I read Doug Sellman's distilled wisdom for the next generation with appreciation [1]. I suspect that we, the old men, need the enthusiasm of the young more than they need our wisdom. Cynicism and despair are the concomitants of addiction, and clinicians risk being infected, for our work has many frustrations. Training young doctors (and nurses, psychologists, counsellors) has been one of the joys, an antidote to burnout.

There is a fault line beneath addiction treatment, between the ‘moral–spiritual’ and the ‘empirical, social sciences’ traditions. The dominant paradigm is moral–spiritual, in which conversion (the ‘epiphany’) is the basis of recovery. In so far as therapists can promote change it is slow, fluctuating, and lacks the black-and-white clarity that fits the dominant paradigm. Worse, we are in a bind—we must engender ‘hope’, while avoiding ‘unrealistic expectations’. Unrealistic expectations of cure contribute to frustration in the lives of addicts and their families, and corrupt the practitioners who seek to meet those expectations. Young practitioners, you must avoid the lure of being a charismatic healer; the ‘first step’ towards helping people is to admit that we are powerless to cure our patients.

However, the discipline of ‘diagnosis’ and ‘prognosis’ can easily be experienced by patients as not just lacking hope, but as being judgemental and objectifying. The resolution of this bind is the critical importance of empathy, of being able to see things from the patient's perspective while offering an informed, dispassionate perspective. In the addictions, more than any other area, empathy is of the highest importance in improving outcomes [2]. Empathy is the sine qua non of addiction medicine. Sellman reminds us it can be learned, but working in a busy service, with a difficult clientele, it can also easily be forgotten.

I agree with him that treatment will continue to be found in talking, and in grounding people in culture. Recovery through culture is not restricted to dispossessed indigenous people; most attendees at addictions services are dispossessed and marginalized, and prey to aimlessness and hopelessness. ‘Culture’ is affiliation, participation in a world outside of self, providing identity and purpose. For a time the ‘addict’ subculture provides meaning and purpose for young, disaffected people. Social re-integration is recovery, whatever forms of affiliation—employment, relationship, church—that re-integration takes. It is relevant to prevention, too; the more social roles a person undertakes, the less likelihood of drinking problems [3].

Unfortunately, people who might respond well to treatment (in Sellman's terms, those who are recruited to clinical trials) do not often come to our services. He wants more research into how to manage the marginalized people who do attend, but I think services need to change their focus. We risk being as stuck as the people we are unable to cure, locked into our own stereotyped responses. Recovery for specialist addiction services is through re-integration with the health care system. If half our primary care practitioners addressed alcohol issues with half their patients, and replicated the outcomes of Project COMBINE, it would make a substantial contribution to reducing the burden of disease associated with alcohol [4]. But they do not [5] and, as George Vaillant has argued, nor do general hospitals [6].

Doctors do not want to be stuck managing patients unless they feel competent to do so, and can obtain help and advice if things get frustrating. The role of specialist services is to support primary care and hospitals, initiating treatment plans and managing complex cases which cannot be managed in primary care. Addiction medicine consultation–liaison services need to be relevant and useful, helping primary care and hospital staff manage complex and chronic patients efficiently and humanely, reducing the frustration felt by generalist staff, and increasing their readiness to ask and advise their patients about alcohol and drug use.

Declaration of interest

James Bell has given a talk for Schering Plough (distributors of buprenorphine) and has had research and travel funded by Reckittbenckiser, research funded by Biomed PL and research funded by Titan Pharmaceuticals.