Helping Your Patients Join the Voices for Recovery
People who work in any health care profession have a good chance of encountering patients with alcohol and drug use disorders—which include misuse, dependence, or addiction to alcohol and/or legal or illegal drugs—as more than 25 million Americans age 12 or older needed treatment for alcohol or illicit drug use disorders in 2002.1
In addition to trained treatment specialists, other providers such as primary care providers, mental health providers, recovery center staff and volunteers, and emergency room physicians all may care for people in need of treatment for an alcohol or drug use disorder. A Substance Abuse and Mental Health Services Administration (SAMHSA) report, Emergency Department Trends From the Drug Abuse Warning Network, found that:
More than 670,000 emergency department visits in the continental United States in 2002 were induced by or related to alcohol and drug use disorders.
Almost half of all drug-related emergency department visits that same year resulted in admission to the hospital.2
Unfortunately, large numbers of people in need of treatment for alcohol and drug use disorders do not receive it. In 2002, 35 percent (266,000) of Americans who recognized they needed treatment for an alcohol use disorder tried but were unable to obtain treatment. Those seeking treatment for drug use disorders have experienced similar difficulties, according to SAMHSA's Overview of Findings from the 2002 National Survey on Drug Use and Health.3
Members of the health care and wellness community can play an important role in helping people in need find treatment for substance use disorders. Doing so, however, requires providers to recognize alcohol and drug use disorders in their patients and then refer them to treatment that can help them achieve recovery.
Because achieving recovery can take many pathways—physical, mental, emotional, and/or spiritual—a new initiative from President Bush empowers individuals to choose the providers and programs that best meet their needs. The centerpiece of this initiative is the Access to Recovery grant program, which provides people seeking treatment with vouchers to pay for a range of effective, community-based, substance abuse clinical treatment and recovery support services.
By providing vouchers to people in need of treatment, the grant program promotes individual support for substance abuse treatment and recovery services. It also expands access to care, including access to faith- and community-based programs, and increases substance abuse treatment capacity.
What Kind of Treatment Is Needed?4, 5
The type of treatment needed for alcohol and drug use disorders varies with the type of substance the person has misused, as well as with the person's personal needs and characteristics. In most cases, the process starts with an assessment so that an individualized treatment plan can be developed. As a component of treatment, some people may require medical detoxification (detox), a process under the care of a physician that helps manage physical withdrawal symptoms that can occur when someone stops taking a drug or other substance. Treatment also may include behavioral therapy (such as counseling, cognitive therapy, or psychotherapy), medications, or a combination of both. Behavioral therapies offer people strategies for coping with their cravings, teach them ways to avoid drugs and alcohol, prevent relapse, and help them deal with relapse if it occurs.
During and after the treatment program, a range of testing, transitional, and after care (follow-up) services—such as mutual support groups—frequently are offered to assist with health care, employment, family concerns, and other issues critical to reaching and sustaining recovery.
How Effective Is Treatment?
A major study published in the Journal of the American Medical Association in 2000 is one of several studies that have demonstrated the effectiveness of treatments for alcohol and drug use disorders. The study found that treatments for alcohol and drug use disorders are as effective as treatments for other chronic conditions, such as high blood pressure, asthma, and diabetes. And the frequency with which people treated for alcohol and drug use disorders experience relapses is similar to the relapse rate among people treated for other conditions, the study found.6
The authors of the study concluded that in most cases, drug dependence is treated as an acute illness. Yet "review results suggest that long-term care strategies of medication management and continued monitoring produce lasting benefits," the researchers reported. "Drug dependence should be insured, treated, and evaluated like other chronic illnesses."7
Other studies confirm these findings and show that even brief interventions can help. For example, a 1999 study published in Annals of Surgery found that even a 30-minute counseling session was found to be effective in reducing alcohol use among people with alcohol and drug use disorders.8 Additionally, an emerging body of research and clinical experience supports the use of the Screening, Brief Intervention and Referral to Treatment (SBIRT) approach for non-dependent persons who are experiencing problems related to the use of illicit drugs.9 More information about the SBIRT approach can be found at http://ncadi.samhsa.gov/govpubs/BKD341/.
Despite the effectiveness of treatment, a Columbia University survey found that only a small number of medical practitioners agree that treatments for alcohol and drug use disorders are very effective, even though most believe in the effectiveness of treatments for other chronic conditions.10 More effective communication and education about the proven benefits of treatments for alcohol and drug use disorders can help all people in the health care field understand the need to increase patients' access to a variety of treatment options.
What Are the Benefits of Treatment?
A number of published studies have shown specific ways that people recovering from alcohol and drug use disorders, their families, friends, and communities benefit from treatment programs designed to guide individuals through the recovery process. In particular, the National Treatment Improvement Evaluation Survey commissioned by SAMHSA's Center for Substance Abuse Treatment found that these programs can decrease:
Alcohol use
Traffic violations and incidents of driving under the influence
Risk-taking behavior and injuries that require hospitalization
Alcohol-related and other arrests11
Homelessness12
At the same time, the SAMHSA study found that treatment improves mental and physical health, while boosting employment rates.13
Health care providers can offer more comprehensive and effective care if they identify and address alcohol and drug use disorders as the primary, underlying cause of some of their patients' health problems. Similarly, it is important to remember that people fighting alcohol and drug use disorders often also have diseases such as diabetes, cardiovascular disease, hepatitis C, and high blood pressure—conditions that can be exacerbated if alcohol and drug use disorders are not addressed head-on.
Mental disorders are common among people with alcohol and drug use disorders; about half of people with a lifetime mental disorder also have a lifetime history of at least one alcohol or drug use disorder.14
Treatment of both mental and alcohol and drug use disorders can help prevent the exacerbation of health problems, according to SAMHSA's Report to Congress on the Prevention and Treatment of Co-occurring Substance Abuse Disorders and Mental Health Disorders.15
What Barriers Do Providers Face in Identifying and Referring Patients?
Primary care providers and other health care providers face numerous pressures that limit their ability to recognize alcohol and drug use disorders in their patients and refer them to treatment, such as:
Time constraints
Skepticism about the effectiveness of treatment
Lack of adequate training to identify the disorders
Discomfort in discussing alcohol and drug use disorders
Patient resistance16
Additionally, staff members working in recovery programs, as well as other members of the health and human services work force, may lack adequate credentials and training specifically in the area of alcohol and drug use disorders. This problem was identified and is being reviewed by SAMHSA's Partners for Recovery initiative, the evolutionary successor to the National Treatment Plan Initiative. Building on prior national efforts, Partners for Recovery is a collaboration of communities and organizations mobilized to help individuals and families achieve and maintain recovery, and lead fulfilling lives.17
Overall, more than 9 in 10 primary care physicians fail to spot alcohol and drug use disorders in adults, and 4 in 10 miss it in teens.18 Additionally, nearly 11 percent of patients in the study said they believed their physician knew about their disorder and did nothing about it.19
There is evidence that training in the identification and diagnosis of alcohol and drug use disorders can have a sustained effect on health professionals' ability to intervene with patients. Five years after participating in a seminar on the detection of and brief intervention for people with an alcohol or drug use disorder, more than 91 percent of participants—including physicians, nurses, physicians assistants, social workers, and psychologists—stated they were still using techniques they had learned at the interdisciplinary seminar.20
Making a Difference: What Can I Do?
Get the facts. Learn about the newest science-based treatment protocols and about the nature of alcohol and drug use disorders. Increase your understanding of the recovery process. Refer to the resources listed at the end of this backgrounder for assistance in locating up-to-date information about alcohol and drug use disorders for medical professionals.
Examine your own perceptions. Even in the medical community, the perception remains that alcohol and drug use disorders are a moral weakness, despite research that clearly establishes them as medical disorders.21 This stigma compromises the ability of people in need to get treatment. Well-trained and informed health care providers, using evidence-based diagnostic and therapeutic practices, can be a major component in the effort to provide treatment to patients with alcohol and drug use disorders.
Employ screening instruments to help identify those in need of services. Make every effort to identify when a patient's health problems may have been worsened by an underlying problem with an alcohol or drug use disorder. Experts recommend that primary care clinicians "periodically and routinely screen all patients for substance use disorders."22 In addition to questioning patients, providers can use a variety of screening instruments, including CAGE (Cutting down, Annoyance by criticism, Guilty feeling, Eye openers), CAGE-AID (CAGE Adapted to Include Drugs), AUDIT (Alcohol Use Disorders Identification Test), TWEAK (Tolerance, Worry, Eye opener, Amnesia, (K)cut down), and MAST (Michigan Alcohol Screening Test). These screening tools are described in depth in Treatment Improvement Protocol (TIP) Series #24, A Guide to Substance Abuse Services for Primary Care Clinicians (DHHS Publication No. (SMA) 97-3139). It can be ordered free of charge from SAMHSA's clearinghouse, the National Clearinghouse for Alcohol and Drug Information (NCADI), at 1-800-729-6686 or 1-800-487-4889 (TDD). NCADI also can be found online at www.ncadi.samhsa.gov.
Take a holistic approach to treating patients. For treatment to be fully effective, health care providers must offer coordinated treatment for both mental disorders and alcohol and drug use disorders.
Recognize that "one size does not fit all." Programs for treating alcohol and drug use disorders are most effective if they are individualized to the needs of the patient, recognizing cultural backgrounds and special needs. A new initiative launched by President Bush, Access to Recovery, expands access to care, including access to faith-and community-based programs, and increases substance abuse treatment capacity. The Access to Recovery grant program provides people vouchers that can be used to select treatment programs that reflect their values and needs. More information about the Access to Recovery initiative and grant program is available from SAMHSA at www.samhsa.gov.
Making a Difference: How Can I Contribute to Recovery Month?
We encourage everyone in a health care profession to participate in National Alcohol and Drug Addiction Recovery Month (Recovery Month) this September. Your voice is vital to the success of the 15th annual celebration of Recovery Month. Here are some ideas you may consider:
Encourage others to take action. Please encourage fellow health care professionals to take advantage of training and continuing education opportunities so they are better equipped to identify patients with alcohol and drug use disorders and can refer them to treatment. Support efforts to increase medical students' knowledge of alcohol and drug use disorders, and offer to lead regular training sessions for volunteers and other staff members. Talk openly about the need for the medical community to overcome stigmas associated with alcohol and drug use disorders.
Examine your own workplace benefits. Objectively evaluate your own workplace benefits to see if there are equal resources for your employees when it comes to mental health services and treatment for alcohol and drug use disorders. Facilitate the provision of adequate treatment services for family members as well as the primary insurance beneficiary.
Participate in a community forum. Many cities around the nation will be hosting community forums during Recovery Month to talk about alcohol and drug use disorders, discuss recovery-related topics, and solve identified problems. Consider becoming a forum participant. Your expertise and commitment will be invaluable. To find more information about local events in your community, visit the official Recovery Month Web site at www.recoverymonth.gov. (Click on the 2004 icon and look under events.) If no activities are scheduled, offer to help develop some. Community-based associations, foundations, local businesses, and faith-based organizations are some groups you can work with when organizing an event.
Tell your own story, if you are comfortable doing so. If you are recovering from an alcohol or drug use disorder (or someone close to you is doing so), you can be a powerful voice for the effectiveness of treatment. As a respected member of your community, you may be able to affect benefit and service delivery decisions. You may want to consult your employee assistance program or human resources representative first to identify the most suitable and receptive audience for your disclosure. For maximum impact, if you have colleagues who also are in recovery, ask them if they would like to join you.
For additional Recovery Month materials, visit our Web site at www.recoverymonth.gov or call 1-800-662-HELP.
PROVIDER RESOURCES
General Information
Alcohol and Drug Services
Educates physicians to prevent and treat dependence on alcohol and other drugs
3900 Jermantown Road, Suite 200 Fairfax, VA 22030 703-934-5477 www.fairfaxcounty.gov
American Medical Association Office of Alcohol and Other Drug Abuse
A collaboration of the AMA and The Robert Wood Johnson Foundation to reduce underage alcohol abuse
515 North State Street Chicago, IL 60610 800-621-8335 (Toll-Free) www.ama-assn.org/ama/pub/ category/3337.html
Association for Medical Education and Research in Substance Abuse (AMERSA) Training and materials for medical professionals and students
125 Whipple Street, Suite 300 Providence, RI 02908 401-349-0000 www.amersa.org www.projectmainstream.net
Institute for the Advancement of Human Behavior Continuing medical education for mental health, chemical dependency, and alcohol and drug use disorder treatment providers in the United States and Canada
4370 Alpine Road, Suite 209 Portola Valley, CA 94028 800-258-8411 (Toll-Free) www.iahb.org
International Nurses Society on Addictions Information and education for nurses concerning prevention, intervention, treatment, and management of substance use disorders
P.O. Box 10752Raleigh, NC 27605 919-821-1292 www.intnsa.org
Johnson Institute Training and technical assistance for counselors, treatment institutions, school teachers, and policy makers
D.C. Office: 1273 National Press Building 529 14th Street NW Washington, D.C. 20045 202-662-7104 MN Office: 10001 Wayzata Boulevard Minnetonka, MN 55305 952-582-2713 www.johnsoninstitute.org
Physicians and Lawyers for National Drug Policy Conducts research on drug use disorders, provides information to the public about substance use disorders, and works to put a new emphasis on the national drug policy by substantially refocusing the investment in the prevention and treatment of harmful drug use
PLNDP National Project Office Center for Alcohol and Addiction Studies Brown University Box G-BH Providence, RI 02912 401-444-1817 www.plndp.org
Specialty Treatment Providers:
Alcoholism and Substance Abuse Providers of New York State
Programs and agencies throughout New York State that provide substance use disorder prevention, treatment, research, and training
1 Columbia Place Albany, NY 12207 518-426-3122 www.asapnys.org
American Association for Marriage and Family Therapy Tools and resources for marriage and family therapists
112 South Alfred Street Alexandria, VA 22314-3061 703-838-9808 www.aamft.org
American Mental Health Counselors Association
Professional resources for licensed mental health counselors and state chapters
801 North Fairfax Street, Suite 304 Alexandria, VA 22314 703-548-6002 www.amhca.org
NAADAC, The Association for Addiction Professionals
Professional organization that serves counselors who specialize in treating alcohol and drug use disorders
901 N. Washington Street, Suite 600 Alexandria, VA 22314 800-548-0497 (Toll-Free) www.naadac.org
National Association of Addiction Treatment Providers
Resources for substance use disorder treatment providers
313 West Liberty Street, Suite 129 Lancaster, PA 17603-2748 717-392-8480 www.naatp.org
National Council for Community Behavioral Healthcare Education, advocacy, and networking for community providers of mental health and substance use disorder treatment services
12300 Twinbrook Parkway, Suite 320 Rockville, MD 20852 301-984-6200 www.nccbh.org
Research
Addiction Technology Transfer Centers
Identify and promote opportunities for advancing addiction treatment research
University of Missouri—Kansas City 5100 Rockhill Road Kansas City, MO 64110-2499 816-482-1200 www.nattc.org
CompassPoint Addiction Foundation
Research about the causes and nature of substance use disorders
7711 East Greenway Street, Suite 211 Scottsdale, AZ 85254 480-368-2688 www.addictionresearch.com
Harvard Medical School - Division on Addictions Provides education and training to health care workers who treat alcohol and drug use disorders and to scientists who study them
401 Park Drive, Second Floor East Boston, MA 02115 617-432-0058 www.hms.harvard.edu/doa
National Center on Addiction and Substance Abuse at Columbia University (CASA)
Health, treatment, and policy research regarding substance use disorders
633 Third Avenue, 19th Floor New York, NY 10017 212-841-5200 www.casacolumbia.org
Psychiatry and Psychology
American Academy of Addiction Psychiatry
Continuing education for alcohol and drug use disorder treatment professionals
1010 Vermont Avenue NW, Suite 710 Washington, D.C. 20005 202-393-4484 www.aaap.org
American Psychiatric Association Mental health information for professionals, individuals, and families
1000 Wilson Boulevard, Suite 1825 Arlington, VA 22209-3901 888-357-7924 (Toll-Free) www.psych.org
American Psychological Association Mental health information for professionals, individuals, and families
750 First Street NE Washington, D.C. 20002-4242 800-374-2721 (Toll-Free) 202-336-6123 (TDD/TTY) www.apa.org
American Society of Addiction Medicine
Information for healthcare providers about prevention and treatment of substance use disorders
4601 North Park Avenue Upper Arcade, Suite 101 Chevy Chase, MD 20815-4520 301-656-3920 www.asam.org
Mutual Support Groups
Al-Anon/Alateen Support for families and friends of alcoholics
Al-Anon Family Group Headquarters, Inc. 1600 Corporate Landing Parkway Virginia Beach, VA 23454-5617 888-4AL-ANON/888-425-2666 (Toll-Free) www.al-anon.alateen.org
Alcoholics Anonymous
Support group that provides sponsorship and a Twelve Step program for life without alcohol
475 Riverside Drive, 11th Floor New York, NY 10115 212-870-3400 www.aa.org
Narcotics Anonymous Organization for people recovering from a drug use disorder
P.O. Box 9999Van Nuys, CA 91409 818-773-9999 www.na.org
Sources
Overview of Findings from the 2002 National Survey on Drug Use and Health. DHHS Publication No. (SMA) 03-3774. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, 2002, p. 8.
Emergency Department Trends From the Drug Abuse Warning Network, Final Estimates 1995-2002, DHHS Publication No. (SMA) 03-3780. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 2003, p. 31.
Overview of Findings from the 2002 National Survey on Drug Use and Health, p. 8.
Principles of Drug Addiction Treatment: A Research Based Guide. NIH Publication No. 99-4180. Bethesda, MD: National Institutes of Health, National Institute on Drug Abuse, October 1999/Reprinted July 2000, p. 3.
Drug and Alcohol Services Information System: The DASIS Report. "Services Provided by Substance Abuse Treatment Facilities." Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, August 29, 2003, Table 1.
Kleber, H.D., O'Brien, C.P., Lewis, D.C., and McLellan, A.T. Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation. Journal of the American Medical Association, 284 (13), Chicago, IL: American Medical Association, October 4, 2000, p. 1689.
ibid.
Gentilello, L.M. MD et. al. Alcohol Interventions in a Trauma Center as a Means of Reducing the Risk of Injury Recurrence. Annals of Surgery, Vol. 230(4) October 1999, p. 473.
Bernstein E., Bernstein J., and Levenson S. Project ASSERT: An ED-based intervention to increase access to primary care, preventive services and the substance abuse treatment system. ANN Emerg Med 30: 1997, pp. 181-9.
Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse. New York, NY: National Center on Addiction and Substance Abuse, Columbia University, April 2000, pp. 21, 22.
ibid, p. 473.
Dean R, Gerstein et al. The National Treatment Improvement Evaluation Survey: Final Report. Chicago, IL: National Opinion Research Center, University of Chicago, March 1997, Table 3.
ibid, Tables 3, 4.
Kessler, R.C., Nelson, C.B., and McGonagle, K.A., et al. The epidemiology of co-occurring addictive and mental disorders: Implications for prevention and service utilization. American Journal of Orthopsychiatry 66(1), January 1996, pp. 17-31.
Report to Congress on the Prevention and Treatment of Co-occurring Substance Abuse Disorders and Mental Disorders. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 2002, p. ix.
Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse, p. 22.
Improving Substance Abuse Treatment: The National Treatment Plan Initiative, Changing the Conversation. DHHS Publication No. (SMA) 00-3479. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 2000, p. iii.
Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse, p. 5.
ibid, p. i.
Naegle, M. (2002). Nursing education in the prevention and treatment of SUD. In Strategic Plan for Interdisciplinary Faculty Development: Arming the Nation's Health Professional Workforce for a New Approach to Substance Use Disorders (Mary Haack and Hoover Adger, Editors). Substance Abuse, 23 (3): pp. 247-261.
Cami J, Farre M. Drug addiction. New England Journal of Medicine 349(10), September 2003, pp. 975-986.
A Guide to Substance Abuse Services for Primary Care Physicians. Treatment Improvement Protocol (TIP) Series 24. DHHS Publication No. (SMA) 97-3139. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, 1997, section entitled "Summary of Recommendations, Screening."
