Addiction is a treatable disease, not a moral failing.

Despite the fact that it was long ago acknowledged that alcohol and drug dependency are diseases (the AMA accepted this a quarter of a century ago), the everyday world of medical practice often reflects the stigmatizing attitudes of medical personnel reported in Angel's story. However, Lozano's article also illustrates the power of medical staff to intervene positively in addictions, and her encounter with Angel's mother stimulates a number of observations.

Individual clinicians can have a great impact on substance abuse through their role in identifying, treating, and preventing the disease. A review of 44 studies of brief interventions in healthcare settings showed that even brief interactions with medical personnel have significant effects on patients' drinking.¹ The vulnerability of a patient in a medical encounter and the authority of the medical provider can be harnessed for the immediate and long-term benefit of the patient, whatever the level of severity of substance misuse.

Clinicians and their patients are often bound by the same unscientific, shaming beliefs about substance misuse; these beliefs create barriers to treatment.² Angel's story conveys her mother's sense of being stigmatized by healthcare providers because of her illness. Lozano's intervention is an example of knowledge dispelling both stigma and pain. Physicians' fear of offending patients often leads to their avoidance of making the diagnosis of substance misuse or dependence.³ Just as knowledge about the Mongolian spot allowed Angel's mother to free herself from her mistaken belief, so too providers can benefit from casting aside unscientific and damaging beliefs regarding substance misuse. Patients and providers need to know that addiction is a treatable disease not a moral failing.⁴

The scope and impact of substance misuse across society are profound. Approximately 1 in 5 outpatients seeking primary care and 1 in 4 hospital patients are dependent on alcohol; yet, only about 1 in 7 people who are dependent on alcohol are ever treated.⁵ A study at a number of mainly urban hospitals found that approximately 1 in 9 infants evaluated had been exposed to illegal drugs in utero.⁶ Unintended pregnancies are one of the consequences for female substance misuser who exchange sex for drugs. Although Angel's problem is far from unique, her mother's—“a woman focusing all her energy on trying to do things right”—experience of an escape from addiction and restoration of the mother-daughter bond is not the norm. Substance misuse is underidentified and undertreated; individual clinicians have the power to change this.

Substance misuse is under-identified and undertreated; individual clinicians have the power to change this.

Lozano's encounter with Angel and her mother shows that substance misuse is not only treatable but is also preventable. Children of current and former substance misusers are at high risk of themselves abusing substances.⁷ Will Angel follow in her mother's footsteps as genetic, psychological, social, and cultural factors often dictate? Or will some intervention occur to prevent her progression to addiction? In a 1-year study of 445 adolescents receiving routine care from 119 family practitioners, 62.5% of the adolescents did not receive any health habit counseling (that is, risky sexual behavior, exercise, tobacco, alcohol and other substances). The authors note this “... clearly represents a missed opportunity for preventive counseling.”⁸

The clinicians in Angel's story have moved the process of treatment, and prevention, forward by educating her mother. Although the medical setting is an ideal context for intervening to stop the progression of substance misuse, medical personnel often fail to act. Clinicians report that they lack the knowledge, skills, attitudes, and practical experience to address substance misuse. Physicians rate doctor-patient communication on substance misuse as extremely important but rate their own related training and skills dramatically lower; cross-cultural and gender issues add to the challenge.⁹ Training programs for health professionals devote too little time to substance misuse, leaving clinicians ill equipped to deal with this widespread health problem. Better training will result in physicians who are better able to prevent, identify, and treat substance misuse in the future—but what about now? Angel's story illustrates that, in the arena of substance misuse, the beliefs and actions of individual clinicians matter.