Addressing Substance Use Problems in Medical Systems
My colleagues and I were one of the first groups in the US to develop treatment services for patients with substance use disorders (SUDs) and co-occurring psychiatric disorders (CODs). This was a difficult process that took considerable time, patience, effort, and help from many to overcome institutional, regulatory, funding, and clinician barriers. On the inpatient psychiatric unit where we developed our first COD program, our team encountered negativity and resistance to our attempts to change the milieu to accommodate the treatment needs of patients with CODs. The irony is that patients with CODs had always been on the psychiatric unit, but prior to my team, patients’ SUDs were not always addressed.
With the help of a consultant to deal with barriers presented by existing unit staff, we integrated our COD program on the unit. We later expanded COD services to other inpatient units and developed community residential programs and a large continuum of ambulatory care that offered partial hospital, intensive outpatient, ambulatory detoxification, and outpatient services. I believe that what we learned from this experience is applicable to the current challenge of integrating the focus on substance use and SUDs in medical settings.
Addiction professionals add value to medical settings by collaborating with medical staff on clinical and educational issues, and providing services to patients and families. The current opioid epidemic has led medical providers to focus on SUDs. Although most of this focus has been on opioid misuse and addiction, this is an opportunity to focus on all types of SUDs, especially since nicotine and alcohol contribute to many medical problems and early death.
Current Challenges for Medical Systems
The National Center on Addiction and Substance Abuse (CASA) at Columbia University published “Closing the Gap between Science and Practice” (2012) based on a review of seven thousand articles, reports, books, national data sets, focus groups, and surveys of professionals and individuals involved in recovery. Following are key points of the report relevant to substance use in medical settings.
- Care for SUDs is often disconnected from medical practices. SUDs are neglected more than other medical conditions because providers are not trained to diagnose or treat SUDs, or they believe it is not their responsibility to do so.
- Providers have limited skills to provide care for SUDs. The large majority of medical providers feel “very prepared” to diagnose and treat hypertension, diabetes or depression. However, only a few feel “prepared” to detect SUDs or risky substance use.
- SUDs affect 15.9 percent of the population, which is higher than rates of heart conditions, diabetes or cancer. Yet spending on these other conditions—$107 billion on heart diseases, $86.6 billion on cancer, and $43.8 billion on diabetes (CASA Columbia, 2012)—is considerably higher than what is spent on addiction care ($28 billion). In addition, heavy drinking, misuse of prescription drugs or use of illicit drugs (“risky use”) affects even more people. Even a single episode of using too much alcohol, ingesting a synthetic drug like molly or using someone else’s opioid prescription can lead to a negative or fatal outcome.
- SUDs contribute to medical, family, psychological, and social problems. The use of and addiction to tobacco, alcohol or other drugs contributes to 20 percent of all deaths, more than seventy medical conditions, and 32 percent of hospital costs (CASA Columbia, 2012). SUDs can contribute to a significant decrease in the lifespan and the risk of early death from accidents, overdoses or medical problems caused or worsened by substance use.
- Too few people with SUDs receive help. Most people with hypertension (77.2 percent), diabetes (72.9 percent) or major depression (71.2 percent) get medical help (CASA Columbia, 2012). Sadly, only 10.9 percent with SUDs (including nicotine addiction) get help. While effective medication and psychosocial treatments are available, less than 6 percent of referrals to publically funded addiction programs come from medical health care providers. The majority of referrals come from the criminal justice system.
How Medical Systems and Providers Can Help
Providers need to acknowledge that substance use and SUDs need to be addressed as part of a comprehensive approach to medical care. They must show empathy, learn intervention skills, and control negative attitudes and behaviors, all of which improve their ability to understand and address SUDs in ways that produce positive results. Medical professionals also need a network of addiction providers and programs for patients and family members. Keeping abreast of evidence-based practices for SUDs, access to case consultations, and sharing experiences with other providers are all imperative for effective management of SUDs in medical settings.
In addition to careful use and monitoring of prescription medications with addictive potential, ways medical providers can help patients in medical settings include the following.
- Screen for substance use. Brief screening instruments are easy to use and access on the Internet. Common ones used include the NIDA Drug Use Screening Tool-Quick Screen, the Opioid Risk Tool, the CAGE questionnaire about alcohol or drug use (four questions), the DAST (ten or twenty questions for drug use), and the MAST or AUDIT-C for alcohol use.
- Assess for SUDs when a brief screen or history indicate a potential SUD. A full assessment may be administered at the medical site or through a referral to a licensed addiction provider in the community. Urine drug screens, blood alcohol levels, and other lab tests can also be used to assess substance use.
- Educate patients and families. Patients and families should be taught about substance use; SUDs (causes, effects, symptoms, addiction and the brain); medication and behavioral treatments; mutual support programs; relapse; recovery; community resources; and the effect of substances on medical, psychological, spiritual, interpersonal, family, and financial functioning.
- Influence or motivate patients (and/or families) to get help. Motivational interviewing (MI) can influence patients to change alcohol or drug use, or get patients with severe SUDs to agree to engage in specialty care in an addiction program. Families who are overwhelmed and emotionally distraught, or individual members with clinical depression, anxiety or other conditions can be influenced to get help with a therapist or counselor. Patients and families can also be influenced to engage in mutual support programs (AA, NA, Al-Anon, Nar-Anon, other Twelve Step, and non-Twelve-Step programs).
- Provide brief interventions for less severe types of substance problems. These may help patients reevaluate and cut down substance use or consider stopping. Brief interventions such as MI may also provide patients with feedback about their problem, give them advice on ways to change, and provide a menu of options to address their substance problem.
- Initiate medication-assisted therapy (MAT) for substance dependence. This includes managing withdrawal for patients addicted to opioids or alcohol, or providing MATs for ongoing recovery. While medical systems are increasing their use of medications like buprenorphine and Vivitrol for long-term treatment of opioid addiction, far too few use medications for nicotine or alcohol dependence. Patients dependent on nicotine or alcohol can be offered options as a tool to aid their recovery. It is recommended that all patients using medications for addiction also engage in therapy and/or mutual support programs. While some medical professionals provide ongoing medications for addiction, others will initiate medication use and then encourage patients to engage in an addiction program for ongoing MATs.
- Monitor progress and/or participation in addiction treatment or recovery programs. Medical professionals can monitor patients’ current substance use and participation in addiction treatment and/or recovery programs. Help may be provided for patients not doing well, who are poorly compliant with addiction treatment or recovery or who may need a higher level of care such as medical detoxification or a rehabilitation program.
- Consider the impact of SUDs on families. Family members often experience emotional, behavioral, and financial problems associated with loved ones’ SUDs. This may lead them to seek medical help for a range of medical complaints or problems: anxiety, headaches, tension, stress or depression. These problems may also be identified during a provider’s discussion with patients about the impact of their substance use on loved ones.
- Consider alternatives for chronic pain. Many nonopioid drugs and behavioral interventions can help patients with pain. SAMHSA and the Center for Disease Control have numerous protocols for prescribing opioids and pain management that can be accessed on the Internet. Nonaddictive medications for pain and alternative therapies can help with many types of pain.
- Educate patients prescribed opioids and family members about naloxone. This drug reverses opioid overdoses. Many individuals have survived an opioid overdose by being administered naloxone by family members, other addicted people, concerned others or first responders such as police, EMS personnel, and firefighters.
Medical providers can help individuals and families if they screen for SUDs, provide brief interventions on site, refer to specialty care if needed, and encourage patients to learn to manage their SUDs by engaging in a recovery program in their community. Many interventions can be adapted to medical settings to impact all types and severities of substance use and SUDs. These problems are the responsibility of all health care professionals, including those in hospitals, emergency rooms, and medical practices in our communities.
CASA Columbia. (2012). Addiction medicine: Closing the gap between science and practice. Retrieved from http://www.centeronaddiction.org/addiction-research/reports/addiction-medicine