The Troubling History of Substance Use Disorder
Our relationship with substances has been documented for centuries. Many substances, including opium, cannabis, cocaine, and alcohol were used for medicinal and religious purposes, and only later devolved into recreational use and overconsumption and dependence. Today, this has led to about 4.2 million people who meet the criteria for marijuana use disorder and about 1.5 million users of cocaine. In addition, excessive alcohol use is the third most leading cause of death in the U.S. and contributes or causes over 200 diseases. In March 2022, the National Institute on Alcohol Abuse and Alcoholism3 reported that 14.5 million people were diagnosed with alcohol use disorder.
The onset of the COVID pandemic hasn’t helped matters. In fact, over 100,000 overdose deaths5 were recorded between 2020 and 2021, up 28.5% from the previous 12 months. The significant increase in overdoses can be attributed to multiple factors, such as programs closing or reducing their hours due to the pandemic and the illegal drug supply becoming deadlier with the availability of fentanyl.
We Need to Fix the SUD Screening Gap
As we continue to fight overdose deaths, we need to work to prevent overuse of substances before a disorder develops. Screening for risky substance use is crucial to this effort.
Despite this, comprehensive addiction training is rare in American medical education. Partially because of that, the National Center on Addiction and Substance Abuse has deemed SUD a “failure of the medical profession at every level”8 .
There’s been a decade-long push to legitimize medical education for SUD. This has moved the needle in the right direction: the House of Representative passed a bill to reimburse education costs for providers who work in addiction-afflicted areas, and 12 of the 52 addiction medicine fellowships received gold-standard board certification status.9
Still, it’s not enough. Only 15 of the 180 American medical programs teach addiction. The content remains unregulated. A bright spot: Boston University weaves addiction training into all four years. They train medical students to keep the conversation going, a technique called “motivational interviewing”—teaching students to include the patient every step of the way and encourages patients to talk about their health goals.
Across the continuum of care, we have little effective screening to identify “pre-addiction”—the period of time in which preventative care could help thwart serious drug use. Common issues with current prevention efforts include too few individuals being screened for substance use, clinicians not asking screening questions well, and individuals not being honest when asked about their substance use. Through early screening, it would be possible to encourage individuals to consider changing risky habits – potentially before they’ve progressed into a disorder.
Disjointed care across mental health, behavioral health, substance use, and physical health remains a large barrier. In fact, substance use disorders have only been classified as primary mental health disorders for less than half a century. Before this, SUDs were considered to be underlying manifestations of a primary psychopathology.1
Research4 suggests that traumatic experiences, especially in childhood, is linked to the development of SUDs. Traumatic life experiences such as physical and sexual assault and childhood neglect compromise brain structure and function. This can cause an individual to be more susceptible to behavioral health conditions like SUDs. Again, this points to the essential link between treatment for mental and physical health and screening for substance use.
Substance Use Disorder is Still Heavily Stigmatized
Once risky or problematic substance use is identified, stigma remains a barrier. Stigma around SUDs stems from the erroneous believe that addiction is a personal choice. While this belief is perpetuated by the general public, it is also common within the professions meant to serve people with SUDs.
While there has been positive movement to destigmatize mental illnesses through public education6, very little progress has been made destigmatizing SUDs. Despite research proving time and again that addiction is a complex brain disorder, many still believe that it is a result of moral weakness and character flaws.
Using “person-first” language, which changes the focus from the disorder to the person, is essential for reducing stigma7.
|Stigmatizing Language||Use Instead|
|Substance abuse||Substance use disorder|
|Drug habit||Substance use|
|Person with a substance use disorder|
|Addicted baby||Babies exposed to opioids or other drugs|
|Problem||Risky, unhealthy, or heavy use|
|Substitution/replacement therapy||Medication for opioid use disorder or AUD|
Evidence-Based SUD Treatment is Available
In cases where we can’t prevent SUD, we need to continue to do a better job treating it. SUDs are treatable disorders, but – like heart disease and asthma – SUD needs to be considered as a chronic disease, which means that it must be managed rather than cured.
Medication-assisted treatment (MAT) is used to treat substance use disorders, as well as achieve recovery and prevent overdose. MAT entails the use of FDA-approved medications, in combination with counseling and behavioral therapies, to provide a comprehensive approach to the treatment of SUD. MAT has proven to be clinically effective, significantly reducing the need for inpatient detoxification services for those with SUD.
In November 2021, The White House released a model law for states to help expand access to naloxone (Narcan), which saves lives by reversing opioid overdoses. This is an encouraging sign that policymakers are moving in the right direction when it comes to addiction, but the work doesn’t stop there: Medically assisted treatment (MAT) needs to be available to all patients struggling with SUD. Not only that, but clinicians need to readily discuss the benefits of such treatment with SUD patients.
The Bottom Line
While there is no cure for substance use disorder, there is definitely treatment available to help an individual into recovery. More importantly, we need to do a better job at prescreening those who are at potential risk of developing SUDs. There also needs to be improvements made both in public education and medical and post-graduate school so that we learned how to speak with individuals with SUDs and help alleviate the stigma.