199511
Substance-Related Disorders
POSITION STATEMENT
Approved by the Board of Trustees, December 1995
Approved by the Assembly, November 1995
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"Policy documents are approved by the APA Assembly and Board of Trustees… These are …position statements that define APA official policy on specific subjects…" -- APA Operations Manual. |
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Substance-related disorders are widespread among the general public and are often accompanied by other psychiatric disorders. However, historical social stigma and other factors have led to underdiagnosis and limited access to care. Cost-effective treatment is best delivered in a comprehensive, flexible continuum of services, which should be accessible on the same basis as other medical care. The American Psychiatric Association should continue to promote access to care, high-quality treatment, education, training, research, parity in third-party coverage, and equal treatment for patients suffering from addictive disorders.
This statement was drafted by the Task Force on Psychiatric Services for Addicted Patients*. It was approved by the Assembly in November 1995 and by the Board of Trustees in December 1995. Background American society has been slow to accept substance-related disorders as treatable diseases. The alternative conceptualization of these disorders (as voluntary, self-inflicted, and immoral behaviors) has produced a powerful stigma to which society has responded in a punitive way, often using criminal justice in preference to public health interventions. Although there is ample evidence that treatment of these disorders is both effective and cost-effective (1), support for treatment is still subject to unreasonable restraints in such areas as health insurance coverage and benefit programs (2). Social stigma has also influenced the behavior of health professionals, resulting in a failure to diagnose substance-related disorders in persons who do not resemble the societal stereotype of an alcoholic or addict (3). As the U.S. health care delivery system continues to change rapidly, from a two-tiered (public/private), free-for-service delivery system to a variety of capitated and managed care models, important decisions made on federal, state, and local levels will determine the accessibility, availability, and quality of addiction treatment in the future. The American Psychiatric Association (APA) has been an active advocate for education, treatment, and research in substance-related disorders and continues to play a leadership role in such advocacy (4,5). The purpose of this position statement is to promote recognition of substance-related disorders as an essential component of medical care.
Problems deriving from the misuse of alcohol, tobacco, and other drugs create suffering if affected individuals, their friends and families, and society at large. The costs to our national morale, self-respect, and self-concept as a democratic and productive society defy calculation. The financial burden of addictive disorders on the national economy is predicted to surpass $273 billion by 1997, exclusive of tobacco-related costs (6, 7). Include here are costs within the health care and social service systems, estimates of lost productivity, costs related to crime, and the costs of special problems, such as fetal alcohol syndrome and AIDS contracted through injection drug use or unsafe sexual practices. Societal costs related tobacco use have been estimated at an additional $85 billion per year (8).
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*Task Force members: Sheila Blume, M.D. (chairperson), Donald J. Gill, M.D., Walter Ling, M.D., Peggy Stephens, M.D., and Myron L. Belfer, M.D.
Substance-related disorders are both widespread among the general public and likely to be associated with comorbid psychiatric disorders. Two extensive surveys of the adult general population conducted during the 1980s found substance-related disorders to be the most common diagnostic group among those diagnosed with mental disorders (9, 10). The Epidemiologic Catchment Area (ECA) study (9) found a lifetime prevalence of alcohol abuse or dependence of 13.5% and a lifetime prevalence of other drug abuse or dependence (exclusive of nicotine) of 6.1%. The National Comobidity Study (10) found a lifetime prevalence of 26.6% for substance abuse/dependence and a 12-month prevalence of 11.3%. For ECA subjects with an alcohol or drug disorder, the probability of having a comorbid disorder of the other category (alcohol or drug) was increased by a factor of 7.0. For those with an alcohol-related diagnosis, the probability of having a non-substance-related mental disorder was increased by a factor of 2.3. For those with a drug-related disorder, the risk was increased by a factor of 4.5(9).
CHARACTERISTICS OF SUBSTANCE-RELATED DISORDERS The American Psychiatric Association Diagnostic and Statistical Manual (DSM-IV) defines substance-related disorders as a cluster of behavioral clinical syndromes related to the consumption of psychoactive substances. Included are 11 classes of substances capable of producing one or more of these disorders.
There are three distinct but related categories of diagnosis: 1) the generic diagnoses of substance dependence and substance abuse; 2) the clinical syndromes directly related to intoxication and withdrawal; and 3) the drug-induced psychiatric disorders phenomenologically related to other specific psychiatric disorders (e.g., substance-induced mood disorder). These are considered, respectively, under the DSM-IV sections on substance use disorders and substance-induced disorders and as a separate category of substance-induced mental disorders grouped with other disorders of the same type.
Substance dependence and abuse are defined in DSM-IV by a cluster of cognitive behavioral, and physiological symptoms occurring within a specific period of time. Central to the concept of substance dependence are compulsive drug-seeking behavior and continued use despite adverse consequences, with or without tolerance or withdrawal symptoms. Substance abuse, on the other hand, includes repeated hazardous use and/or harmful consequences form repeated use, in an individual who has never met the diagnostic criteria for dependence on that substance. Substance-induced disorders include the specific manifestations of intoxication, withdrawal, and delirium.
While the prevalence of substance-related disorders varies among ethnically, socially, and culturally distinct populations, the core disorders appear to occur consistently throughout the world. This is reflected by the parallel description of these disorders in DSM-IV an ICD-10.
RECENT ADVANCES IN KNOWLEDGE ABOUT SUBSTANCE-RELATED DISORDERS Over the past several decades the locus, functional relationships, and neurobiology of brain reward systems, including the receptors and neurotransmitters involved, have been well delineated, as have the interactions of most substances of abuse with these systems (11). The acute and chronic effects of addictive drugs of abuse on the living human brain have been visualized with new imaging techniques: positron emission tomography (PET) (12-14), single photon emission computed tomography (SPECT), and magnetic resonance imaging (MRI) (15). Other studies have described the nature of withdrawal syndromes following cessation of cocaine (16) and nicotine (17) use, the role of genetic factors in the vulnerability to the development of substance dependence (18, 19), and the influence of comorbid psychiatric disorders on the incidence and clinical course of dependence (9, 10, 20).
Research on the biology and psychology of dependence has also led to the development of medical interventions that have profoundly influenced the effectiveness of treatment. For example, methadone maintenance treatment for heroin addiction, developed in the 1960s, has been shown repeatedly, in several countries, to reduce dramatically the use of heroin and its associated antisocial behavior (21,22). Furthermore, it has been demonstrated that patients who remain in treatment are far less likely to become infected with HIV (23). Longer acting alternatives to methadone, such as methadyl acetate (L--ace-tylmethadol, or LAAM), are now available (24, 25).
On the basis of an understanding of the role of learning and conditioning in evoking drug craving and contributing to relapse, researches have developed effective oral long-acting opioid antagonist drugs (e.g., naltrexone), which are now used to prevent relapse in drug-free patients who were previously opioid dependent (26, 27). Findings emerging from clinical trials, based on hypotheses regarding the underlying mechanisms of brain reward systems, have suggested the utility of naltrexone in treating alcoholism (28, 29).
Other important developments include the use of the 2 agonist clonidine to ameliorate opioid withdrawal symptoms (30, 31) and techniques to accelerate the resolution of opioid dependence by precipitating withdrawal with opioid antagonists in patients simultaneously receiving clonidine (32, 33).
Benzodiazepine treatment of alcohol withdrawal is based on accumulated knowledge derived from empirical studies. In addition, there is evidence that nicotine gum and nicotine transdermal patches significantly increase the likelihood of patients' being able to discontinue cigarette smoking, although the ability to avoid relapse usually requires other forms of ongoing treatment (34.).
Psychiatrists have pioneered in combining psychological treatments, such as relapse prevention, with biological interventions (29, 35). They have also been instrumental in synthesizing the findings from biological research with developments in psychology, sociology, and the experience of individuals who have recovered from dependence, into comprehensive treatments for substance dependence (36, 37).
DIAGNOSIS AND TREATMENT OF SUBSTANCE-RELATED DISORDERS Despite their well-documented prevalence in psychiatric and medical/surgical populations in all age groups, substance-related disorders are often underdiagnosed, leading to a failure of intervention and/or referral (3, 38-40). Thus, it is important that all medical/surgical and psychiatric patients be routinely screened for substance-related disorders. Additionally, because of the high prevalence of psychiatric comorbidity, a psychiatric evaluation of all patients referred for treatment of substance-related disorders is warranted. Therapists' skills and attributes appear to be important factors in the outcome of addiction treatment (41).
The treatment of substance-related disorders should be individualized with regard to the modalities used, the intensity of treatment, and the settings in which treatment is delivered. Treatment should be appropriate to the various stages of illness and recovery, and it should address treatment of any coexisting physical, psychiatric, and psychosocial problems. The phases of treatment generally include detoxification, aftercare, relapse prevention, and rehabilitation. Addictions must be seen as chronic, relapsing illnesses, rather than acute disorders. Chronicity and severity in many patients necessitates flexibility in treatment planning and continuity of care. There is accumulating evidence that in some cases treatment must be sustained for months or years (42).
In spite of vastly different populations and treatment methods, the majority of outcome studies have shown that treatment for substance-related disorders is effective, cost-effective, and productive in terms of costs offsets within the health care system (42). Such studies have shown the following:
• Addiction treatment is effective in reducing alcohol and other drug abuse and associated problems, including unemployment, crime, poor psychosocial functioning, and transmission of AIDS among users of intravenous drugs (41-43).
• Addiction treatment is substantially less expensive than the treatment of other medical illnesses related to untreated alcohol or other drug abuse/dependence (44).
• The costs of providing addiction treatment are almost entirely recouped during the treatment period, and savings to society after an individual leaves treatment represent further returns on the investment (45).
• The average alcoholic's treatment costs can be offset b reductions in other health care costs within 2-3 years following the start of treatment (46).
PREVENTION Medications used in general medical and psychiatric care have the potential for dependence when prescribed inappropriately or when misused by patients or others. The potential is particularly important in psychiatric practice. Because the vast majority of potentially addicting psychotropic drugs are prescribed by nonpsychiatric physicians, the potential for misuse of these drugs must be recognized and addressed by other caregivers as well. APA supports educational efforts to improve prescribing practices.
APA sponsorship of a broad range of information materials and events has helped educate providers and the general public regarding the prevention and treatment of addictive disorders. Collaboration with many professional associations and citizen groups has helped bring the expertise of psychiatry to the general public and professionals.
Addictive disorders are more readily treated before the secondary medical, social, psychological, and legal complications impair the individual's capacity to achieve rehabilitation. Through consultation and liaison activities in health care settings, participation in workplace programs, and the education of providers, psychiatrists can facilitate early identification of any intervention in addictive disorders. Consultation-liaison activities that alert providers and patients to the dangers of the inappropriate use of pain medication, the misuse of psychotherapeutic medications, and the potential for self-medication are important preventive interventions.
Use of injected drugs, the abuse of alcohol, and the trading of sex for drugs are dominant contributors to the spread of HIV infection. The associated spread of drug-resistant tuberculosis and sexually transmitted diseases makes psychiatry's involvement with these complex problems a key part of any public health initiative. Psychiatry recognizes its responsibility to respond to the potential for injection drug use in its patient populations, through education of caregivers and by providing addiction treatment.
ROLE OF THE PSYCHIATRIST From medical school through psychiatric residency and beyond, there has been increasing exposure to improved psychiatric training in the care of patients with substance-related disorders. The current generation of psychiatrists is in a position to diagnose substance-related disorders in patients seen in traditional psychiatric setting where comorbidity is high, and in other settings, where at-risk patients are plentiful (e.g., general medical facilities, courts, schools and industry). The individual psychiatrist may assess and diagnose a patient, develop a comprehensive treatment plan, and deliver the medicated treatment either directly or as a leader/member of a clinical team.
The range of knowledge and training that psychiatry brings to bear on substance-related disorders allows for an informed selection of the least restrictive and most cost-effective interventions available at any given time. Of equal important, psychiatry, with its firm grounding in the methods used in the development of new psychopharmacological agents, is equipped for, and committed to continual testing of innovative treatments that may prove even more effective than those currently available.
The American Board of Psychiatry and Neurology, through its examinations that demonstrate a psychiatrist's added qualifications in addiction psychiatry, has objectified the profession's ongoing commitment to state-of-the-art care for addicted patients.
APA RECOMMENDATIONS 1. The diagnosis and treatment of substance-related disorders should be recognized as an essential part of medical care. Screening for the se disorders should be a routine part of all medical assessment.
2. Treatment of these disorders is cost-effective and should be accessible on the same basis as other medical care. In any proposed health system reform, demonstrably effective treatments for substance-related disorders should be covered on a parity basis with effective treatments for other diseases.
3. Treatment of substance-related disorders should be comprehensive and flexible enough to meet the complex needs of affected individuals and their families.
4. Psychiatry should increase its efforts to assure adequate psychiatric training and clinical experience at the medical school, residency, and fellowship levels to develop competence in the diagnosis, treatment, and prevention of substance-related disorders in adults and children.
5. Psychiatry should continue to promote, and participate in, education about substance-related disorders among physicians and allied health and mental health professionals.
6. Psychiatrists should continue to take a leadership role in providing high-quality treatment and in assessing the quality, appropriateness, and effectiveness of services for substance-related disorders.
7. Psychiatrists should continue working to eliminate societal stigma and guarantee access to quality treatment for persons suffering from addictive disorders. Psychiatrists should also participate in developing public policies that offer adequate addiction treatment services to adults, youth, the elderly, under-served minorities, and those in the criminal justice system.
8. Psychiatrists should continue to work for increased support for both basic and applied research into the causes, manifestations, treatment, and prevention of substance-related disorders, their familial and social consequences, and the cost-effectiveness of efforts directed at prevention, treatment, regulation, and law enforcement.
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