Substance use disorders are among the most compromising
problems that confront health professionals. In the
United States, 18% of people experience a substance use disorder
at some point in their lives, and some 20% of patients
in general medical facilities and 35% in general psychiatric
units present with substance use disorders. Although the sequelae
of addiction, such as cirrhosis, psychopathology,
trauma, and infection, generally receive proper medical attention,
patients' primary addictive problems often go untreated.
Public and governmental awareness of the need for
greater research and treatment resources has, however, increased
in recent years, and substance abusers now seek help
earlier, at a point when treatment can be administered more
effectively. Additionally, health care providers have been well-alerted
to the need for early diagnosis and comprehensive
care, and new treatment concepts, both pharmacological and
psychosocial, have made a recovery process a possibility for
most alcohol and drug-abusing patients. The longstanding
struggle to assure parity for treatment of substance use disorders
with other medical illnesses therefore takes place in a society
increasingly cognizant of the medical and humanitarian
benefit of pursuing this goal.
We are heartened by the important advances made in the
underlying science, the technology of psychosocial modalities,
and the growth of pharmacotherapies in our field. At the
same time, however, one very important issue must be implicit
in the clinician's work: one's opportunity to help substance
abusers overcome their illnesses still rests on the ability
to relate to each given patient. The defensiveness and
denial characteristic of the disorders we examine in this book
can only be overcome by an intuitive and empathic engagement
with their suffering and a willingness to stay with the
patient through the vicissitudes of recovery. We hope that
this volume enables the reader to gain the knowledge necessary
to apply this important skill.
Substance abuse is a major problem both nationally and
internationally. Drug trends tend to rise, peak, fade, and then
re-emerge. Methylenedioxymethamphetamine (MDMA;
“ecstasy”) rose sharply in the 1990s, dropped dramatically in
the early years of the current decade, and is now on the rise
again. Heroin use increased during the 1990s and has lately
been stable, but prescription opioid abuse has sharply increased.
Part of the shifting trends relate to generational forgetting
(e.g., in the case of ecstasy); others relate to increased
purity and decreased price (e.g., heroin) or changes in availability
secondary to prescribing patterns (e.g., prescription
opioids and stimulants).
Drug use patterns observed in the United States also appear
in other countries. Australia and Canada, for example,
now have similar patterns of static or decreased heroin use
and increased prescription opioids. Numerous countries, especially
in Asia, are experiencing sharp increases in the use of
amphetamine-type stimulants. Regardless of the trend, we
unfortunately can be certain that substance use and abuse
will remain major public health problems for the foreseeable
future. This has led to the formation of several organizations
overseas established to address the addiction problem. One
such group that seeks to bring together researchers and clinicians
is the International Society of Addiction Medicine, with
a large complement of members in countries throughtout the
six continents, including a sizeable American membership,
and with ties to the National Institute on Drug Abuse in the
United States.
The first edition of this volume emerged from the growing
commitment of the country to address the problem of
substance abuse. In the decades before the first edition came
out, a number of significant events occurred, including the
establishment of National Institutes on both alcohol and
drug abuse in the early 1970s. In 1982, the American Psychiatric
Association established its Task Force on Treatment of
Psychiatric Disorders, consisting of 26 panels. We served as
chairpersons of the panels on disorders of alcohol and other
drug abuse, respectively. In response to this APA initiative,
we brought together a group of experts who could provide a
carefully drawn perspective on addiction treatment, perhaps
the most comprehensive one to date.
Soon after the publication of the Task Force's volumes,
we decided that it was important to update and amplify the
substance abuse treatment information. We wanted to focus
on the most recent developments in biological and psychosocial
therapies and the problems of specific populations.The resulting volume, the first edition of this textbook, was
published in 1994. The second followed in 1999, and the
third in 2004. We are now pleased to present a fully updated
version of this textbook, tailored to present the most current
basic science and clinical information on the substance
abuse field. In accordance with the need to provide fresh perspectives
on the issues presented, new chapters have been
added and new authors have been invited to present the issues
covered. For example, because of a growth in the basic
understanding of mechanisms of action of different drugs of
abuse, we are now presenting separate chapters on the biology
and clinical management for each of the drug categories
in the second section of this book. The nature and role of buprenorphine,
an important addition to the armamentarium
of physicians treating opioid addiction, is now presented in
much greater detail. A greater understanding of the nature of
12-step programs and their role in addiction treatment has
allowed for more attention to this fellowship. In order to increase
the utility of this volume, we have made more use of
tabular presentation of material.
Substance abuse training is now an integral part of undergraduate
curricula in most medical schools and is allocated
a one-month, full-time equivalent component in psychiatry
residency programs. The approval of the American
Board of Psychiatry and Neurology (ABPN) for an Added
Qualification in Addiction Psychiatry was of major importance
in establishing addiction as a medical subspecialty. The
American Board of Medical Specialties, under its guidelines
for establishing subspecialties, sanctioned this process. Certification
is given by APBN on the basis of an examination,
first given in 1993. A minimum of 1 year of associated training
in an accredited PGY5 residency is now required as well.
The Accreditation Council for Graduate Medical Education
reviews the curricula of these respective training programs,
and completion of such a program is required by candidates
to sit for the subspecialty examination.
More than 1,800 psychiatrists have been certified in addiction
psychiatry. These subspecialists meet a variety of
clinical and academic needs, and the range of training experiences
provided by the addiction residency programs has
been designed to prepare them for this. Postresidency fellowships
in addiction psychiatry now number more than 40.
Addiction fellows spend about half their time on patient care
and devote the rest of their time to research, teaching, and
their own learning. These programs have shown considerable
vitality and are playing an influential role in ensuring
quality treatment for the future. Unfortunately, however,
less than half of the population in need of substance abuse
treatment actually receives it. This is a function of both the
reluctance of private and public payors to adequately fund
treatment and the affected population to seek it. More needs
to be done on this latter issue.
We have designed this volume to serve clinicians in practice
and researchers as well as trainees in psychiatry who are
concerned with addiction, general medicine, and other
health professions. We hope that this book will serve as a
valuable treatment resource for any health care professional
concerned with the problems posed by patients with substance
use disorders.