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OBJECTIVES

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Objectives

  • Define substance use disorders.

  • Describe the burden of substance use on individual and public health.

  • Outline barriers and facilitators to good patient care.

  • Describe screening, brief intervention, and patient communication techniques.

  • Review effective pharmacologic and nonpharmacologic treatments.

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INTRODUCTION

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Mr. Wayland is a 45-year-old disabled ironworker. He presented to the emergency department after an auto accident. He was hospitalized when he began to show signs of alcohol withdrawal. While hospitalized, he learned that he had hepatitis C infection.

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Alcohol and drug use burdens individuals and society the world over through its association with acute and chronic illnesses such as overdose, trauma, liver disease, and human immunodeficiency virus (HIV) infection, and its connection to social problems, such as family violence, homelessness, and poverty. Neuropsychiatric illnesses are the largest contributors to the global burden of disease, with substance use second only to depression as a specific causative factor.1 The contribution of substance use to mortality and morbidity varies by country (for country-by-country statistics, see WHO interactive maps at http://gamapserver.who.int/gho/interactive_charts/substance_abuse/treatment_alcohol_drugs/atlas.html) and by state in the United States (http://nccd.cdc.gov/DPH_ARDI/default/default.aspx).

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Stigmatization of people who use substances by society in general and the health-care system in particular compounds these burdens. An estimated 22.2 million US citizens suffer from alcohol and drug use disorders.2 The annual economic cost of alcohol use disorders in the United States alone has been estimated at greater than $223.5 billion dollars.3 Although tobacco use is the leading cause of preventable death in the United States, the nature of addiction to alcohol and drugs reduces patients’ ability to function and reduces providers’ desire to provide care, making alcohol and drug use disorders a vulnerability in a way that smoking is not. Hence, this chapter focuses primarily on addictions other than smoking, although much of what is presented here can be used to address cigarette use as well (see Chapter 40). This chapter describes the individual and societal burdens of alcohol and drug use with a focus on substance use in the United States, and provides specific strategies to address substance use disorders and advocate for patients.

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THE SPECTRUM OF SUBSTANCE USE

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People often begin using alcohol or drugs because they believe it will make them feel better. Those who are physically dependent on alcohol or drugs use them to avoid withdrawal. Others with underlying disorders such as chronic pain, schizophrenia, and posttraumatic stress disorder may use substances to cope with the symptoms of these conditions.4 Clarifying the nature and consequences of use for each patient and then diagnosing substance use disorders will guide clinicians’ prevention and treatment efforts.

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Limited use of alcohol is associated with health benefits such as decreased risk of heart disease. However, recommending alcohol for its potential health benefits is controversial because it is very difficult to determine whether the potential ...

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