking and, because they did not experience withdrawal symptoms, were falsely reassured that they were not addicted to alcohol? How many lives have been ruined by addiction to marijuana and cocaine over the past century because this of mistaken view of addiction? How many patients taking opiates for pain or benzodiazepines for anxiety have been labeled as “addicted” by themselves and their physicians when nothing could be further from the truth.^8,9,10

What is wrong with this picture of addiction that has held sway for nearly a century? Begin your re-education about addiction by noticing that all addicts have been off drugs many, many times, sometimes voluntarily, often involuntarily. These periods of abstinence have never helped them. Detoxification is not a treatment for addiction. Stopping the use of an addicting drug is easy; addicts have done it many times. What is hard, and what many observers concluded is impossible, is for the addict is to stay abstinent.¹¹

If withdrawal is not the essential feature of addiction, what is? There are two features that distinguish addiction: continued drug use despite serious problems resulting from that use, and dishonesty. Addiction is that simple. To understand how addiction works it is necessary to understand the crown jewel of the modern study of the brain biology of addiction. This study has focused not on withdrawal but on brain reward, mediated by specific neurotransmitters, most importantly dopamine.¹² What makes a drug addictive is not that it is “psychoactive” but that it produces specific brain reward. It is not withdrawal that hooks the addict, it is reward. The addicted brain does not forget intense, repeated reward even after years of not using drugs.

Brain reward can be identified in one of two ways: animals in the laboratory can be given a drug in a setting in which they have to work to get it. It is not difficult to measure how much work the animal will do to get a dose of a drug by a particular route of administration. The more the animal works to get it the more addictive the drug. There is an even more direct way to quantify the addictive nature of specific drugs: give them to chronic drug addicts, the connoisseurs of brain reward. In a double-blind setting, ask them how much they would pay for the experience. This approach permits precise scaling of any drug’s addiction potential.

It is hardly surprising that many “psychoactive” drugs produce no brain reward: laboratory animals will not work to get them and drug addicts will not pay for them. Fluoxitine (Prozac) and Lithium are good examples of a brain affecting drug with no abuse potential. For this reason they are not “Controlled Substances” under law, the category reserved for medicines that produce brain reward and that are therefore subject to abuse by alcoholics and drug addicts. There is no black market in Fluoxetine or Lithium, in fact the challenge in prescribing these psychoactive drugs is to get patients to take them.

Drugs of abuse have hijacked the brain’s natural reward system. What is the biological role of this brain function? The closest analogy is contained in two of the most fundamental behaviors: sexual behavior and eating behavior. Those are natural stimuli for the brain reward mechanism. That is why any behavior that produces pleasure has been linked to addiction. Think of sexual addictions, eating disorders but also think of gambling addiction, workaholism and even, as I have found in the ACCA an often malignant “BlackBerry addiction. Some people are more vulnerable to these addictions than others. However to the extent that behaviors produce pleasure (often mixed with pain of course) they have the potential for addiction.

Having broadened the focus of addiction to many pleasure-producing behaviors let me put addiction to drugs into biological perspective. The behaviors that produce the most intense reward, that get laboratory rats to work the hardest and the longest for reward, are the drugs of abuse. Laboratory rats hate electric shocks and will not venture out onto an electrified grid to get food or sex. In fact they will starve to death before they will go onto that grid to get food. But when it comes to drugs of abuse, once the rats have repeatedly experienced the brain reward of drugs like cocaine, they walk across that grid as if it were not there. Think about those rats the next time you see an addict behaving in incomprehensible ways.¹³

That is only the start of the story of the biology of addiction. The midbrain where the brain reward centers are located exerts powerful control over the higher brain functions. Part of the hijacking process is the way these primitive brain centers take over the thinking of addicted humans. Addicts typically cannot explain to themselves – or anyone else, including their physicians – why they use drugs, or more specifically why they use drugs despite the problems their drug use has caused them. In fact, addict’s efforts to put into words their reasons for using drugs often appear to be not only pathetic but laughable. They are neither. Instead these are rationalizations that the “selfish” or “hijacked” brain invents to explain what is unexplainable – the primitive drive addicts experience to use drugs despite the devastating consequences that drug use entails.

Remember those two central features of addiction: continued use despite serious problems and dishonesty. The biologically driven pull of the drug explains the repeated use but what explains the dishonesty? Why is lying an essential element of addiction? Rats don’t lie, only human addicts lie. Lying is the inevitable reaction of drug addicts to the fact that the people who care about them want them to stop their use of addicting substances. Addicts have no choice but to lie since they want to use the drugs and to hold onto important relationships, whether that be parents, spouses or children, and whether it be judges, employers or physicians.¹⁴

An analogy helps to explain the power of drug addiction: addicted people are in the grip of abusive chemical lovers. Like people in abusive love affairs after suffering terrible pain at the hands of their lovers, addicts are nonetheless sure that they can go back to those lovers. They believe that the next time their love affairs will have different outcomes. The job of those around addicted people, including the addicts’ physicians, is to help them realize that, contrary to their hopes, the outcome of their next drug use will not be different.

One of the hardest lessons for most physicians to learn about addiction is that for an addict simply cutting down is futile. Cutting down the use of drugs is a seductively attractive but doomed strategy for addicts precisely because addiction is defined by continued use despite the serious consequences. If addicts could cut down, and stay at a low level of use, this solution would already have been achieved. Many people who are not addicted to drugs can, and do cut down on their drug use once they have problems as a result of that use. For them cutting down is reasonable advice, although staying at low levels of use often is more problematic than it at first appears. Addicts trying to solve their drug problems by cutting down are as doomed as are people in abusive love affairs hoping to eliminate their suffering by cutting down on their visits to their abusive lovers.

Once it is clear that a person has tried to cut down or stop drug use but has failed to achieve that goal, then it is time for the addicted person and those who care for that person – including especially his or her physicians – to recognize that cutting down is the road back to chaos and suffering and not the road to getting well. Once addiction has been established, zero is the only stable number for further drug use.

I began by describing three stories of physicians suffering from addiction: Abraham Verghese’s tennis partner and Frank Abboud’s two faculty colleagues. All three of those stories of addiction in physicians ended in death. Here are three stories of distinguished physician patients of mine each of whom came to see me for the first time about 8 to 10 years ago. The first, I will call Tom, was a nephrologist who came about opiate analgesics which he started using for the pain associated with his extreme workouts as an Iron Man triathelete. The second, Bill, was an academic research professor whose specialty was cardiology. Bill’s problem was alcohol. The third physician, Jim, was a pain specialist whose problem was opiates.

Before we start these stories let me briefly introduce you to the 12-step fellowships which play a central role in the addiction story. They are not treatment; instead they are “fellowships” of people who have banded together to deal with the problem of addiction to alcohol and other drugs. The 12 step fellowships are less about getting clean and sober than they are about staying clean and sober. Founded by Bill Wilson and Robert Smith, M.D. on June 11, 1935 (the day that Dr. Bob had his last beer on his way to perform surgery) this program is built on the observation of Bill Wilson that the only way he could stay sober was to help other alcoholics stay sober. Meetings are free and ubiquitous. I only half jokingly say that no one in America is more than two hours and two blocks away from a 12-step meeting. Alcoholics Anonymous (AA) is how it started but to deal with other drugs Narcotics Anonymous (NA) was created. For families and others affected by someone else’s addiction there is Al Anon.¹⁵

Let’s start with Bill who was referred to me by another psychiatrist who did not want to deal with an alcohol problem. On the first visit after taking Bill’s drinking history I asked if he would be offend if I diagnosed him as an “alcoholic.” He said, “No, that is the problem that got me to see you.” I asked him if he knew what the treatment was for this diagnosis. He said he did not. I suggested as an initial step he go to 90 meetings of Alcoholics Anonymous over the course of the next 90 days. He had never been to an AA meeting and needed some advice about how to find meetings and what to expect there. Once he had that information Bill jumped into this 12-step fellowship like a newly hatched duck takes to water. Bill has not had a drink since our first meeting. He goes to 5 or more AA meetings a week and has become a leader in the AA community. Sounds easy? Sometimes it is.

Now let me tell you about Tom, the triathelete with an opiate problem. He had a history of opiate use for weeks at a time sometimes with minor withdrawal when he stopped but he had had no prior addiction treatment and his practice and his life outside of medicine were flourishing. I did not refer Tom to treatment and he did not like Narcotics Anonymous although he dutifully went to a few meetings at my urging. Over several years of infrequent visits to me Tom had several slips to using opiates. Each time his use was discovered by his vigilant wife, who called me to report this disturbing information. Each time Tom quit drug use without treatment assuring me and his wife that his drug use was behind him. I ordered half a dozen drug tests – all of the results were negative. Tom’s visits to me dwindled until I lost track of him until he called me with an update: “My wife caught me again. This time she said that if I used again I was out of the house and our marriage was over. To seal the deal she called the state medical board to report me as an opiate addict. I have been under the care of my Physicians’ Health Program for the past 6 months. I spent 3 months in residential treatment. I go to 7 to 10 NA and AA meetings a week. My life, my practice and my athletic career have never been better. By the way, Dr. DuPont, thanks for all your help.” What help you may wonder was Tom referring to – because that is what I wondered. I was no help to Tom. In fact for several years seeing me was a cover for his continued opiate use – a role that physicians, even experienced physicians, often unwittingly play in addict’s lives.

To round out this trio of addicted physicians we come to Jim, the pain specialist with an opiate problem. Jim had a problem with depression that complicated his care. He had a novel source of opiates. Many of his patients were terminally ill. Frequently when they died their families brought in their drugs to Jim for disposal. He did that! Over several years Jim got a lot of the finest addiction treatment medicine has to offer not only from me but from the nation’s best residential treatment programs designed for physicians. One of them was the excellent program attended by Abraham Verghese’s resident physician. Jim not only relapsed after each treatment but he lost his wife and 4 children. He lost his medical license. Heedlessly pursuing his addiction career Jim became penniless and homeless despite my best efforts to help him over four years of frequent therapy – much of it aimed at keeping him from killing himself, a real concern of both his and mine. When Jim no longer came to see me and had no phone and no address I kept track of him by talking with his 75 year old mother. For a couple of years the news about Jim was not only bad but it got worse month after month. He was arrested and imprisoned for forging prescriptions after he has lost his license. Before his money ran out he went to Amsterdam to indulge his heroin habit. He told me later that that was the scariest place he ever was, far worse than the streets of the District of Columbia, which he had come to know only too well.

Then the news changed. Jim’s mother told me that he had turned himself into a nearby VA hospital as a homeless IV heroin addict. When his inpatient stay was up Jim stayed at the VA hospital as a gardener living on the hospital grounds for nearly a year. Jim got into the state Physicians Health Program. After three years of tightly monitored abstinence, and regular visits to me, he regained his license. Jim is practicing medicine again and going to 10 NA and AA meetings a week. Like Tom, Jim continues to be randomly tested for drug and alcohol use by his state PHP.

The score? Three out of three. These were three different clinical courses but – up to now – all have happy endings. Bill defines the “high bottom addict” with only the gentlest hint of a problem prompting him to grab the lifeline of AA like a drowning man. Jim on the other hand defines the “low bottom” addict for whom loss of his medical career, loss of his family and being homeless were not enough to get him to take advantage of the best treatment medicine has to offer. The two physicians with the lower bottoms succeeded under the care of their Physicians Health Programs. All three found lasting help in the 12-step programs.

Central to my professional experience with these three wonderful doctors were persistence, patience and confidence that success was not only possible but likely. I never gave up on any of them and, thankfully, none of them gave up on themselves. All three lives and medical careers were saved. But that is only the beginning of this story. Each of these men is now living a life that is enhanced by recovery from addiction. They each have achieved not only long-term abstinence from any use of alcohol or other drugs of abuse but they have gotten solidly into “recovery,” that post addiction state of being that is an inspiration to everyone around them, including their grateful psychiatric physician.¹⁶

Here is another story about the miracle of recovery from a physician patient of mine. A 55 year old psychiatrist, whom I have treated over the course of a decade for Obsessive Compulsive Disorder, confronted the worst crisis of her life. After a long marriage, which was stormy at times but which grew to become the secure foundation of her life – especially after her three children left home – her husband died within 6 months of the diagnosis of colon cancer. Bereft, this physician reached out for support not from me, her psychiatrist, but from her longtime friends who were in the 12-step programs. She did not have an addiction problem but she explained to me that she had observed that people, in her life and her practice of medicine, who were in 12-step recovery lived life at a deeper level than most other people. That is why, at her moment of greatest need, she turned to them for understanding and guidance in her efforts to build a new life for herself.

Having shared these clinical stories let me turn now to a bit of data, the coin of the realm of the ACCA. Everyone knows that addiction treatment often fails. For most physicians relapse is a defining feature of the disease of addiction. I have come to believe that this conventional wisdom, while understandable, is wrong. It is not optimistic enough. I have reached this conclusion from my own experience working with addicted people during four gratifying decades of clinical practice.

My skeptical colleagues challenged me to come up with evidence for this hopeful prognosis for addiction treatment. Seeking evidence I turned to the dean of addiction treatment evaluation, Tom McLellan, Ph.D., head of the Treatment Research Institute at the University of Pennsylvania with a proposal: that we study the long-term outcomes of physicians under the care of the nation’s Physicians Health Programs. Our study, begun two years ago, was funded by the Robert Wood Johnson Foundation.

We worked with the Federation of Physicians Health Programs to identify 16 state programs willing to provide outcome data over a period of 5 to 11 years (average 7.2 years). What we found may change the way people think about the potential outcomes of addiction treatment.

PHPs do not deliver treatment or conduct monitoring. They are case managers unlike any you have ever seen. The goal of their case management is not to reduce costs but to improve outcomes. To this end they offer participating physicians choices of selected treatment programs that the PHPs have found to be excellent. Drug testing is done by other companies in which the PHPs have confidence. The care, including both treatment and monitoring, is paid for by the participating physicians and often by their health insurance. Treatment is intense and prolonged, often beginning with 3 months of residential treatment during which time the physicians are not practicing or engaging in any work other than their efforts to get well. Monitoring is not limited to the typical 5 drug panel used in workplace drug tests but uses an expanded 20 drug panel that includes not only tests for synthetic opiods as well as alcohol but also tests for Ethylglucuonide (EtG) the alcohol metabolite that is found in urine for up to a week after taking a single drink.¹⁷   Physicians being monitored typically call a number each workday morning at which time they are informed whether or not they need to have a drug test that day. This random testing process means that even if they were tested yesterday they could also be tested today. Typically PHP monitoring requires weekly random testing early in monitoring period followed by twice monthly testing. After many tests verifying no use of alcohol or other drugs, the testing frequency is reduced to once a month. Even late into monitoring every physician is subject to random testing every workday. Consequences for failure to remain abstinent from all alcohol and drug use include possible loss of the physician’s license. However the initial response to a relapse to drug or alcohol use is typically not revocation of the physician’s license but intensified treatment and monitoring, unless the relapse occurred in the context of patient care in which case it is usually reported to the Medical Board. The PHP care typically lasts 5 years, but many successful physicians voluntarily continue to participate in monitoring for even longer.

Of the 904 physicians in our sample, about half were treated primarily for alcohol problems, about a third for opiate problems and the remainder for other drugs, most often stimulants, although about half of the sample were poly-drug abusers or had drug problems in addition to alcohol problems. These were severely ill physicians, almost all facing loss of their medical license as a result of their addictions prior to entering PHP care. Nearly 40% had had prior addiction treatment, 17% had at least one arrest on a drug or alcohol-related charge and 14% abused drugs intravenously. Twenty three percent had a prior episode of PHP care. Eighty-eight percent met diagnostic criteria for substance use dependence, the most severe form of substance use disorder.

The outcomes of this sample of physicians were striking: 72% completed their PHP care successfully or were still being monitored for substance abuse at follow-up. Of those who did not complete care there were 6 suicides among 22 deaths. A total of 48(about 5% of the sample) lost their licenses to practice medicine while being monitored. Outcomes were as good for physicians with drug problems as those with primary alcohol problems. Physicians who used drugs intravenously did as well as other physicians.

Most impressive were the drug and alcohol test results. For the total sample, both those who succeeded and those who failed, the average number of alcohol and drug tests was 83. Seventy-eight percent of these physicians did not ever test positive for either alcohol or other drugs over this long period of tight, random monitoring. Of those who had a single positive test for either alcohol or drugs, just a quarter had a second (or more) positive test result. The rate of positive tests overall was about 1 per 200 tests, or about 0.5%. I know of no study of any population that has such a low rate of alcohol or drug use, including populations that are not addicted to alcohol or other drugs.

What do these data mean? They mean that the environment in which alcohol and drug abuse treatment occurs has a profound effect on the outcome: when the standard is no use of alcohol and drugs, and when that standard is enforced by tight monitoring linked to meaningful consequences the outcome of treatment rises dramatically.¹⁸ PHP care is inspired by the 12-step fellowships. This fact is reflected in the PHPs view that if a physician has an opiate problem he is monitored not only for opiates but also for stimulants, alcohol and other drugs of abuse. In this view all of these brain rewarding substances are part of one disease of addiction rather than seeing the disease as limited to the single drug that was the identified as the physician’s primary drug of abuse.

Of course physicians are different from other patient populations. The care these physicians received was remarkable for its quality, duration and sophistication. However many other patients use in these same treatment programs. These other patients do not have results that match the physicians’ results reported here. In addition to the quality and intensity of care the distinguishing features of these programs include the close monitoring linked to very serious consequences – potential loss of license. Relapses were handled with compassion as well as toughness.

The PHPs are explicitly focused on the twin goals of protecting the public health from potential harm from addicted physicians as well as saving the careers of addicted physicians. The PHP programs are tenacious in their efforts to help addicted physicians get and stay well. These are not just tough programs, they are deeply compassionate programs dedicated to helping physicians not only become drug-free but also to get into stable long-term recovery.

If a large sample of physicians had dramatically better outcomes than other patient populations suffering from the same serious and often fatal disease this would be a major public health finding. It is important to draw attention to these dramatic findings not to brag about how well physicians do, or how good PHP case management is but to use the elements of this unique system of care more widely in the treatment of other populations of addicted patients. These findings are a much-needed antidote to the pessimism that too often discourages the identification and treatment of the disease of addiction.

As a physician I am proud of organized medicine for the creation of this unique system of case management. This achievement fulfills the Hippocratic Oath to support other physicians. PHP care is a gift not only to physicians but to all addicted patients as this evidence is more widely recognized and this model of care is more widely emulated.

Conclusion

I cannot hope for you to remember my talk, but I want you to know how deeply grateful I am for the honor to speak with you this evening. You have my respect and my sincere thanks.

Beyond thanking you, I have three action steps to suggest:

1. Think again about your addicted patients, family members and colleagues. Appreciate, as I am sure you already do, the seriousness of their progressive and potentially fatal disease but add the vital leavening of hope. Help them find their ways to drug treatment and to Alcoholics Anonymous, Narcotics Anonymous, and Al Anon – the three related 12-step programs.
    
2. Go to at least 3 meetings of a 12-step group yourself so that you understand how these marvelous programs work. I have heard more honesty in every meeting I have gone to than I hear in a good year in my psychiatric office. You need to be personally familiar with these programs to be able to help your patients and others find and use them. I guarantee that you will enjoy these meetings and that you will be amazed by what goes on there. A good way to find an AA or an NA meeting is to find a physician colleague, friend or family member who is a member of these fellowships who will take you to a few open meetings and help you understand what is going on in these fellowships.
    
3. Contact the Director of your state’s Physicians Health Program and invite a physician member of that program to speak regularly to your students and residents about addiction among physicians and to introduce them to the PHP program. The PHPs have set a new standard for getting well from this terrible disease, a disease that I call a “pitiless teacher.”

My goal tonight is to engage you personally and professionally in the challenging task, to which I have devoted my medical career, of identifying addiction and helping the addicted person get well. I have given you some new ways to understand the predicament of the addicted person and even more I hope that I have opened your eyes to the wonder of recovery. Finally I have put the disease of addiction into a hopeful perspective. Without wanting to minimize the threat of addiction, including not just the threat of relapse but also the very real threat of death, I want you to know that it is possible for addicts to get well and I want you to appreciate that physicians are uniquely able to help addicts get well and stay well.

Thank you!

1 Verghese, A. (1998) The Tennis Partner. New York, NY: HarperCollins.

2 Verghese, A. (2002). Physicians and Addiction. New England Journal of Medicine, 346 (20), 1510-1511.

3 DuPont, R. L. (1971). Profile of a Heroin-Addiction Epidemic. New England Journal of Medicine, 285, 320-324.

4 DuPont, R. L. & Greene, M. H. (1973). The Dynamics of a Heroin Addiction Epidemic. Science, 181, 716-722.

5 Alcoholics Anonymous Big Book 4th Edition. (2001) New York, NY: Alcoholics Anonymous World Services, Inc.

6 DuPont, R. L. (2005). Conversation with Robert L. DuPont. Addiction, 100, 1402-1411.

7 DuPont, R. L. (1984). Getting Tough on Gateway Drugs: A Guide for the Family. Washington, D.C.: American Psychiatric Press.

8 O’Brien, C. P., Volkow, N, and Li, T. K. (2006) What’s in a Word? Addiction Versus Dependence in DSM-V. American Journal of Psychiatry. 163(5), 764-765.

9 O’Brien, C. P., Volkow, N, and Li, T. K. (2006) Dr. O’Brien Replies. American Journal of Psychiatry. 163, 2016-2017.

10 DuPont, R. L. & Gold, M.S. (1995). Withdrawal and Reward: Implications for Detoxification and Relapse Prevention. Psychiatric Annals, 25, 663-668.

11 DuPont, R. L. (1998). Addiction: A New Paradigm. Bulletin of the Menninger Clinic, 62, 231-242.

12 Erickson, C. K. (2007) The Science of Addiction: From Neurobiology to Treatment. New York, NY: W. W. Norton & Company.

13 Wise, R. A. (2003). Brain Reward Circuitry: Insights from Unsensed Incentives. In A. W. Graham, T. K. Schultz, M. F. Mayo-Smith, R. K. Ries, & B. B. Wilford (Eds.), Principals of Addiction Medicine (3rd ed., pp. 57-71). Chevy Chase, MD: American Society of Addiction Medicine.

14 DuPont, R. L. (2000). The Selfish Brain: Learning from Addiction (Revised and Updated). Center City, MN: Hazelden.

15 DuPont, R. L. & McGovern, J. P. (1994). A Bridge to Recovery: An Introduction to 12-step Programs. Washington, DC: American Psychiatric Press.

16 The Betty Ford Institute Consensus Panel. (in press). What is Recovery? A Working Definition from the Betty Ford Institute. Journal of Substance Abuse Treatment.

17 DuPont, R.L., Skipper, G.E. & White, W.L. (in press). Testing for recent alcohol use. Concurrent publication in Counselor, Student Assistance Journal, and Employee Assistance Digest.

18 DuPont, R. L. (1999). Biology and the Environment: Rethinking Demand Reduction. Journal of Addictive Diseases, 18(4), 121-138.


Robert L. DuPont, M.D.