Dr. Miller is a founding member and the second president of the American Academy of Addiction Psychiatry. He is the recipient of the 2002 AAAP Founders’ Award. He is the Lizzy Gilman Professor and past chairman of the Department of Psychiatry and Behavioral Sciences of Northwestern University Medical School. Prior to his arrival at Northwestern in February 1991, Dr. Miller was chairman of the Department of Psychiatry at the University of Medicine and Dentistry of New Jersey/New Jersey Medical School. Dr. Miller is a graduate of Oberlin College and received his medical training at Tufts University School of Medicine. He is a graduate of the psychiatry residency program of Case Western Reserve University, where he also served on the faculty for 11 years.

Dr. Miller has authored many articles, book chapters and a recent book. Many of these are in his principal area of interest, which is alcoholism and other chemical dependencies. He is also the editor of The American Journal on Addictions.

Dr. Miller was appointed a director of the American Board of Psychiatry and Neurology in 1991 and a director of the American Board of Emergency Medicine in 1999. He is a fellow of the American Psychiatric Association and the American College of Psychiatrists and a member of the Board of Directors for the Accreditation Council for Graduate Medical Education. He serves on a number of committees of the American Psychiatric Association, and he is a member of the AAAP Board of Directors.

This has been a long journey, and it’s not over yet. It’s incredibly encouraging that this is the largest meeting we’ve had, at a time when most meetings are getting smaller, not bigger. That says something about the people who are interested in this field and who are dedicated to the issues that we’ve all struggled for. I thank everyone: past, present and future.

As a resident in the mid 1960s, the only thing that was consistent in our training is that there wasn’t any. I began in a very classical, psychoanalytically-based residency program where I was convinced that the major issue in addiction was interpreting the issues that caused the problem and diagnosing the underlying problem of which addiction was the result. In fairness, that was what we were in the mid 1960s. We really didn’t have a very broad view of addictions. My course in psychopharmacology lasted a total of 1 hour, and we had plenty of time for discussion. We had a lot to learn.

I got interested in this field from being immersed in a world that was dominated by addictive disorders. In those days, it wasn’t addictive disorders — you were either an alcoholism person or a drug person. The whole concept of addiction psychiatry or the field of addictions simply didn’t exist.

My immersion was in alcoholism by becoming an officer in the U.S. Public Health Service and spending from 1968 to 1970 living with and treating the Navajo Indian tribe. It became clear very quickly that I didn’t have a clue what I was doing. Half of the people who came in to see me, male or female, were clearly addicted to alcohol. The society was being devastated by alcohol. I saw 11-, 12-, 13- and 14-year-old children dying of cirrhosis. My task, with 1 hour of lecture on the topic, was to treat them. This society has its roots in Eastern philosophy, not Western philosophy, and the best that we had to offer them was an approach of self-help through an AA mechanism, which isn’t exactly the driving philosophy behind their approach to the world. We were left with Antabuse and a lot of wondering what to do. I’d like to say that we solved that problem, but we didn’t. I left there frustrated, interested and determined to see if we could move this field farther than we were. It was also very clear to me that what I had been taught was wrong. The only problem was, I didn’t know what was right.

We’ve gone from that to issues looking at learning theory. We’ve gone through the controlled drinking movement. We’ve now come into an age where we’re beginning to understand the genetics and the biological roots of this disorder.

We’ve gone from an unwavering belief that the only goal is abstinence to beginning to understand that this is a process that has to go through a series of steps. We now take the concept of dual diagnosis, however we describe it, as a given.

It’s natural; it’s what should be. Many of us have gone through this transition of having to separate addictions from psychiatry with a stone wall, whereas now we understand that one thing doesn’t offer immunity to another. There is interaction and interplay.

I started my career very much involved with the volunteering movement. Early after returning to the faculty at Case Western in Cleveland, I became involved with the National Council on Alcoholism, which in the 1970s was a very strong, serious movement. The Board of Trustees was made up of a collection of people from many walks of life. Some of them were recovering; some of them were citizens interested for various reasons; and some were professionals. It was an eclectic, diverse board that was dedicated to the founder’s mission of education and of bringing this out into the world in a very mainstream way.

The whole movement of employee assistance programs — the whole concept of recognizing addictions early in the workplace — was the product of that board. That board got the first NIAAA grant to initiate the process of employee assistance programs on a national basis. We got one of those grants in Cleveland, and it was a multicentered grant. I had the privilege of working on some of the early programs and being involved in a vibrant, active and exciting volunteer movement. Then, it went away and really has not re-emerged in the strength that it was at that time. That’s very sad; we need to think about that.

We struggle with moving our field, with worrying about health care financing and with worrying about sufficient research dollars to move us forward in the field. We compare ourselves in the frequency with which our illnesses appear with a number of other organizations, including the heart people and the cancer people. We wonder at times why those folks have mainstreamed their illnesses and have become very public and effective at lobbying Congress and other organizations. We wonder why the stigma of cancer, which was a stigma for many years, has begun to disappear and why the stigma of addictions has not disappeared at all. It has gone underground, but it is very much present.

One of the issues is the absence in our field of a strong, visible, vibrant, vocal volunteer movement, and we almost had that at one time, but sadly, we have lost it. Without it, it’s going to be very difficult for us as professionals to carry the torch alone. We need our patients with us, and we don’t have them right now — not visibly, not vocally, and nowhere near what the rest of mental health has been able to put together with the establishment of the National Alliance for the Mentally Ill and of the National Mental Health Association. These are visible, active people, and they are making a difference.

When I first started, there was no such thing as insurance. You charged; you got paid. My bookkeeping system was on the back of a note card. It was a wonderful time. The words "managed care" didn’t exist. Management meant that we managed to the extent of the inpatient coverage. If the patient had 120 days, he or she was usually discharged at about 115, sometimes as late as 120.

It’s important to remember that that’s where we started because that’s also where the trouble started.

I was there when Medicare "happened." That was the beginning of the end as far as the medical community was concerned. Medicare was going to be the death of medicine. Most of us would love to get those Medicare patients right now. Eventually, Medicare decided that it needed to do business in a different way, and the concept of diagnostic related groups (DRGs) came into being. At that point, the medical services in many of the general hospitals began to empty.

If you remember how DRGs work, you are basically given a certain amount of money for the care of an episode depending on the diagnosis of the medical patient. There is no incentive to stay 5 seconds longer than what they’ve given you because you begin to lose money very quickly at that point, so beds began to open up. Psychiatry had an exemption from DRGs. Hospitals began to look around for ways to fill those empty beds. At that time, we were able to charge exactly the same amount per bed-day as any surgical or medical patient, so it was very profitable to fill those empty beds with a low-intensity, high-profit set of patients such as ours.

Additionally, there were successes in the inpatient treatment of addictive disorders. The Navy program in addiction disorders showed us that there was a positive outcome for treatment. Some serious and positive things had happened in the field that made it make great sense to start treating people on an inpatient basis.

We went forward with the 28-day model, but the "we" wasn’t just us. The "we" became the business community. This became an opportunity and a niche. Then, there was the development exponentially of beds available for 28-day treatment for addictive disorders in the for-profit sector. Millions of dollars were made on this process, and we were all involved. We believed that this was the right way to go.

The search for the dollar became dangerous. I was in New Jersey when the business world began to get very worried about this. There was immense abuse of this system. We saw daily horror stories of families becoming destitute to have their children treated. Studies were published that questioned the efficacy of inpatient treatment versus less-intensive, less-expensive treatments. People began to ask why, for this illness and no others, there was a magic number of days at which point somebody either gets better or doesn’t. We had no evidence. Quite the reverse, the evidence that did exist indicated that ambulatory treatment was probably a much better approach.

Prudential Insurance Company wanted to know why 28 days of treatment and what justified it. They wanted to know why everybody got the same thing. They wanted to know why we threw people out of the hospitals. That didn’t make sense to them. They also wanted to know why we kept patients when no progress was being made. Those were questions that I never could answer.

The carve-out mental health businesses began. We went from huge numbers of beds to virtually none, which is what we are facing now. People became interested in the health care system and looked at where the biggest costs were.

The biggest growth in costs, frankly, was in two areas: one was adolescent mental health care and the other was our field. It became easy for them to determine where they were going to put their efforts in cutting costs. We had the privilege of being first. We’ve been joined by our medical colleagues, but they have never experienced what we have experienced.

In 1980, the American Psychiatric Association came of age because its thinking changed. Until that time, our position in American psychiatry was, at best, questionable. We were seeing massive abuses, not because people were intentionally trying to do the wrong thing, but because they simply didn’t know.

Don Langsley became president of the APA in 1980. Under his leadership, the first committee on alcoholism and the first committee on drug abuse were founded. I served as the first chair of the alcohol committee. We had this one little committee, and we began to think about what we should do.

We finally came to the decision that those people in APA who were making any headway whatsoever all had a political position. It’s a highly political organization, as most large medical organizations tend to be. If you wanted to be heard, you had to have a power base. There had to be a group of people whom you represented. Many of them had organizations, and they seemed to be the ones who were moving forward. At that point, we got the alcohol and drug abuse committees together and began to discuss this as a possible goal.

We felt we needed to begin an organization. It’s one thing to have an idea; it’s another thing to make it happen. We contacted a lawyer, and we drew up articles of incorporation. We drew up a mailing list of people from the APA who had expressed an interest in addiction, and we sent out invitations to join. Within months, we had 300 members.

We began to visualize ourselves as a profession unto itself and as a potential subspecialty. If we were really going to further this business, it was going to be important to become a significant part of the house of medicine — that means a formal beginning of a subspecialty called addiction psychiatry. We knew we had a special content. We knew we had special issues. We knew we had something to offer, but without the recognition that goes along with the establishment of a formal medical subspecialty, you don’t get into certain councils and you can’t develop yourself.

The life of any field is in its young people and in its research. Without some identity, we believed we would have great trouble attracting young people into our field. Certainly we felt we would have great trouble, given the specialization of medicine, of buying a place at the table in the academic world. We began the process, which was long and arduous, of trying to establish the subspecialty that became addiction psychiatry.

There were a lot of hurdles, not the least of which was that this was not a popular idea outside of our own group. We were viewed by many as a serious threat. We discovered subspecialties at the time that the rest of medicine decided they didn’t want them. However, after overcoming many hurdles, we became a subspecialty.

The whole development of subspecialty was never meant to replace anyone’s ability to practice, and it still isn’t. We are the teachers and the researchers. We deal with the hardest patients. That’s who the people who are certified in addiction psychiatry are. But, this organization should have two groups of people in it. We would love to see this organization heavily populated by general psychiatrists who are interested. Subspecialists are a smaller group and have a special role.

We need to do much more as a profession in public policy, in lobbying and in carrying forth to Congress. For this field to move into the mainstream, we need a strong voluntary component. Any opportunity we get to support recovering patients who are willing to come out is golden.

We need to continue our research. We have to make sure that we have evidence behind our treatments. This organization needs to grow in order to further what we want, in order to further the care of our patients and in order to further our own careers. The more we grow, the more powerful we become.

"I still believe it’s the most exciting field one could imagine. We have truly gone from boats to rocket ships."