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Addiction Medicine: Closing the Gap between Science and Practice

586 Pages · 2012 · 3.46 MB · English

  • Addiction Medicine: Closing the Gap between Science and Practice





    Addiction Medicine:


    Closing the Gap between Science and Practice













    June 2012






    Funded by:


    The Annenberg Foundation


    The Diana, Princess of Wales Memorial Fund and The Franklin Mint


    The New York Community Trust


    Adrian and Jessie Archbold Charitable Trust


    Board of Directors


    Lee C. Bollinger Rev. Edward A. Malloy, CSC


    President, Columbia University President Emeritus, University of Notre Dame



    Ursula M. Burns Doug Morris


    Chairman and CEO, Xerox Corporation CEO, Sony Music Entertainment



    Columba Bush Bruce E. Mosler


    Former First Lady of Florida Chairman, Global Brokerage,


    Cushman & Wakefield, Inc.


    Joseph A. Califano, Jr.


    Founder and Chairman Emeritus, CASA Columbia Manuel T. Pacheco, Ph.D.


    President Emeritus, University of Arizona and


    Kenneth I. Chenault University of Missouri System


    Chairman and CEO,


    American Express Company Joseph J. Plumeri


    Chairman and CEO,


    Peter R. Dolan Willis Group Holdings PLC


    Chairman, ChildObesity180


    Jim Ramstad


    William H. Foster, Ph.D. Former Member of Congress (MN-3)


    President and CEO, CASA Columbia


    Shari E. Redstone


    Victor F. Ganzi President, National Amusements, Inc.


    Chairman of the Board PGA Tour


    E. John Rosenwald, Jr.


    Melinda B. Hildebrand Vice Chairman Emeritus, J.P.Morgan



    Ralph Izzo, Ph.D. Michael I. Roth


    Chairman of the Board, CEO and President, Chairman and CEO, The Interpublic Group


    Public Service Enterprise Group, Inc. (PSEG) of Companies, Inc.



    Gene F. Jankowski Mara Burros Sandler


    President, CBS Broadcasting, Retired


    Michael P. Schulhof


    David A. Kessler, M.D. Chairman, GTI Holdings LLC



    Jeffrey B. Kindler Louis W. Sullivan, M.D.


    President Emeritus, Morehouse School of Medicine


    Jeffrey B. Lane


    Chairman, CASA Columbia John J. Sweeney



    Alan I. Leshner, Ph.D. Clyde C. Tuggle


    CEO, Executive Publisher, Science, American Senior Vice President, Chief Public Affairs and


    Association for the Advancement of Science Communications Officer, The Coca-Cola Company



    Directors Emeritus


    James E. Burke (1992-1997) Donald R. Keough (1992-2010)


    Jamie Lee Curtis (2001-2009) LaSalle D. Leffall, Jr., M.D., F.A.C.S. (1992-2001)


    Jamie Dimon (1995-2009) Nancy Reagan (1995-2000)


    Mary Fisher (1996-2005) Linda Johnson Rice (1992-1996)


    Betty Ford (1992-1998) George Rupp, Ph.D. (1993-2002)


    Douglas A. Fraser (1992-2003) Michael I. Sovern (1992-1993)


    Barbara C. Jordan (1992-1996) Frank G. Wells (1992-1994)


    Leo-Arthur Kelmenson (1998-2006) Michael A. Wiener (1997-2009)



    Copyright ©2012. All rights reserved. May not be used or reproduced without the express written permission of The National Center


    on Addiction and Substance Abuse at Columbia University.


    The CASA Columbia National Advisory Commission on Addiction Treatment






    Drew E. Altman, PhD (Chair) June E. Osborn, MD


    President and Chief Executive Officer President Emerita


    The Henry J. Kaiser Family Foundation Josiah Macy, Jr. Foundation



    Harvey V. Fineberg, MD, PhD Manuel T. Pacheco, PhD


    President President Emeritus, University of Arizona


    Institute of Medicine and University of Missouri System



    Mark S. Gold, MD The Honorable Jose R. Rodriguez


    University of Florida College of Medicine Circuit Judge


    and McKnight Brain Institute Ninth Judicial Circuit of Florida


    Departments of Psychiatry, Neuroscience,


    Anesthesiology, Community Health & Family Reverend Msgr. Stephen J. Rossetti, PhD, DMin


    Medicine Clinical Associate Professor


    Chairman, Department of Psychiatry Associate Dean for Seminary


    and Ministerial Programs


    Shelly F. Greenfield, MD, MPH The Catholic University of America,


    Chief Academic Officer, McLean Hospital The School of Theology and Religious Studies


    Professor of Psychiatry, Former President and Chief Executive Officer


    Harvard Medical School Saint Luke Institute, Inc.


    Director, Clinical and Health Services Research


    and Education Leonard D. Schaeffer


    Division on Alcohol and Drug Abuse, Judge Robert Maclay Widney


    McLean Hospital Chair & Professor


    University of Southern California


    Elizabeth R. Kabler


    President Steven A. Schroeder, MD


    Rosenstiel Foundation Distinguished Professor of Health and Health


    Care, Department of Medicine


    Myles V. Lynk, JD Director, Smoking Cessation Leadership Center


    Peter Kiewit Foundation University of California, San Francisco


    Professor of Law and the Legal Profession


    Faculty Fellow, Center for Law, Science & Louis W. Sullivan, MD


    Innovation’s Program in Public Health Law President Emeritus


    and Policy Morehouse School of Medicine


    Sandra Day O’Connor College of Law


    Arizona State University



    Table of Contents



    Foreword and Accompanying Statement by Drew Altman, PhD ............................................. i


    I. Introduction and Executive Summary .....................................................................................1


    The CASA Columbia Study.................................................................................................4


    Key Findings ........................................................................................................................6


    Addiction Is a Brain Disease..........................................................................................6


    As with Other Health Conditions, There Are Clear Risk Factors for


    the Development of Addiction .................................................................................7


    Addiction Frequently Co-Occurs with Other Health Conditions ..................................7


    Addiction Can Be a Chronic Disease.............................................................................7


    A Lack of Standardized Terminology Compromises Effective Interventions ...............7


    Multiple Addictive Substances and Behaviors Frequently Are Involved in


    Risky Use and Addiction .........................................................................................7


    Public Attitudes about the Causes of Addiction Are Out of Sync with the Science .....8


    Physicians and Other Health Care Providers Should Be on the Front Line for


    Addressing this Disease ...........................................................................................8


    Screening and Intervention Are Effective at Addressing


    Risky Substance Use and Forestalling Addiction ....................................................9


    Effective Therapies to Treat and Manage Addiction Exist ............................................9


    The Importance of Tailored Interventions and Treatment ...........................................10


    Public Attitudes about Addiction Treatment Reflect the Prevailing


    Non-Medical Approach to Addiction Care ............................................................10


    Most People in Need of Treatment Do Not Receive It ................................................10


    Most Referrals to Publicly Funded Treatment Come from the


    Criminal Justice System .........................................................................................11


    Less than Half of Treatment Admissions Result in Treatment Completion ................12


    Patients Face Formidable Barriers to Receiving Addiction Treatment .......................12


    The Spending Gap........................................................................................................12


    Most Funding for Addiction Treatment Comes from Public Sources .........................13


    The Education, Training and Accountability Gap .......................................................13


    The Profound Disconnect between Evidence and Practice ..........................................13


    Recommendations and Next Steps.....................................................................................14


    Reform Health Care Practice .......................................................................................14


    Use the Leverage of Public Policy to Speed Reform in Health Care Practice ............15


    II. What Is Addiction? .................................................................................................................19


    Addiction Is a Brain Disease..............................................................................................20


    The Risk Factors for Addiction..........................................................................................22


    Genetic Risks ...............................................................................................................22


    Biological Risks ...........................................................................................................23


    Psychological Risks .....................................................................................................23


    Environmental Risks ....................................................................................................23


    Early Initiation of Use ..................................................................................................24


    Risky Use and Addiction Frequently Co-Occur with Other Health Conditions ................24


    Addiction Can Be a Chronic Disease.................................................................................25 Models for Understanding Addiction ................................................................................26


    Evolving Approaches to Addressing Addiction ................................................................26


    Defining the Terms ............................................................................................................29


    The Continuum of Substance Use................................................................................29


    Public Attitudes about Addiction .......................................................................................34


    Perceived Causes of Addiction ....................................................................................35


    III. Prevalence and Consequences ..............................................................................................39


    Defining the Problem .........................................................................................................40


    Risky Substance Users .......................................................................................................41


    Risky Tobacco Use ......................................................................................................43


    Risky Alcohol Use .......................................................................................................44


    Risky Illicit Drug Use ..................................................................................................46


    Risky Use of Controlled Prescription Drugs ...............................................................47


    Addiction............................................................................................................................48


    Special Populations ............................................................................................................51


    Pregnant Women ..........................................................................................................51


    Adolescents and Young Adults ....................................................................................51


    Older Adults .................................................................................................................52


    Co-Occurring Disorders ...............................................................................................52


    Members of the Military Exposed to Combat..............................................................53


    Involvement in the Justice System ...............................................................................55


    Consequences of Risky Substance Use and Untreated Addiction .....................................55


    Tobacco ........................................................................................................................58


    Alcohol .........................................................................................................................59


    Illicit Drugs ..................................................................................................................60


    Controlled Prescription Drugs .....................................................................................61


    IV. Screening and Early Intervention ........................................................................................63


    The Need for Patient Education, Screening and Intervention throughout the Lifespan ....64


    Childhood and Adolescence ........................................................................................64


    Young Adulthood.........................................................................................................65


    Middle and Later Adulthood ........................................................................................65


    Attending to Co-Occurring Conditions ..............................................................................66


    Patient Education and Motivation ......................................................................................66


    Screening............................................................................................................................66


    Laboratory Tests ..........................................................................................................68


    Brief Interventions and Treatment Referrals .....................................................................69


    Tobacco ........................................................................................................................69


    Alcohol and Other Drugs .............................................................................................70


    Effectiveness of Screening and Brief Interventions...........................................................71


    Tobacco ........................................................................................................................72


    Alcohol .........................................................................................................................72


    Other Drugs ..................................................................................................................73


    Implementing Screening and Brief Interventions in Health Care and Other Settings .......74


    Primary Care ................................................................................................................74


    Emergency and Trauma Care.......................................................................................76


    Health Care for Pregnant Women ................................................................................77


    Mental Health Care ......................................................................................................78


    Dental Care ..................................................................................................................78


    Pharmacies ...................................................................................................................78


    High School, College and University Settings ............................................................78


    Justice Settings .............................................................................................................79


    The Workplace .............................................................................................................80


    Government-Funded Social Service Systems ..............................................................81


    Barriers to Effective Implementation of Screening and Brief Interventions .....................81


    Insufficient Training ....................................................................................................81


    Competing Priorities/Insufficient Resources ...............................................................82


    Inadequate Screening Tools .........................................................................................83


    V. Treatment and Management of Addiction ...........................................................................85


    A Comprehensive Approach to Treatment ........................................................................86


    Assessment .........................................................................................................................87


    Stabilization .......................................................................................................................88


    Cessation of Use ..........................................................................................................88


    Detoxification ..............................................................................................................89


    Acute Care .........................................................................................................................92


    Pharmaceutical Therapies ............................................................................................92


    Psychosocial Therapies ..............................................................................................102


    Combined Therapies ..................................................................................................104


    Nutrition and Exercise ...............................................................................................106


    Chronic Disease Management .........................................................................................107


    Medically Supervised Disease Management .............................................................107


    Case Management ......................................................................................................108


    Support Services ..............................................................................................................109


    Mutual Support Services ............................................................................................109


    Auxiliary Support Services ........................................................................................113


    The Use of Technology in Addiction Treatment and Disease Management ...................114


    Public Attitudes about Addictive Substances and the Need for Addiction Treatment ....114


    Perceptions of the Relative Need for Treatment Based on Substance of Addiction .114


    Perceptions of the Goals of Treatment .......................................................................115


    Perceptions of the Types of Interventions that Constitute Treatment ........................116


    Perceptions of the Effectiveness of Treatment ..........................................................116


    VI. Tailored Treatment for Special Populations .....................................................................119


    Co-occurring Medical Disorders......................................................................................119


    Co-occurring Mental Health Disorders ............................................................................120


    Tobacco Cessation .....................................................................................................121


    Treatment for Addiction Involving Alcohol and Other Drugs ..................................121


    Adolescents ......................................................................................................................122


    Tobacco Cessation .....................................................................................................122


    Treatment for Addiction Involving Alcohol and Other Drugs ..................................123


    Women .............................................................................................................................124


    Pregnant Women ........................................................................................................124


    Older Adults .....................................................................................................................125


    Racial and Ethnic Minorities ...........................................................................................126


    Individuals of Minority Sexual Orientation .....................................................................126


    Veterans and Active Duty Military ..................................................................................127


    Individuals Involved in the Justice System ......................................................................128


    Juvenile Offenders .....................................................................................................128


    Adult Corrections .......................................................................................................128


    VII. The Addiction Treatment Gap .........................................................................................131


    Most People in Need of Treatment Do Not Receive It ....................................................133


    Variations in the Treatment Gap by Primary Substance Involved ............................134


    Variations in the Treatment Gap by Key Patient Characteristics ..............................135


    Regional Variations in the Treatment Gap ................................................................137


    Sources of Funding for Addiction Treatment ..................................................................137


    Privately-Funded Treatment ......................................................................................138


    Publically-Funded Treatment.....................................................................................138


    Trends in Spending on Addiction Treatment .............................................................139


    Expenditures by Providers and Types of Services .....................................................139


    Treatment Admissions .....................................................................................................141


    Treatment Referrals and Venues ......................................................................................142


    Treatment Completion .....................................................................................................145


    Variations in Treatment Completion by Source of Referral ......................................146


    Variations in Treatment Completion by Primary Substance Involved ......................146


    Variations in Treatment Completion by Key Patient Characteristics ........................146


    Link between Funding Source, Type of Service Provided and Treatment Completion ..146


    Barriers Patients Face in Accessing and Completing Addiction Treatment ....................147


    Misunderstanding of the Disease ...............................................................................147


    Negative Public Attitudes and Behaviors Toward People with Addiction ................148


    Privacy Concerns .......................................................................................................150


    Cost ............................................................................................................................151


    Lack of Information about How To Get Help ...........................................................152


    Limited Availability of Services ................................................................................152


    Insufficient Social Support ........................................................................................153


    Conflicting Time Commitments ................................................................................153


    Negative Perceptions of the Treatment Process.........................................................153


    Legal Barriers.............................................................................................................154


    Barriers to Treatment Access and Completion in Special Populations ...........................154


    Individuals with Co-Occurring Conditions ................................................................154


    Pregnant and Parenting Women.................................................................................155


    Adolescents ................................................................................................................155


    Older Adults ...............................................................................................................156


    The Homeless.............................................................................................................156


    Veterans and Active Duty Military ............................................................................157


    Rural Populations .......................................................................................................157


    Native Americans.......................................................................................................158


    VIII. The Spending Gap ............................................................................................................159


    The Rational Approach to Risky Substance Use and Addiction .....................................159


    Costs of Our Failure to Prevent and Treat Addiction as a Medical Condition ................160


    The Largest Share of Costs Falls to the Health Care System ....................................160


    Cost Savings of Addiction Screening, Intervention and Treatment ................................161


    Screening and Early Intervention ...............................................................................162


    Addiction Treatment and Disease Management ........................................................164


    Insurance Coverage of Addiction Treatment is Limited ..................................................166


    Parity Laws ................................................................................................................166


    The Patient Protection and Affordable Care Act of 2010 ..........................................168


    Gaps in Coverage within Public and Private Insurance Plans Continue to


    Impede Comprehensive Addiction Care .................................................................169


    IX. The Education, Training and Accountability Gap ...........................................................175


    The Size and Shape of the Addiction Treatment Workforce ...........................................176


    Licensing and Credentialing Requirements for Individuals who Provide


    Addiction Treatment .....................................................................................................177


    Medical Professionals ................................................................................................178


    Mental Health Professionals ......................................................................................183


    Acupuncturists ...........................................................................................................185


    Addiction Counselors.................................................................................................186


    Licensure, Certification and Accreditation Requirements for Addiction Treatment


    Programs and Facilities .................................................................................................187


    State Licensing Requirements....................................................................................188


    Federal Regulatory Requirements ..............................................................................189


    Accreditation Requirements.......................................................................................190


    Professional Staffing Requirements ...........................................................................191


    Treatment Service Requirements ...............................................................................193


    Quality Assurance Requirements ...............................................................................195


    X. The Evidence-Practice Gap ..................................................................................................199


    Current Approaches to Risky Substance Use and Addiction Are Inconsistent


    with the Science and Evidence-Based Care ..................................................................199


    Patient Education, Screening, Brief Interventions and Treatment Referrals .............200


    Assessment, Stabilization and Acute Treatment ........................................................204


    Tailored Treatment Services ......................................................................................208


    Chronic Disease Management ...................................................................................210


    Barriers to Closing the Evidence-Practice Gap ...............................................................212


    The Addiction Treatment Workforce is Not Qualified to Implement


    Evidence-Based Practices .......................................................................................212


    Health Professionals do not Implement Evidence-Based Addiction Care Practices .216


    Inadequate Use and Development of Pharmaceutical Treatments for Addiction ......219


    Inadequate Quality Assurance ...................................................................................220


    Inadequate Insurance Coverage .................................................................................222


    No Overarching Organizing Body for Addiction Science and Treatment .................223


    Efforts to Integrate Substance Use Prevention and Treatment into


    Mainstream Medicine ...................................................................................................223


    XI. Recommendations and Next Steps .....................................................................................227


    Reform Health Care Practice ...........................................................................................228


    Incorporate Screening and Intervention for Risky Substance Use,


    and Diagnosis, Treatment and Disease Management for Addiction


    into Routine Medical Practice ..............................................................................228


    All Medical Schools and Residency Training Programs Should Educate and


    Train Physicians to Address Risky Substance Use and Addiction ......................229


    Require Non-Physician Health Professionals to Be Educated and Trained to


    Address Risky Substance Use and Addiction ......................................................229


    Develop Improved Screening and Assessment Instruments ......................................230


    Establish National Accreditation Standards for All Addiction Treatment


    Facilities and Programs that Reflect Evidence-Based Care .................................230


    Standardize Language Used to Describe the Full Spectrum of Substance Use and


    Addiction..............................................................................................................230


    Use the Leverage of Public Policy to Speed Reform in Health Care Practice ................231


    Condition Grants and Contracts for Addiction Services on the Provision of


    Quality Care .........................................................................................................231


    Educate Non-Health Professionals about Risky Substance Use and Addiction ........231


    Identify Patients at Risk in Government Programs and Services where Costs of


    Risky Use and Addiction Are High .....................................................................231


    Develop Tools to Improve Service Quality ...............................................................231


    License Addiction Treatment Facilities as Health Care Providers ............................232


    Require Adherence to National Accreditation Standards that


    Reflect Evidence-Based Care ..............................................................................232


    Require that All Insurers Provide Coverage for Comprehensive Addiction Care .....232


    Expand the Addiction Medicine Workforce ..............................................................232


    Implement a National Public Health Campaign ........................................................233


    Invest in Research and Data Collection to Improve and Track Progress in Addiction


    Prevention, Treatment and Disease Management ................................................233


    Implement the National Institutes of Health’s (NIH) Recommendation to Create a


    Single Institute Addressing Substance Use and Addiction ..................................234


    Appendix A-Methodology .........................................................................................................235


    Appendix B-Key Informant Interview Guide and List of Key Informants ..........................245


    Appendix C-National Addiction Belief and Attitude Survey (NABAS) ...............................253


    Appendix D-Survey of New York State Addiction Treatment Directors .............................269


    Appendix E-Survey of New York State Addiction Treatment Staff .....................................285


    Appendix F- National Panel and National Online Survey of Members of Professional


    Associations Involved in Addiction Care ...........................................................................297


    Appendix G-Survey of Participants in Recovery ....................................................................305


    Appendix H-Screening and Assessment Instruments .............................................................311


    Notes ............................................................................................................................................325


    Bibliography ...............................................................................................................................429


    Accompanying Statement by


    Drew E. Altman, PhD, Chair, The CASA Columbia


    National Advisory Commission on Addiction Treatment



    In homes, doctors’ offices, hospitals, schools,


    prisons, jails and communities across America,


    misperceptions about addiction are undermining


    medical care. Although advances in


    neuroscience, brain imaging and behavioral


    research clearly show that addiction is a


    complex brain disease, today the disease of


    addiction is still often misunderstood as a moral


    failing, a lack of willpower, a subject of shame


    and disgust. Addiction affects 16 percent of


    Americans ages 12 and older--40 million people.


    That is more than the number of people with


    heart disease (27 million), diabetes (26 million)


    or cancer (19 million). Another 32 percent of


    the population (80 million) uses tobacco, alcohol


    and other drugs in risky ways that threaten


    health and safety.



    Like other public health and medical problems,


    we understand the risk factors for addiction. We


    have effective ways of screening for risky use


    and intervening. While as of now there is no


    cure for addiction, there are effective


    psychosocial and pharmaceutical treatments and


    methods of managing the disease. But as this


    landmark report by CASA Columbia shows in


    sharp detail, this is where the comparison with


    other health conditions ends. Unlike other


    diseases, we do little to effectively prevent and


    reduce risky use and the vast majority of people


    in need of addiction treatment do not receive


    anything that approximates evidence-based care.



    The medical system, which is dedicated to


    alleviating suffering and treating disease, largely


    has been disengaged from these serious health


    care problems. The consequences of this


    inattention are profound. America’s failure to


    prevent risky use and effectively treat addiction


    results in an enormous array of health and social


    problems such as accidents, homicides and


    suicides, child neglect and abuse, family


    dysfunction and unplanned pregnancies. CASA


    Columbia estimates that risky substance use and


    -i-



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