Addiction Medicine: Closing the Gap between Science and Practice

586 Pages·2012·3.46 MB·English

by  Susan P. Brown

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-